Elana

Healing Anxiety With A Holistic Approach

January 24, 2019 By Elana 10 Comments

About six months ago a patient came to see me in my psychiatry practice—let’s call her Sarah (this is a general example of the kinds of patients I see rather than a specific person).

Sarah was a 32-year-old woman who worked in digital marketing. She was recently married and had a good relationship with her husband, enjoyed her job, and tried to take care of herself with decent diet and lifestyle habits, including going to regular yoga classes.

However, over the few months before seeing me, Sarah had been dealing with progressively worsening anxiety that led to her having a panic attack while giving a presentation at work. Now she felt constantly afraid it would happen again and found herself avoiding situations where she might have to speak in front of other people. The anxiety started to spread over to her personal life, and she stopped seeing friends and started relying on her husband to drive her places, afraid that she might have a panic attack while driving.

Sarah had been hesitant about seeing a psychiatrist because she was afraid of taking psychiatric medication, but her progressive trouble functioning at work, and her husband’s insistence, let her to google local psychiatrists, find me, and make an appointment.

As I was getting to know Sarah she described herself as always being an anxious person with a tendency to worry. She identified as being a “perfectionist” and often held herself to unreasonably high standards, feeling guilty if she ever made a mistake.

She was highly conscientious and had always done well in school and at work, but the intense stress she put on herself was beginning to come at a great personal cost. She would often have trouble sleeping because she couldn’t “shut off” her brain at night.

What Does It Mean to Heal Holistically?

Before I go into the details about how I treated Sarah, I want to introduce the concept of Integrative Psychiatry.

Integrative psychiatry addresses the “whole” person—mind, body, and spirit

Mental health issues do not exist in a vacuum, and stressors on one part of the system will inevitably affect the system as a whole. For example, if I am working with a patient with severe depression because of a divorce, it would not make sense for me to treat the depression with medication without also talking through the patient’s divorce and helping him come to an understanding and peace about what happened, and helping him find a healthy way of moving forward.

Similarly, if a person has anxiety, even the perfect nutritional regimen will not be effective if they live in an apartment polluted with noise where they can’t relax. Each part of the system affects the other, and the major levers all need to be addressed to have a successful outcome.

Integrative Psychiatry is NOT anti-prescription medication

Extreme opinions are usually unwise opinions. I’ve seen a lack of wisdom on both sides of the table, both from medical doctors who criticize supplements and herbal medicine as nonsense and alternative providers who perpetuate stigma against prescription medications, telling misleading tales about how pharmaceuticals will destroy your brain.

To me there is more in common between how prescription medications, supplements, and herbal medicines work than there are differences, and all are just MOLECULES that work on our brains, often on the exact same neurotransmitter pathways.

To generalize broadly (there are exceptions to this), medications are stronger, work faster, and are more likely to have side effects, while supplements take longer to take effect, have more subtle benefits, and are less likely to have side effects.

Therefore they can work well when used together, with prescription medications used to acutely stabilize the system and then supplements added in order to create a healthy micronutrient environment in the body, allowing us to use lower doses of the medication and taper off of them sooner.

But most important to the definition of Integrative Psychiatry is this:

Integrative psychiatry respects the patient’s individual belief systems and preferences, and emphasizes a relationship between doctor and patient characterized by respect, kindness, and genuine concern

My job is not to tell someone they’re “wrong” about what they’re experiencing or what they think is causing their symptoms—my job is to listen, understand, and create a treatment program to help the patient achieve his or her goals safely and effectively in a way consistent with that person’s beliefs and preferences.

I get very frustrated when a patient tells me their last doctor told them their symptoms were “not possible” or “in their head.” If a patient tells me they are experiencing something, I believe them. I am trained in medicine, but the patient is the expert in his or her own body. I am also always learning, and no matter how much I study there will always be things I don’t know. Therefore my patients are also my teachers.

Let’s get back to Sarah:

The first thing I did for Sarah was start her on Lexapro (a prescription SSRI) for anxiety. Within a few weeks, she was already starting to notice a difference.

We used low doses of Valerian Root, Lavender oil capsules, and Kava tea for acute episodes of anxiety as we were waiting for the Lexapro to start working.

