Attention Span

Never took Ritalin. Adderall, or Vyvanse.  My guess is that if my childhood occurred now, I'd have a prescription.  Might have even done better in college and beyond medicated, as my ability to stay at task always challenged me.  Instead, I compensated, doing multiple small tasks, choosing a medical specialty where patients would come at short intervals without my ever having to stay focused in the OR or other procedure room for hours.  Yet there is also hyperfocus, similar to Flow, getting absorbed in a project without intent, then pursuing it to completion, sometimes to the neglect of more important things.

After depending on my timer, whether to exercise or focus mentally on something I might not have tackled at all, I engaged in two episodes of absorbed attention.  It had been my intent to tackle the clutter in my basement as a semi-annual project.  Work for 25 minutes three times a week, my usual approach.  Instead, I asked myself how much I could get done there if I did only that for an afternoon.  So downstairs yesterday, half an afternoon.  No timer.  I still thought in small segments, culling a box of artwork, going through unselected boxes where I could separate like things.  Tools went one place, hardware another, painting supplies someplace else.  Recycling went into a dedicated box.  Stuff for the weekly trash pickup into a plastic kitchen bag inserted in a supporting plastic receptacle.  And onward.  Did OK.  Worked for about an hour and a half without once checking my watch.  Put calendars from ten years ago and a box of jars into recycling.  Good effort.  

Later, it was my monthly day to log expenses.  Signed onto my credit card and banking sites with a sheet of loose-leaf paper.  Then each charge for the month of June written by date.  Then transfer to Excel by category, playing with the sequence of columns to make data transfer easier and making a big mistake that had to be corrected as I went.  Then wife's cards logged the same way.  At the end a query to my wife on some expenses in which the categories were not obvious and in which I think what was spent may not have been the wisest purchase.  No interruptions.  At the end, all completed, that loose-leaf page went into the annual folder behind last month's expense log.  Then I had Excel calculate how much I spent in each category this quarter and for the half year.  No surprises.

What I was able to do for these tasks, or maybe for yesterday afternoon irrespective of the nature of the task, was to string together multiple small efforts without interruption.  It's possible.  Perhaps this can be applied to other things, a half-day writing instead of a focus session, a half-day at My Space instead of a few short bursts over three days.  I do this when I drive, paying attention to the highway for about two hours at a time.  I sometimes succeed this way at the supermarket, though more often I go from aisle to aisle or department to department.  And when I make an elegant dinner, my attention is sustained, though the various tasks, whether making one dish or a single process such as chopping, are often put into short compartments of a few minutes each.   This would change my Daily Task List a bit, some things not appearing at all on the page some days to allow for concentration on other things. Worth experimenting a bit more.

Fully Absorbed

My minimal, difficult to maintain attention span took a sudden reversal.  I had been watching some YouTube's on religion, more anti than pro, of late, scrolling past anything that took more than 15 minutes.  Comments by the late Christopher Hitchens repeatedly captured my interest, so I proceeded to check his most prominent book, God is Not Great, from the library.  The transfer of an e-book electronically failed so I requested the print version which I began reading.  And reading. And reading some more.  About a third of the book, when my intent was a chapter a day for ten days.

He writes of a more global attrition, or maybe a wishful attrition that has not happened yet, unlike my focus on decline that has already occurred.  He takes the view that religious institutions with the discipline they impose on adherents generate evil, which they do.  They also generate art, literature, music, and intricate discussions.  My spin seems more that the experience of being there falls short of other options that can be pursued instead.

After interminable Hebrew School flashbacks while I sit at services in my own congregation, with a Rabbi feeding me strings of interAliyah Sound Bites, though not at all evil, it's good to have my mind challenged in this more profound way, not so much about the merits of the Judaism that I have inherited, but the idea of deity and its historical legacy that we make so many often unconvincing excuses to defend.

Perhaps even more importantly, I had begun to doubt if I had the capacity to focus on any ideas or undertakings without the use of a timer to keep me captured on what I was doing.  This reading went on for hours, only needing short breaks to better absorb what I had just learned.  I really do have the capacity to grant full attention and derive pleasure.  I wasn't sure before.

