Thread by @YinYinFalcon

Hello World

About a year ago I suddenly got so severely depressed and anxious that I became incapable of responding to anything online. I didn't understand what happened there or what to do about it for the rest of the year.

I do now and need to share for two reasons. (that I remember)

First of all similar threads from others have helped me a lot in the past. I hope I can pay that forward here, even if I will never know about it helping anyone.

Second, this is gonna be part of my recovery.

Forgot about the third reason, but it's not like I need any more :)

Let's start at the beginning. Being depressed on occasion isn't unnatural to me. I get that a few times per year, lasting a few days each. To me it's like others get the flu. This didn't feel any different at first.

It did not end after a few days and instead escalated to bring back the worst kind of past grief I've ever had. (among other things)

Fortunately the depression was only a symptom. And I've had great support to get myself out of that half of the problem over the next two months.

I already met up weekly with my parents before this. But continuing that by itself wasn't particularly helpful. With me unresponsive, Tim managed to contact someone of my family to ask how I am doing. Now we swapped to alternating 1 on 1 meetings and those were very enlightening.

One of my parents is surprisingly capable of discussing emotions. I did not know this for decades. While the other can't deal with talking about them at all. I would have loved to know and make use of that as a kid, but perhaps it only developed over time.

In any case, to assess where I was at I took a PHQ-9 by myself and started doing an online moodgym.

Stubborn, depressed me was in no shape to seek or accept medical help in person. And I'm quite certain being forced to do so would've made things worse initially.

I almost maxed out the PHQ-9 questionnaire, landing in the top severity with two notable exceptions. I didn't score high on the hopeless question and had a 0 for the self-harm question. I was certain to be getting out of this, but still had no idea how.

Moodgym helped tracking my depression and anxiety. It's why I have a timeline at all. And I wasn't aware of the anxiety component before. But lessons and exercises themselves weren't useful to me. One half wasn't anything new, the other half relationship advice that didn't apply.

Chugging through that moodgym feeling like it's not made for what I'm facing was exasperating. But I was tackling the physical side as well by increasing the two Vitamins I supplement: D3 and B12. (I only learned then that lacking one of those can cause depression symptoms, cool)

I think I had actually run out shortly before this and forgot to restock. In the end a deficiency in one or both of them is likely what made the depression so severe. Unfortunately I didn't get it checked at the time. (I checked since then to make sure the levels are right)

So that's the depression gone after two months, but I'm still left with crippling anxiety. Anxiety specific to being active online 👋 I tried acclimating myself back into that over time. But it wasn't much use without knowing how to unlearn the anxiety response to it.

That's enough for today. To be continued u_u

Moving on! I planned to continue chronologically. But there is lots of sorting needed to not go off on useless tangents. (I'll just tack them to the thread whenever later)

Because it's very present now and in my opinion highly useful, let's talk about somatic anxiety responses.

Thoughts and feelings from anxiety can be as bad or worse, but the somatic stuff is what's inhibiting me in the moment. I'll talk about the other two and why this one dominates my anxiety some other time. For now I'd like to just describe the symptoms that affect me.

In general those physical reactions to fear or anxiety are there to prepare for and protect you from danger. They are pretty cool like that. Until of course they impede your functioning in a world they didn't evolve for. There are 3 relevant to me, but lots more for other people.

First one is pulse. Most lists just talk about it going faster, but for me it's going stronger. And it makes sense if you know it's in anticipation of danger. I am not yet burning more oxygen. Higher throughput would not prepare every single cell, but higher blood pressure does.

Second: trembling. This one can have several causes. Primarily your joints will become more flexible to improve movement. Your muscle memory won't be as used to this, fumbling movements that are otherwise familiar. And your muscles can tense up as protection.

These two have already been very familiar to me. Anticipating this can keep me from doing something optional despite wanting to. It won't stop me from doing something necessary, but it can ruin a whole day. The symptoms take forever to subside and I'll be stressed for a long time

Besides rewiring my brain to reverse the process of this getting worse, getting more fit should also help make these symptoms less severe :')

I've had a lot of trouble describing and understanding the last one until recently. German does not have a good description for it. It starts with a cold flash radiating out from the center of my chest. It persists feeling like bleeding out downwards in that spot. It's painful.