I also saw Sarah weekly for psychotherapy, where I taught her how to challenge the perfectionistic thinking that led her to create rigid standards for herself and contributed to anxiety. I showed her how to shine a light on her negative thinking, and rather than believe her anxious thoughts automatically, to look at them objectively. She began to realize that she tended to overestimate the possibility of bad things happening while underestimating her ability to handle those things. I taught her concrete skills she could implement on a day-to-day basis to better cope with stress.

I taught Sarah about good sleep habits, and worked with her to create a calming evening routine to help her relax her mind at night. I also taught her to prioritize sleep, and to shut down anything work-related at least two hours before bed.

I taught Sarah about the concept of mindfulness meditation and led her through guided meditations in session. I showed her that meditation is not actually a relaxation practice, but rather a practice of being at peace with our present experience without criticism or judgment, even when that experience is painful. I taught her that instead of getting caught up in the narrative of her anxious thoughts, she could watch them pass through her without believing their story.

Within two months, Sarah felt the tide was turning in a positive direction. She hadn’t had a single panic attack, was driving again, and was starting to branch out at work and volunteer for presentations. I was happy with her progress but knew our work wasn’t done—I wanted to make sure we stabilized these gains and continued them.

We started to take a closer look at her diet. I had her keep a food journal for two weeks, and after looking at it more closely I noticed she ate more processed food than she initially described and tended to rely on caffeine and sugar to get through the day. I was concerned she could have some micronutrient deficiencies and ordered specialized nutritional lab testing for her.

In fact, we found she had evidence of elemental nutrient deficiencies and low B vitamins (very common these days with the high amount of processed foods in the typical American diet). We added an an elemental nutrient supplement and B vitamin complex from a reputable company that makes pharmaceutical-grade supplements.

I also referred Sarah to a resource that teaches meal planning so she could work on improving her diet without having to rely on frozen meals or convenience foods. We eliminated caffeine and reduced refined sugar, which gave her a more stable level energy over the course of the day and improved her sleep.

After about six months, Sarah told me she felt “completely better” and “like myself again.” I see her periodically for tune ups, and in another six months our plan is to taper her off the prescription Lexapro and maintain her gains with behavioral change and lifestyle modifications.

Using an integrative and holistic approach isn’t a “silver bullet,” but rather seeks to achieve small gains over time in a healthy way consistent with the patient’s values.

It’s important to recognize that anxiety isn’t “wrong” or “bad.” Anxiety is an adaptive emotion that in many situations keeps up motivated, helps us work toward our goals, and helps us recognize dangers and prevent them. Healing anxiety holistically is not about eliminating the emotion, but rather about restoring balance.

Are you interested in working with an integrative psychiatrist? If you’re near the Los Angeles area you can work with me, or check out the provider listings on the website of the Academy of Integrative Health & Medicine.

Fatigue After Cancer Treatment: How To Overcome It (Especially If You’re A High Achiever)

September 12, 2018 By Elana 23 Comments

Quick note: Thank you everyone for the really nice comments in response to my last post! I know I don’t post that frequently… I am working to change that in the near future so from now on you’ll be hearing from me more often.

This article is a long one, so if you don’t have time to read it now, I recommend you bookmark it and come back to it later, because it has a lot of good information. I also noticed some people have been googling “elana miller wedding,” so I added in a little photo at the end just for fun…

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If you’ve experienced fatigue after cancer treatment, I bet you’d do anything to experience the following day:

It’s the morning, and your alarm goes off. You open your eyes. You’re a little tired, but it’s “normal” tired and you’re still ready to face your day. You get dressed, shower, make yourself breakfast without a second thought, and head off to your job. You get a text from a friend inviting you to a concert that weekend, and you think, That sounds fun!” and text back that you’re in.

After work you head to the gym and get a workout in. You arrive home, satisfied that you’ve had a productive day, that you’ve made some money for yourself, and that you felt like a basically normal, interactive human being. Sure, there were some annoyances to your day, like deadline stress at work and the traffic jam you hit on the way home, but you feel happy to be able to experience “ordinary” problems rather than earth-shattering ones.

If the title of this post resonates with you, though, your situation is probably something like this:

You’re a young adult in your 20s, 30s, or 40s, and in a previous life were a high achiever.

Then, you got cancer.

You managed to get through the emotional pain of the diagnosis, and the physical pain of treatment, but now you’re stuck with a different kind of pain—the slow, seeping torture of wanting to get back to your regular life but having no energy to do it.