SSRI Holiday

My daily pill container once had seven tablets.  Multivit not renewed after finally completing the contents of a one year supply of horse pills that took a lot more than a year to finish.  I've just never seen beriberi, scurvy or night blindness in all the years I took care of patients.  Some probably took a vitamin.  The majority did not.  The popularity of these escapes me, but also drew me in at one time.  Not expensive but not efficacious either.  Aspirin can be had at the Dollar Tree for $1 for a package of 60 tablets which is $6 a year, even less than the multivit.  The efficacy of this for people my age who do not have heart disease, which would be me if my stress test is accurate, does not seem to be there when studied in the manner of mainstream medical studies.  I've not had any adverse effects but people in the study groups have.  Just finished my weekly supply one week ago and never went back to reloading it into the weekly container on Sundays.  My need for an NSAID varies.  There are weeks when lumbago of some type makes this a scheduled medicine.  It has been my good fortune to go into remission, making this a prn medicine.  I keep a bottle between the front seats of my car but no longer put a daily dose in my case. And it delays my platelet donations which might be among the more useful things I do for people.  I could say the same about that prostate stuff the doctor prescribed a few years ago.  It alleviated symptoms which then stayed in remission after I stopped taking the medicine.  Usage has been minimal.  It is not a prn medicine so when I need it again, it will reappear in the weekly case, but hasn't for a while.  My PPI is still there.  The intent of these drugs is a two week course unsupervised medically for GERD.  And I have stopped it for brief periods only to have GERD symptoms come right back.  An EGD showed no Barrett's or other serious disorder, so the SSRI is for symptoms which have demonstrated themselves as either persistent or recurrent.  That one stays.  There is a statin.  My cholesterol level is well beyond dietary modification, as was my father's who developed symptomatic angina at an age slightly less than mine and a CABG at an age somewhat older than mine.   The medicine has been efficacious, at least by lab numbers if not by patent coronaries, when I am faithful about taking it.  The cost is not burdensome.  I had transient minor myalgia when my current high grade treatment was introduced but in recent years no adverse effects have been noted.  That one stays.  So does the ACE inhibitor.  My BP has been consistently above optimal when I have let it lapse.  There have been no side effects.  So my pill case in recent weeks has been depleted to three:  PPI, ACE, statin.

There remains one more variable, the SSRI.  I might have ADHD by childhood restlessness and inattention but I've never been treated or even tried a stimulant.  As a 60-something, I've succeeded pretty well and rarely if ever speculate to what loftier heights I might have soared had my attention span exceeded that of a Brussels sprout.  Or maybe I wouldn't have does as well.  What I seem to have, though, is compulsivity and hyperawareness.  I can be maniacal to detail, abrasive and impatient, particularly with people less astute than me.  INTJ's like me tend to be that way so it's not necessarily pathological but often not helpful either.  Maybe a dozen years ago I asked my doctor a therapeutic trial of an SSRI might improve this, remembering Peter Kramer's Listening to Prozac published a few years after the medicine became available but listened by me on audiobook quite a few years later.  While these drugs are antidepressants primarily, the have a role in tempering compulsivity.  Dr. Kramer described a patient whose personality, focus, and productivity soared on the drug with a setback on withdrawal and return of favorable results on retreatment.  That's a pretty fair prototype for me.  The pills had declared themselves safe, if not annoying at times. 

Starting with office samples of Prozac 10mg I avoided side effects.  It made me sleepy which is better than making me wired.  Paxil samples were easy to come by.  I lasted about three days.  It made me feel like I took something.  Then 20 mg Prozac by prescription for a while.  Eventually Celexa came out, better tolerated by office samples, then continued indefinitely by prescription with lapses.