I now know it can be described as "flau im Magen", but "sinking feeling in the stomach" is far more descriptive. I don't get this for most outside social situations, but I get it lots here. Another situation where I know it happens is looking down a big drop without guard rails.

It makes me want to leave a situation more than anything else. But what the fuck happens there and what's it for? Apparently blood is being withdrawn from the digestive system to focus on everything else. Another cool optimisation honestly. Knowing what's going on helps a lot.

To be continued

Let's turn more inside out.

I'm gonna skip something major as it is a better fit for another day. Today will be about how I tried to acclimate myself back to being online last year. It didn't work because I didn't know how to rewire things. Might've made things worse actually!

I tried approaching it in small steps. Testing the waters and my reaction. Which isn't a bad idea by itself, but I wasn't facing the troubling situations. I was further avoiding them. And I didn't process the results to learn either. At least I'm learning from it now ¯\_(ツ)_/¯

It still is a bit nebulous to me, but it seems the anxiety response correlates to how much social value I see in the connection? The more important it seems, the higher the anxiety is. 🎉

Let's bring some examples.

I tried some comments in Elite Dangerous communities while I was still in the depressive hole. The anxiety response was terrible.

That wasn't a good benchmark considering I feel like I can get lost in that crowd. I don't feel recognised there despite having some impact.

The next one I felt compelled to do. @MartiWong announced that he'd remaster Little Fighter 2. This game used to be what Lethal League is to me now. Modding that is how I acquired most of my skills. Usually attempting to create things indistinguishable from the original assets.

Little Fighter 2 is the polar opposite to Elite Dangerous. A smaller community that I had a larger impact on. I can't say the anxiety was worse as I have quite a bit of distance to it now.

Further cemented by Marti peddling NFTs and casual bigotry among the active community u_u

There were a few more like asking for support porting a board game to Tabletopia or engaging with Metroid Dread speedrunning. (not running myself, but the glitches are tasty)

But without guidance none of that helped the anxiety. And anything a step up had me running every time.

Early on I already knew I'd need help. I actually considered therapy two times before this, but of course the anxiety itself likes to stand in the way of that.

And this time I had something extra standing in the way on top of that 😩

good cliff hanger

to be continued

Alright, let's clear that cliff hanger.

The other thing next to anxiety standing in the way of getting medical help was: health insurance! 👏

What happened? At some point my insurance decided I must be rolling in dough after a few years of freelance. I hadn't really noticed what kind of difference that made. They started charging the maximum rate and hit the bottom of the account while I was in the depressive phase.

Luckily those weren't my only savings. But I couldn't afford to let them go for the rest of it at the maximum rate. Even if I were in a better mental state. That meant no vitamin level check and no therapy.

Unfortunately I have no idea how I managed to negotiate myself out of that one. It was pretty intransparent to me. Somehow my rate was reset retroactively and I was refunded all of the overcharge.

Now clear to get a blood test, right?

Wrong.

I must've also missed out on getting a new card during that gap. Despite there being a clear expiry date on it (next year I think), it got rejected for being outdated. A version update without backwards compatibility as I found out later.

Being turned away was a great boost to the anxiety I came there for in the first place.

It was the exact scenario I was afraid of if I had tried to get help before clearing the insurance kerfuffle.

There was a simple online process to print your own temporary card replacement at home. I did that the same day. But the new card arrived before I could bring myself to try again with just a piece of paper.

That's the vitamin levels finally checked. Way too late. And for better or worse looking good. (just treating a deficiency still looked like an easy way out)

So now there was only anxiety standing in the way of the inevitable therapy. Therapy for said anxiety 🤦

to be continued

Of course I did not immediately look for a therapy 🙃 who in their right mind would do that when your insurance has another online program on offer you can try out instead?

This section is gonna be all about how that didn't work either.

Fundamental differences that should have made it better than the moodgym:

It has more than one course on offer, helping you to pick the best fit.

It has actual therapists on the other end you can talk to, assigning you one when you start out.