Your doctor’s appointments have spread out because, well, you’re in remission, and your treatment has ended. You even “look” fine—no one who saw you would guess there’s anything wrong under the surface. You don’t feel fine, though—at all. Even basic activities like cooking, showering, and cleaning incite a sense of panic because you have no energy to do them.

The problem compounds: You’re desperate to get back to your job or get back to school (because you want some meaning and purpose to this life you worked so hard to save), but you can’t even do the basics. You’re stressed about money. You’re tired of feeling a sense of dread whenever you get an invitation to do something (“Oh god, how will I have the energy for that, my friends are going to get tired of me saying “no” to everything all the time…).

Meanwhile, you see your peers, coworkers, and friends all moving forward with their lives, while you are totally stagnant. And if you have to see one more travel Instagram post captioned how great Bali is at this time of year (#blessed #nofilter), you might just #shootyourself.

Here are the kinds of things people say about their fatigue after cancer:

“It hits you like a stone wall once your body is trying to recover after all the chores are done and family errands or business pursuits are seen to. Your bones ache, your head is heavy and your back’s yearning for that soft bed in which to curl into for the longest of time.”

“Fatigue is not something you can put away in a closet – out of sight and out of mind. It usually overstays its presence; bearing down on you despite all the “rest” you give your body. With fatigue, one almost has to take a mandatory lie-down once in the morning and then once in the afternoon, just to store up a supply of energy for later.”

“Preparing my own meal was exhausting – I needed a one-hour nap or rest before actually cooking the meal. It is different from the usual tiredness that is usually short-lived. I was too tired to even sleep. I had sleepless nights, which made me even more tired the next day.”

“People are always telling me that “You look good” and “You don’t look sick”. And as I mentioned, people usually see me on my good days. Somehow when I meet people, I do feel happy and I guess it shows and this masks the fatigue.”

“There are days when I really struggle. Sometimes, it feels like I’m a deep-sea diver wearing a heavy lead suit. As I try to cross the bottom of the ocean floor, it takes every ounce of energy I can muster to just lift my foot.”

The kind of fatigue that hits you after cancer treatment is way beyond what a typical human being ever experiences. This is not “Oh, I just ran a marathon yesterday and I’m kind of tired,” or “I stayed up late last night and I sure could use a nap.” It’s a completely bone-chilling feeling that you literally don’t have enough energy to perform basic bodily functions like focus your eyes, digest food, have your heart beat normally, or breathe.

This was me about a year and a half ago. It was particularly painful in contrast to how I used to be pre-cancer, when I was an uber-active high achiever. I was known as the person who always had “a project” going on (writing, business ideas) in addition to the demands of being a medical resident. I was also really athletic. I was a college water polo player and kept up with sports through swimming, surfing, snowboarding, etc.

Here’s me surfing at Sunset Beach in Los Angeles in my pre-cancer days:

In contrast, here’s me in June 2014, lying in bed, which is basically how I spent most of my life from December 2013 through early 2017.

Here’s me with the strange sponge-bob-square-pants body (fat stomach, skinny stick legs and arms) I developed from the combination of chemo and steroids… a far cry from the athlete I used to be:

(The stuffed dog is a story for another time).

By early 2017 I was in the same place that many cancer survivors have probably found themselves in. I had finished treatment about six months earlier and felt I didn’t have an “excuse” to feel so terrible anymore. I had a lot of chronic pain.

My disability payments were ending because I was no longer on treatment (which I understand). My savings were dwindling and I could not see any discernible path to get better and go back to a normal life of working and supporting myself (let alone simple things like cooking for myself and running my own errands). I seriously wondered if I was just “lazy” now and had to accept this was how the rest of my life would be.

Now, I found this very depressing, but I also believed that there had to be a way out, and so I tackled it the way I had become accustomed to tackling problems in my life—through obsessive research and planning.

Just so you understand a little how my brain works, for context:

When I was 10 years old and wanted a dog, I didn’t just go ask my parents for a dog, I created a filofax with different dog breeds and carefully tabulated FAQ’s to counter the objections I was sure would be raised.

(I didn’t get the dog… my parents tricked me and said I could get a cat now or wait two years and get a dog when I was twelve… what 10-year-old knows how to wait for two years for something??)

