When the Monkey Falls Out of the Tree: inside a psychiatrist's office

On the front of her brochure, my psychiatrist (yes, I actually got one. . . it was a complete fluke; I happened to call right after a patient canceled an appointment so the receptionist stuck me in that slot. Really. And no. The psychiatrist is not covered by my insurance. *Sigh*) was tall-ish and blond-ish and smiling. In living color, she was lanky and gray-haired and frighteningly skinny. She also had glasses that she had to frown to see through. And she had a lot of bookshelves with oversized books about pretty much everything.

I think I liked her. When I think about the $400 I dropped for the two hour intake exam, besides feeling nauseous, I thinkI really like her. Finding a new psychiatrist would tantamount to burning money at this point.

For simplicity's sake I think I'll refer to her as my Personal Female Freud, or the PFF, from here on out.

I was a little nervous going in. The kiddos had swim lessons today and that is always stressful. (Three cold, hungry children plus one mommy multiplied by a germy, slippery locker room equals a gazillion bemused/horrified on-lookers and a lifetime of embarrassment. Someone please remind me of that next summer when I'm signing up for swim lessons.) And we had to run to the library. And my visiting teachers also came today. And the sliding door of our Toyota Sienna got a massive scratch--you can see it from far away--in the rec center parking lot. I was pretty tired and stressed--and late!--by the time I reached my PFF's office.

I sat down on her cushy couch, checked the clock, and immediately began talking--rapid fire style. I quickly listed all the dates of my pregnancies and deliveries along with my medicines and dosages. When she asked for a family history I listed in all the people with mental health issues in generational order, complete with relation to me and treatments received. I began giving her examples of my symptoms (what I am like when I'm raging, what I'm like when I'm truly down, what are my panic attacks like, what types of intrusive thoughts I have and what happens when they get too loud) when she interrupted me.

I was startled. My therapist, who is more of a BFF than a PFF, rarely interrupts me, which is a major reason why I like her. I have a real need to be heard and understood and I don't always get that in my life. So when the PFF cut me off, I was little offended. But then I realized that a PFF is not a therapist. She's an MD. A doctor. A diagnoser and prescription writer. I slowed down and began giving condensed, yet honest, answers. My PFF wanted specific details and a few big picture clarifiers, but not my memoirs.

After a few more history questions, she began getting out her big books and a magnifying glass. The big books were full of such small print that she couldn't read them without one. She opened her Physician's Desk Reference, held her magnifying glass about half an arm's length away, and began reading aloud about my medication and pregnancy and lactation. Here are my notes (which, I feel obligated to point out, don't serve as a substitute for a trip to your own PFF. Seriously. Get your own!):

*Cymbalta is new. As in, only two years old. The previous generation drug, Cymbalta's mommy, was called Effexor. There isn't a ton of research on Cymbalta directly, but there are some conclusions you can draw based on research about the older drug.

*In pregnant rats and rabbits who took 7 to 15 times the human dose of Cymbalta, there were issues. Duh! You could give them 7 to 15 times the human dose of water and they'd have issues. You know, when you consider that animals are spiritual beings too, well, that's really sad that some of them are experimented on that way. I'm grateful to them. I also think I'll have to search out quite a few vermin in the next life and thank/apologize to them. (That last part was my conclusion. Not the PFF's. The Physician's Desk Reference doesn't talk about spirituality. Even though it's so big it will hang off the end of your knees when you put it in your lap and looks like it's the actually the Big Book of Everything.)

*In women who took Cymbalta while pregnant there were some correlated complications, especially for those who too them during the third trimester. The symptoms the newborns exhibited (like an increased startle reflex, difficulty regulating body temperature, and shallow/irregular breathing) were similar to those in adults who were having a serotonin overdose. No one knows if that's what is really going on with the babies, but there is something different about some of them. No long term effects were mentioned. Probably because the drug is too new to know.

Then the fun started. The PFF started running a battery of tests that I believe she called a mental status exam. She asked me common sense questions (What's today's date? Who's the President of the United States?) common knowledge questions (Who was the previous President? And the one before that? And the one before that? And the one before that--at which point I told her I hadn't been born yet, but I was willing to guess. So then she asked me, "What's the capital of Spain?") and some non-sensical questions (What does it mean when someone says, "Even monkeys can fall out of trees?"). Then she had me draw some pictures, copy some shapes and repeat back lists to her. Then came the toughest question I have ever answered: Count backwards from 100 by sevens. I started to sweat. "It won't take as long as you think," the PFF intoned. I began to calculate and fumbled and tittered and lost my place. I shook my head. I closed my eyes, took a deep breath, furrowed my brow, counted on my fingers, and managed to get the answer right. Turns out the test, my PFF told me when I was done, was to test my concentration. Apparently a lot of people who have been treated for angry/anxious depression are actually ADD. My counting backwards skills proved I'm not that, but as the PFF pointed out, it sure "Looked like your performance anxiety got to you, huh?" Awesome.

As two hours wound down I was tired--it was draining to focus on my issues for that long--but good conclusions were drawn: in my case, particularly because of my perinatal depression, it's probably best to stay on an antidepressant with my next pregnancy. Cymbalta is not the best choice and it's worth trying to wean off it--slowly--and start a different drug near the end of the pregnancy (probably Prozac. Oy! I've never felt so cliche). Apparently there's some estrogen variant that is produced by the placenta that makes pregnant women feel good and we're hoping that will keep my mood adjusted for the bulk of the pregnancy. I'm supposed to call after a month on the reduced dose and we'll decide how fast to take it from there. If I get preggers before the Cymbalta is out of my system, that's okay. No need to cold turkey. It's only the third tri that appears to be a problem.

Walking out of the office, I felt good. we have a plan I can stick with. And the PFF is another supporting fixture in my life, which feels really good. After all, like I answered about the monkey falling out the tree, "Even when you're doing something that should be natural to you, that you should know how to do, you can still end up on your butt."

Oh, and the icing on the cake: one of my visiting teachers cleaned my house while I was at my appointment. The place was trashed when I left and gleaming when I came home. I cried a little. For real. The Visiting Teaching program is just one reason why I love my church.