But it failed on too many levels to help. Some probably specific to me, but many are in my opinion general shortcomings. Which is quite a let down for such a fancy presentation. (moodgym looked a decade old compared to this)

Most of all the pacing was off all over the place. It's a 3 month course with 12 modules lasting a week each. Once that time is up you lose access to the therapist. Matching available and expected time to complete isn't too great. Kind of unnecessary pressure in my opinion.

The reminders to continue with the course generally came far too late, with no options to adjust them. (too frequent wouldn't be better)

Free mobile learning/exercise apps have better systems than this. 😕 (like, remind me if I haven't made progress by a certain time each day)

It didn't have a good mood/status tracking like moodgym. That would've both allowed me to keep track of how much time has already elapsed on the course, but also how it's actually helping me.

It also hid all upcoming modules once logged in. Perhaps in an attempt to not overwhelm. Which I'd say was necessary, because everything gets presented in even smaller sub modules. Makes gauging how you are doing on time really hard and you've got less to look forward to.

I lost overview on that quickly. While more on point, the modules were once again mostly boring info dumps interjected by mammoth tasks like "list all your low points in order of severity". Cool! Let me quickly figure that out by reliving them. Can't take more than a week, right?

Had great examples to help you figure out how severe or benign things on that list can be, but no context on what that exercise is supposed to achieve. And then suggests talking to the therapist *after* completing such an exhausting exercise, not while you are wasting time on it.

Best of all these suggestions to talk with the "available" therapist after a difficult task did not go away once the 3 months were up.

So if you try to continue on your own, you now essentially get mocked for being that exhausted by the exercises at the worst possible moments.

In hindsight I should have leaned on the therapists all the time. But I'm not sure I would need this if I was capable of doing that. I had maybe two or three exchanges with them that didn't really do much at all.

The course also had you enter a "goal" at the beginning. I set mine to being able to write morning pages again, because I know that's an indicator of me doing well. Which modules are important and how exercises relate to this goal would've been the thing to ask the therapist.

Specifically insulting to me was an exercise of "expressive writing" I wasn't aware of (due to hidden modules), which I think came up after I had lost access to the therapist.

It's another form of morning pages. The goal I had set myself for the course in the first place ...

Oh and the website logs you out after minutes of inactivity.

There were many times I was half done pondering one of those difficult exercises and got auto ejected from the session - erasing everything I had already managed to enter into the field. 👌

Had to swap to a notepad 🤦‍♂️

I got maybe half way through that course, still have a few more months access to it - but it's way too frustrating to continue.

I already started to dump some of the grievances into the exercise fields once therapist access was gone. Because I genuinely want this to be better.

I might even distil this down into action points to improve the service and @ them. QA on a mental health tool from a patient who's into UX!

Then again they are based here in Berlin and their service isn't free. Not feeling like providing that work for free either then 😑

That was quite the rant.

I'm afraid the next section won't be much better.
That'll be about finding an in person therapy.

As said before I've considered therapy twice in the past. Once for grief in school. Once in university when I slowly realised some of my behaviour patterns are holding me back. A catch-22 really, but I just told myself I'm doing fine on my own.

https://twitter.com/YinYinFalcon/status/1513634816754864132

I've also watched a friend go through multiple (in my opinion useless) therapies and even sat in on a session once. Lots of contradicting infodumps, bad photocopies of extra material to read and unsuited exercises. It felt like a complex form of "have you tried not being sad".👍

And then there is the more nebulous perception of mental health. While my social bubble has become more and more therapy positive, every language I speak is still entirely drenched in mental health negativity. Decades of living that aren't undone or to be ignored so easily.

I can't exactly say what effect the parts I grew up with as "normal" had.

But every time I encounter and recognise new things of that nature, it noticeably disgusts me.

As an example, the most recent term I've noticed growing popular in the western gaming bubble: "cope"

This word now gets massive use as a disparaging term. Fuck that.

urbandictionary.com/define.php?ter…

I think that's a good background on why I may have been averse to seeking therapy before, but I was down to no other choice. At least I already knew exactly what type I needed: a behavioural therapy for anxiety. Can't be that hard in a big city, right?

Search results were disappointing. The prominent 3 kinds:

therapist with zero info on all review sites, nothing else. (what therapy method do they even use?)

therapist with a bunch of negative reviews.

therapist with blindingly beautiful webpage, private patients only.