Then, when I was 16 and got my driver’s license, I wanted a Karmann Ghia. I saved up two thousand dollars in a piggy bank from working at Macy’s, and by now had discovered color-coded binder tabs and Powerpoint—my organizational presentation skills could have sold ice to an Eskimo.

(I didn’t get the Karmann Ghia though because my parents said it was too dangerous… goddamn it mom and dad why are you so immune to my powers??)

Anyway.

So when I was struggling to figure out my post-cancer energy problem—and I realized most information available online was nonspecific and pointless (“Make sure to exercise,” “Get rest,” “Talk to your doctor”)—I broke out my Moleskin and multicolored pens and started to think about the problem very methodically.

I read about a dozen books and a hundred articles and created a little program for myself. After about three months, I felt good enough to start working part time. This is how I did it…

How I did it: The Energy Points System

When you have post cancer fatigue, it can feel hopeless—but I am telling you, it is not. But to get better requires a mindset shift. There is no silver bullet and it will require hard work on your part. It also requires a lot of patience and time. If you follow the steps I am laying out for you, you won’t feel better in a week, but you will probably feel a little better in a month, a lot better in three months, and perhaps completely better in a year.

I know a year feels like a long time… but it is shorter than never. You’ve already gotten through worse. Start taking steps to feeling better now, and over time those small, incremental improvements add up.

Step I: Get Your Basics Set Up

I learned a lot about fatigue after cancer treatment from reading about what I consider to be an extremely similar syndrome pattern—Chronic Fatigue Syndrome and Fibromyalgia. I read a bunch of books on the subject, and the one I referenced in my last post “A New Beginning” that helped me a lot was:

From Fatigued to Fantastic by Jacob Teitelbaum

Jacob Teitelbaum’s book explains the biology of Chronic Fatigue and Fibromyalgia really well. Essentially, both of these syndromes are not diseases in themselves but are final common endpoints to a number of problems—for example, certain viral infections, a physical trauma or accident, or an illness.

When your body is overcome with a problem it cannot handle it shuts down as a protective mechanism, the same way as when you turn on every light in your house and the hair dryer and the vacuum cleaner the fuse will blow. You have not actually damaged the electrical system in your house, but the fuse has shut off in order to protect itself.

The same happens with your body. Your body is not actually broken or damaged, but your fuse has blown and your body has shut down to try to protect itself. The problem is that long after the physical insult has resolved (in this case chemotherapy, radiation, or other cancer treatment), your fuse is still blown. Healing is the process of turning your fuse back on.

I put myself on the following supplements as recommended in Dr. Teitelbaum’s book:

Ribose: 5 grams three times a day — Ribose is a sugar that is the backbone to ATP, the energy molecule of our bodies. I use the Nutricost brand, but you can also consider the Bulk Supplements brand, which is a little cheaper and also worked fine for me
Multivitamin powder — I used the From Fatigued to Fantastic branded product, which worked for me, although any high quality multivitamin powder is probably good): 1 scoop/day

A Quick Note About Prescription Medications For Fatigue

Prescription medications—in particular stimulants such as Modafinil, Adderall, and Ritalin—can absolutely be helpful for fatigue. I have used them and I would use them again if I needed to. I took and passed my psychiatry board exam last year (with flying colors, might I add) while using a prescription stimulant. There is no way I would have been able to get through an 8-hour test and an hour drive there and back at that point without a little assistance.

However, stimulants give you borrowed energy that you will have to pay back, in the same way coffee gives you borrowed energy (and may perk you up at the time, but then you need more and more to have the same effect). You should also count over-the-counter stimulants and supplements such as tyrosine in this category. Stimulants do not change the underlying problem.

Therefore I recommend using stimulants for fatigue on an “as needed” basis (for example, you have a doctor’s appointment you really need to make, or you have to get through your work day, or you have a social event you just can’t skip) rather than relying on them in lieu of the strategies I am describing. In general, if you feel that tired, it probably means you need to rest.

Step II: Get Your Sleep In Order

You have to sleep, and probably a lot more than a typical person. I am nearly two years out from treatment and I still sleep an inordinate amount of time. If I’m in a social situation that requires me being out of the house past 9pm I start to get a little panicked. When I tell people how early I go to bed, they’ll sometimes say, “Wow, you must get up really early!”

Nope. I don’t.