This month, I thought it time to hit the reset button.  Avoided my shul on shabbos, withheld Facebook, withheld Celexa (citalopram), bringing the pill case to its current three.  Facebook hiatus a very good thing to do with return next month in a highly scheduled way, much like I did for Sermo six months back.   My shul in its current circumstances still annoys me but I will return in a scheduled way and maybe return to tossing blogbarbs at the Rabbi and Executive Committee.  Not having the SSRI, though, took a real toll and has been resumed.

I found myself mentally a little sharper without it, sometimes hyperaware, sometimes hyperfocused.  I also found myself unusually impatient, overreacting to minor glitches like losing something which may also hint that I didn't pay attention to detail as well, too eager to move on to the next activity.  I was not as nice a person, much as Dr. Kramer described his patient in his book when on and off Prozac.  I exercised less but tolerated the effort the same.  My appetite seemed unchanged but weight might be up about a pound.  Insomnia unaffected.

Before/After assessment shows that I like myself better when toned down a little, so the pill case for the evening doses has returned to four.

Artifical Contentment

I ingested my last Celexa tablet a few weeks ago, part of a drug holiday I gave myself after muffing a scheduled platelet donation last month by mindlessly taking an 81mg enteric coated aspirin tablet that I neglected to omit from my weekly pill case. So until the next platelet donation last weekend, I treated myself to a drug holiday. No aspirin as the blood bank program requires but also no statin, PPI, multivit or SSRI. Other than some wicked heartburn tided over by antacids, while disabling initially but just slightly annoying at present, no medicines. Yesterday, I restored the pill case with all but the SSRI. Aspirin and statin have evidence of life prolongation and other than some achiness early on as the Crestor dose was increased, there have been no adverse effects, though I always wondered if I really would need the PPI if I deep sixed the aspirin. I accept the endoscopist's finding that there really is some reflux but no Barretts, so both the aspirin and omeprazole returned to the pill case. I have a whole jar of OTC house brand men's formula multivitamin, so that went back to the pill case too. My citalopram tablets, even though of ample supply, stayed in the amber tube that I got from the Super G pharmacy a couple of months ago for $10.

Other than some annoying reflux, I clearly feel better without the medicine. It has been a tenuous course with the SSRI, starting many years ago with Prozac samples from the office, then Paxil samples which made me feel drugged and finally Celexa samples which became the generic citalopram. It is not my first withdrawal but unless a lot of people start complaining about me I do not plan to return to this medication.

Peter Kramer in his Listening to Prozac best seller of twenty years back described using the medicine for Obsessive-Compulsive Disorder, which at the time was an experimental use, and for which I worked out with my doctor my first trial of it in the 1990's. Dr. Kramer described Tess who became charming and sociable. I did not become charming, or at least nobody gave me feedback. What I became instead was dulled, almost emotionally neutral, without placing a value judgment on it. Irritants no longer irritated me. My patience improved and I could read or watch TV for longer periods of time with greater safety than if I had tried to achieve the same result with ADHD agents. In exchange for some form of artificial inner peace and perhaps a slightly better attention span, my mind wasn't as sharp. I had no particular inclination to look up medical information I did not already know. My abiltiy to write in an incisive way and to follow thoughts in sequence declined dramatically. Moreover, I felt tired, this being the symptom that prompted each of the previous withdrawals and return of irritibility guiding each restart.

So now I again find myself able to think clearly with very little inhibition to my natural candor. I am less tolerant of myself for not accomplishing at the end of the day and less tolerant of others who now irritate me.

Another book on the subject, Artificial Happiness, comes from Ronald Dworkin a few years ago. While the writing and analysis seem almost primitive next to Dr. Kramer's more elegant prose, he makes an important point that sometimes life's goals are best persued while irritated. If AKSE leaves me unsatisfied and treats me like a picador with multiple little sharp provocations, then using a pill as a surrogate to disaffiliating when I should diminishes my Jewish future. While patients may also irritate me more, I owe them the full measure of my skill which should not be set aside for my own inner peace. As I compile my intentions for the next six months I really want to work on conducting myself in a more gracious, less abrasive fashion than has been my history. But I need to give myself a genuine chance to do this without the phony pharmaceutical restraint.