Okay, forget the web search. What about the official database?

It's another UX nightmare
(╯◕◡◕ )╯︵ ┻━┻

First of all the front end can only return up to 50 results, pointlessly spread over 5 pages. In Berlin even the smallest search radius exceeds this limit for some reason. Meaning there is no reasonable way to squeeze every therapist in the city out of it.

Selecting behavioural therapy under extra search criteria yields no results. It wasn't possible to filter for what I need.

They since added therapy method under main search criteria 👍 (not enough to land below 50 hits)

The broken extra search criteria is still there as well 👎

But it's not just trash on the surface, the content also doesn't appear to be maintained by anyone. From what I could gather trying to use the results, therapists are automatically entered into the database when they get their license. At minimum that's just a name and address.

That address is often outdated, because therapists ,like doctors, tend to get their start working together with an established therapist and move into their own office later. In some cases that office is not even in Berlin anymore. This invalidates the whole radius search idea.

But not just the basic address and contact information tends to be outdated. Some therapists also appear to swap from public to private insurance or stopped practicing altogether and shouldn't even be listed in this database anymore.

This is why there are always over 50 results.

I tried to wrangle this mess into a usable list I could go through. Basically filter out therapists that are still doing behavioural therapy in Berlin, still doing public insurance, have an email address, don't have bad reviews or other red flags in their online presence.

60 entries melted to maybe 4. One of which had their website disappear to never be seen again. I hope they are okay.

A much more believable result for 2 out of 196 zip codes.

But still really useless considering I'd gladly go to the other end of the city for a good therapist.

Exhausted by that and dreading to hear how long I'd have to wait for a spot just to figure out they are not a good fit for me, I never contacted any of them.

But then I found out that there is an online appointment service. This is where the big city bonus finally kicks in.

I have since recommended this to others over on mastodon, only to learn that it isn't available in their region (of Germany). And it makes sense, because the line up of therapists on it was already sparse here in Berlin. I bet most places just don't have any therapists using it.

Once more it wasn't possible to filter for therapy method, but with so few therapists having open appointments that wasn't exactly a problem.

What was a problem were their custom descriptions:
"must call / speak onto the answering machine to confirm your online appointment" 🤦‍♂️

I had seen similar next to email addresses of therapist websites before: "appointments only via phone call"

I can't really trust anyone to treat social anxiety sincerely when they restrict their access like that.

There was only one without this restriction.
Easy pick.

to be continued ✨

Okay. Before we get to the good stuff - some things on how a therapy is supposed to go here. In perfect German fashion my insurance has an exact 6 step process. It looks quite intimidating when you need a therapy. (a bunch of it is officially mandated)

More so to me, because step one is a consultation with a therapist. Which was the hardest one to get to in the first place. Only step four is an examination to rule out physical causes, which I did loong before on my own ...

There is also some wording about how waiting time for an appointment should not exceed four weeks. I got my consultation just before new years and first sessions in January, so that actually worked out. But previous experience from others was measured in months.

If the consultation confirms you need therapy, you get four test sessions covered by insurance no questions asked. The full therapy requires an application. The phrasing from them made it sound like I'd have to do that. But the therapist did all the paperwork.

My therapist didn't explain any of this to me, which may be my only gripe with them. But then again 45 minutes per session are barely enough to do the actual therapy and I had already informed myself.

Now onto how that consultation session went.

First I got a custom form print to fill out. One sided. Surprisingly sparse! Way less than any doctors or online tools had asked of me before. Then I got to describe my issue and what my goal with the therapy is. Abridged version of this thread. My filled form helped a lot there.

I know some people would already struggle with that. But if the past year had felt like a giant waste before, at least I was somewhat over prepared for this.

If you can't articulate what therapy is supposed to help with, it won't be able to help 😔
(that needs more acute care)

One form field stood out to me: my education level. (science bachelor)

Because all the first sessions were essentially private crash course lectures on human behavioural biology. Or how behaviours (specifically somatic anxiety reactions) are formed. Very academic. I loved it.

And they were cleverly intertwined with fitting examples I could provide on my own.