So, just suck it up and accept you will need a ton of sleep. When I was in treatment I was generally only awake 8 hours a day. Yes, I mean that I slept 16 hours a day, usually crawling my way out of bed around noon and then counting down the hours until I “got” to go to sleep again around 8pm and put myself out of my misery.

I probably sleep 8-9 hours/night now, but go to bed an hour or two before that so I can rest and read in bed. Anything less than that will catch up with me and I’ll start to feel sick.

So, you need to sleep, and you probably need to sleep more hours than the average person. So you absolutely need to protect your sleep time and follow good sleep hygiene habits, which include:

Follow a regular sleep routine: go to bed around the same time and wake up around the same time every day.
No screens (TV, phone, iPad, etc) for an hour before bed—this is because screen emit a type of blue light that tricks your body into thinking its daytime and suppresses your brain’s normal melatonin release.
Keep your bedroom cool and dark—use blackout shades if necessary, because any ambient light can interfere with good sleep.
Use the bed for sleep only and not things like watching TV or work-related tasks. At most, you can read a relaxing novel before bed, but nothing stressful or stimulating.
If you can’t fall asleep in a reasonable amount of time (~30 minutes), get out of bed and wait to get until you are tired to get back into bed (remember, you want to associate your bed with relaxation and sleep, rather than feeling stressed about not being able to sleep).

Now, the above sleep hygiene measures are the cost of admission, but are often not enough. For some reason cancer fatigue is also associated with the frustrating inability to get restful sleep at night.

If you’ve been in this situation, you know what I mean—that there’s a difference between being “fatigued” and “sleepy.” You are always fatigued, but never sleepy… each monotonous, exhausted day blending into a monotonous, wired night.

If that’s the case, consider talking to your oncologist or primary care doctor about getting a sleep medication. Medication can be helpful to make sure you get adequate sleep so your body has a chance to recover overnight, because bad sleep will just exacerbate the pain and fatigue.

Okay, so now you have the basics in order. You are:

Taking ribose 5 grams 3x/day
Taking a daily high quality multivitamin powder
Getting adequate (probably 9-10+ hours) of sleep a night, with the help of prescription or over the counter medication if needed

Now, we’re on to my favorite part…

Step III: The Energy Point System

I got a lot of questions in response to my last post about the energy points reference I used for myself—let’s call it the Elana Miller Energy Points System. It’s based on a concept I learned about through my research called “pacing.”

The concept is this: When you have cancer-related fatigue, many people will (unhelpfully) suggest that you just need to get out of bed and “do more”… but the problem is the opposite. The problem is that you’re doing too much.

People with cancer-related fatigue, especially high achievers, get trapped in a predictable pattern. You hold yourself to the same standard you had before you had cancer. You overdo it for a day or two, then get exhausted and sick, and then spent a week in bed to recover, and then overdo it again, get sick, another week and bed…etc. The cycle continues and your energy levels become completely unpredictable, making it impossible to plan for the future.

Will you be able to go to your friend’s birthday party next weekend? Or go to work tomorrow? Or go on that vacation you have planned in a month? You have no idea, which is frustrating and debilitating.

On top of this, people who have no idea what they’re talking about will unhelpfully suggest “Maybe you just need to get more exercise.”

Oh really?? Thank you for that very obvious suggestion that never occurred to me, because it’s not like I don’t think about this literally every waking second of my day.

Yes, you know you are supposed to “get exercise,” but how are you supposed to do that when just the act of making breakfast is so exhausting you need to take a nap afterward?

The answer is this: The key to getting out of this cycle is to do LESS, but to do it EVERY DAY.

It’s so important it bears repeating: You do LESS but you do it EVERY DAY.

Then, you save a little bit of energy each day for exercise (just a few minutes at first), and you gradually increase the amount of exercise you can do over weeks and months. And you don’t do this process by guessing—you do it by fastidious planning. Hence the Elana Miller Energy Points System.

How the Energy Points System Works

The premise is this: Every waking hour of every day is assigned a point level based on how much energy is expended during that hour. There are only four point levels. They are:

0 points: Sleeping or lying in bed with your eyes closed

1 point: Reading or watching TV, or some similar mindless activity, while lying down

2 points: Sitting up or standing doing a more engaging activity, such as sending emails, cooking, cleaning, showering, eating, etc.

3 points: Anything out of the house (literally anything — working, running errands, exercise, driving, sitting in the passenger seat while someone else is driving), and anything involving interacting with a person (talking on the phone, or someone visiting you at home, unless you are extremely comfortable with that person, such as a spouse)

There are two really important things about this system that will probably require a mindset shift for you:

If your eyes are open, YOU ARE USING UP ENERGY POINTS. Watching TV, scrolling through your phone, and reading all use up energy points. THE ONLY THINGS THAT DO NOT USE UP ENERGY POINTS ARE RESTING WITH YOUR EYES CLOSED AND SLEEPING.
Interacting with people, including talking on the phone, and ANYTHING outside of the house, including the most mundane activities like sitting in the passenger seat of a car—let alone things like working or exercising—use up THE MAXIMUM LEVEL of energy points. For a healthy person there is a difference between standing versus running or between presenting at a work meeting versus zoning out at your desk. But, for you, anything outside of your comfort zone is using up a huge amount of energy. Even looking at bright lights uses up energy!

So starting today, for the next two weeks your job is to record what activity you are doing for every hour of the day, and how many energy points it is using. If you spent half of the hour doing one level of activity, and half doing another level, round up.

A weekday may look something like this, if you are working:

6:00am – sleeping – 0 points
7:00am – wake up, brush teeth/shower, make/eat breakfast – 2 points
8:00am – read news online – 1 point
9:00am – drive to work – 3 points
10:00am – work – 3 points
11:00am – work – 3 points
12:00pm – work – 3 points
1:00pm – work – 3 points
2:00pm – exhausted so you leave work early and drive home – 3 points
3:oopm – in bed watching TV – 1 point
4:00pm – in bed watching TV – 1 point
5:oopm -in bed watching TV – 1 point
6:00pm – make/eat dinner – 2 points
7:00pm – watch TV – 1 point
8:00pm – watch TV – 1 point
9:00pm – sleeping – 0 points

Total points: 28

A weekend may look like this:

6:00am – sleeping – 0 points
7:00am – sleeping – 0 points
8:00am – sleeping – 0 points
9:00am – sleeping – 0 points
10:00am – wake up, eat bowl of cereal while half asleep – 2 points
11:00am – in bed watching TV – 1 point
12:00pm -in bed watching TV – 1 point
1:00pm -in bed watching TV – 1 point
2:00pm -in bed watching TV – 1 point
3:oopm – phone call with friend – 3 points
4:00pm – in bed watching TV – 1 point
5:oopm -in bed watching TV – 1 point
6:00pm – make/eat dinner – 2 points
7:00pm – watch TV – 1 point
8:00pm – watch TV – 1 point
9:00pm – sleeping – 0 points

Total points: 15

See what I mean about the pattern? You work too hard one day, then spend the next day in bed to recover, etc…

Once you have collected a few weeks of data your next task is to review everything and figure out your daily average—the maximum number of energy points you can expend on a daily basis without having an energy crash. This might require some experimentation. You daily maximum is whatever you can expend without feeling worse the next day.

So now you have your number; for the sake of the example let’s say it’s 20. Now at the beginning of the week (I did this on Sundays) you pencil in a schedule for every every waking hour of the day using up all of these points, and no more.

(Did I mention I’m obsessive?)

I can’t stress this enough — you can never use more than your allotted energy points! It’s like money—you can’t spend what’s not in your bank account (credit cards aside). Imagine at the beginning of the day you are given $20 and you get to choose how you spend it, and once you’ve spent it you’re out of luck.

So if you know you need to buy gas in the afternoon, you better not spend your money on on $18 avocado toast in the morning. The same goes with your energy points—if you have something you NEED to do you need to save your energy points for that and not spend them in advance.

When you are penciling in your schedule for the week, you first fill in all the things you NEED to do—things like eating, showering, errands, your job, taking care of your kids, if applicable.

But, you may ask, what if I have so many things I need to do it exceeds my allotted energy points?

The answer is: If you don’t have the points, you can’t spend them!

What if you’ve worked a long day and then you come home and your kids need to eat dinner? I DON’T CARE, LET THEM STARVE… YOU DON’T HAVE THE POINTS! (I jest, but in all seriousness can’t your spouse or friend or parents take care of the kids this one time?)

The point is you may have to sacrifice things that seem important, if not necessary, to you in the short term in order to get where you want to be in the long term.