This would probably have been awful for anyone not academic/science minded. But I came away thinking why the fuck haven't I learned any of it earlier.

I think everyone should know how their brain works in that regard. Perhaps not to the brain region/biochemical level. But certainly in a broad sense to know how and when you are training your unconscious brain functions.

Because that is both the underlying issue and the "cure".

I wanna try to share the basics as best as I understood them next time.

Okay, to the juicy bits. Early on I was asked to graph the intensity of my anxiety in the worst social situation I can think of. This revealed a misconception I had: I drew a linear increase with no limit.

In my experience if I did not resolve or get out of the situation, the symptoms would keep increasing with no end in sight. This is somewhat frightening when it involves an ever more powerful heartbeat and the feeling of your stomach bleeding out. That would lead to a collapse.

The reality however is a plateau. Your body can only produce a limited flow of stress hormones and eventually dials back down even if the situation persists. The most extreme case (a panic attack) only averages a maximum length of 30 minutes. I don't think I've ever even had one.

That dialling back down section is the "cure". All the systems in your brain responsible for the anxiety response learn that the situation isn't actually dangerous and adjust accordingly. The reaction won't be as severe anymore next time around.

Swell! That means all you gotta do is some exposure therapy, yes? Just throw yourself into the anxiety situation! Yesn't. Similar to muscle training you can overdo it and cause more harm than good. You can end up doing what caused you to learn this anxiety in the first place.

So how do you learn a social anxiety response? Let's take the internal process step by step:

1st you already perceive a situation as a threat. Maybe you have a disposition, maybe some past experience - but you fear something about it.

For me all examples so far boiled down to fearing a "loss of control", going hand in hand with that misconception I had.

2nd you judge the situation accordingly, conscious or not.

3rd you feel matching emotions. In my case mostly fear and shame.

4th you get somatic reactions.

All of 3 these, thoughts, feelings and body sensations will focus your perception back onto anything that will confirm the fear you have. This can be a circular process. I for example perceived the somatic reactions as a loss of control and hence get the fear confirmed by itself.

Your self reinforcing process of fear can also be focused on thoughts or feelings.

In any case this can increase your anxiety around a situation beyond what's reasonable for it. But that's not all there is to it, because if you let it play out it'd dial back down and never stick

The other component are anxiety reducing behaviours that prevent the process from playing out. You could flee the situation, trivialise it via thoughts, distract yourself, breathing exercises, soothe yourself with stimming or other safety signals. Anything to reduce the anxiety.

Getting through the situation is now attributed to the anxiety reducing behaviour. Which unfortunately keeps your systems from learning that the situation is not actually dangerous and makes you depend on that behaviour in the future as well, once again reinforcing the process.

That is not to say these behaviours are entirely bad. If it's the only thing to get you through a critical situation without getting a panic attack, do fall back on that.

But be aware that it does you a disservice otherwise.

To unlearn an anxiety response you need a situation where it occurs (not so difficult that you use anxiety reducing behaviour), let thoughts, feelings and somatic reactions around it play out long enough for your body to learn that there is no danger. And then rinse and repeat.

The situation doesn't need to be entirely natural. You can force thoughts, prompt feelings through memory/media and do physical exercise to get some stress hormones flowing. Your brain goop won't know the difference. But it will need to be specific to what you want to train.

My discord exercises for example are still quite different from mucking about on twitter. Before both of that I did out and about situations. And I'll be far away from something like public speaking for quite a while. (I've never been close to that, but now I know how I could!)

Planning, judging and evaluating those exercises can be quite difficult on your own. This is where a therapist continues to be helpful. (It's also where they can be useless if they don't understand your situations.)

An anxiety reducing behaviour for example can be as simple as leaning on something or standing with your back to a wall. It's easy to overlook these things or options to adjust and modify an exercise.

I think that finally completes this thread and exercise :)
I no longer have any problems being here.
And I've shared in my opinion absolutely essential information when it comes to mental training.

Happy to answer any questions as well.

I plan to continue in a bit more detail on what other exercises I've done and whatever else comes up in this therapy over on mastodon.online/@YinYinFalcon

You can already find things over there I no longer want to or never have put onto twitter. Mostly more cat pictures and photos.