This may mean getting on partial/full disability for your job, or getting financial help from others so you can reduce your hours, or cutting expenses and moving in with your parents, or depending on your spouse to do most of the work at home, or skipping out on social events. It’s not easy, but it’s important if you want to be in a better place in three to six months than you are now.

Step IV: Integrate Exercise

So you’ve pencilled in the necessary things that you absolutely can’t get out of, and your next step is to pencil in exercise.

Exercise is ultimately the key to this entire system working.

Unlike what you’ve tried to do in the past, though, that hasn’t worked, this time you will start extremely small. Remember our refrain?

You do LESS, but you do it EVERY DAY.

Every day means at least 5 days a week. You start extremely small—whatever you are able to do without feeling worse the next day.

In my case I started doing light weight lifting with the help of a personal trainer, which I liked because I felt it helped build my endurance and fight all the muscle atrophy I had experienced over the past few years. As I got in better shape I added in walking on a treadmill and going up and down stairs.

Basically, you want to do as much exercise as you can without going over your energy points, and increase that amount steadily week over week, about 10% at at time. So if you are starting with 10 minutes a day of exercise, the next week you do 11 minutes. Yes, I’m serious! Then 12 minutes, then 13, then 14, and then when you get to 20 you go up to 22, then 24 minutes, etc.

You will probably need some sort of exercise tracker or heart monitor to do this accurately. I used a heart rate monitor called MyZone, but if you have a Fitbit or Apple Watch or some equivalent that’s great too.

I liked the MyZone because it gave me a number of points to easily measure the energy I exerted (not the same as my point system, but it allowed me to get a quick objective measure of how much effort I was expending). It made it easy for me to stay within my limits, and also to decide how much to increase my activity for the following week. If you’re walking you can use an iPhone or Fitbit to see how many steps you’re doing, and then increase this by 10% a week.

This process can be emotionally painful for a former high achiever or athlete to stomach, since you are probably used to doing quite a bit more than 10 minutes of exercise. But trust me, it is much better to incrementally work your way up than to get stuck in a cycle of overdoing it and crashing.

So at this point, you have filled out your schedule with the absolutely necessary things you need to do, and you’ve added in your daily exercise. Now, as you go through the rest of your schedule, fill in whatever else you want to do with the remaining points you have left (fun stuff, socializing, watching TV). Eliminate activities that aren’t essential if you don’t have the points left for them. A lot of activities will probably need to be eliminated.

You also need to strategically fill your day with periods of rest. If you know you will have a busy day, schedule blocks for time (at least 20 minutes, and up to an hour) when you are resting lying down with your eyes closed (remember, this is the only activity that doesn’t use energy points). Short rests like this serve to strategically recharge your battery.

Here’s what your planned schedule might look like:

6:00am – sleeping – 0 points
7:00am – sleeping – 0 points
8:00am – wake up, brush teeth, make/eat breakfast – 2 points
9:00am – exercise – 3 points **even if you’re only exercising a few minutes count the entire hour as exercise
10:00am – shower, get dressed – 2 points
11:00am – rest, eyes closed – 0 points
12:00pm – make and eat lunch – 2 points
1:00pm – relax, scroll through social media – 1 point
2:00pm – send emails, apply to jobs – 2 points
3:oopm – send emails, apply to jobs – 2 points
4:00pm – rest, eyes closed – 0 points
5:oopm – household chores – 2 points
6:00pm – make/eat dinner – 2 points
7:00pm – watch TV – 1 point
8:00pm – watch TV – 1 point
9:00pm – sleeping – 0 points

Total points: 20

Another key part of this program: You don’t go over your energy point allotment, but you also don’t go over it.

You have to use all your energy points—if you don’t use them, you lose them. If you’ve had a lazy day and have some extra points, get up and do some exercise. You have to get out of the cycle of overdoing it, crashing, and then spending days in bed to recover.

Step V: Gradually Increase Your Energy Points

Now on to what is ultimately your goal: to expand the number of available energy points to a level where you can function and do all the things you want to do. Imagine a world where you can work a part-time or full-time job, go out with friends, enjoy time with your family, and deal with everyday inconveniences without it feeling emotionally and physically crippling. This is all possible.

You achieve this by:

Increasing the amount of exercise you do by 10% every 1-2 weeks.
Keeping yourself within your energy points, but increasing your total available number of energy points by 10% every 1-2 weeks.

If one week I was at 20 energy points, the next week I would aim for 22, then 24 the next. Once I realized this was achievable for me, the ability to plan felt really freeing.

If there was an event I wanted to go to, all I had to do was pencil out my schedule and make sure I budgeted points for it. Or if I was scheduling patients, I knew exactly how many patients I could see while reserving enough points to do my commute back home. I knew exactly when I was ready to start working part-time, and then full-time.

For me, between the supplements, good sleep, energy points system and incremental exercise, I was able to be able to go back to work part time after about three months and work full time after about six months. I’m not in perfect shape now but I’m able to work nearly full time, and I ride my bike to work (10 miles a day round trip). I may go to bed at 9pm, but I live a basically happy and functional life.

In case you’re curious, here’s a photo of me now, at my wedding this past May (I got married). And yes, I saved up points so I got to stay up past 9pm:

Readers: Is fatigue after cancer treatment an issue for you? I’d love to hear about your experience in the comments.

A New Beginning

November 13, 2017 By Elana 130 Comments

Maybe this is a story
Maybe this is a poem
It starts where the last one ended—a new beginning
It continues, unafraid, without knowing

It’s been one year, one month, and eight days since I last published a post.

How to even start with what has happened in the meantime? As I sit down to write I feel compelled to offer an explanation for why this update has taken so long. After such a prolonged delay without word from me—a delay that, I know, left some people wondering, if not a little worried—I feel I should give a better answer than “a lot has happened.”

There are a few reasons for my absence, and I suppose the most obvious is that I’ve been busy. However, busyness is not the complete picture. It would be more accurate to say the greatest reason for my absence is that I’ve been focused. And perhaps the word “focus” is an understatement. It would be most accurate to say the greatest reason for my absence has been obsession—a soul-consuming obsession, a ravenous fire in the pit of my stomach, a blinding preoccupation with one thing, and one thing only—to recover.

I had beaten cancer, but I was a long way away from getting back the life I had before. My body was crippled with pain and fatigue; I had no job and no ability to earn money (a generous disability policy had supported me thus far, the payments for which would soon end since I was no longer on chemotherapy). I barely remembered anything I had learned during my seven and a half years of medical school and psychiatry residency—years spent studying my passion and vocation, years that were so inconveniently interrupted when I was diagnosed. I had survived, but felt light years away from putting the pieces of my life back together.

Are you surprised? Tales are written of great men who go out and fight battles and win wars and slay monsters, but what happens after? Men who slay monsters will tell you that slaying monsters is the hard part, but it’s not. The hard part is finding your way back home.

For three months I waited and planned. I went to Hawaii for my brother’s wedding, then Mexico for a college friend’s wedding. I loved these trips, but you must understand that simple things like walking through an airport and sitting up on a plane—what most people would consider the gentle lead up to a relaxing vacation—took up, for me, an inordinate amount of energy.

When I got back from Mexico I decided the first step would be to taper off pain medications, which I had been taking daily for the previous three years. I still had pain (a chronic effect of the chemotherapy), but I didn’t want to take pain pills forever, and as hard as it would be to stop now it would be harder to wait until later when I would hopefully have a job.

I took all of my bottles and counted up my remaining pills and wrote out an elaborate taper schedule. First one pill three times a day, then three quarters three times a day, then half four times a day, then half three times a day, then one quarter four times a day, then one quarter three times a day, then one quarter two times a day, then one quarter once a day. It took about two months.

For most of these two months I cocooned myself under the covers of my bed, imagining ways I could kill myself to end the torture. To distract myself I copied and then recopied my taper schedule in my daily planner (a planner that was largely empty except for the reminders to “take pill”). I soaked in epsom salt baths, I took vitamins, I popped a hundred other pills that were not opioids. On more than one occasion, I shit my pants. About two weeks after my last dose I no longer fantasized about committing suicide. As I started feeling better, that burning pit of desire rekindled in my belly, and as it grew I once again narrowed my focus onto the one and only goal that mattered.

At this point my primary problem was energy—not the average person’s perception of low energy like, “I’m kind of tired” or “I need a nap,” but the kind of crippling fatigue that resulted in days without showering and skipped meals because it took too much energy to walk to the fridge. At best, I could do one thing a day, such as running an errand or going to a doctor’s appointment. If I wanted to reach full recovery, this simply would not do.

So first I sought out information. I established that my symptoms were characteristic of the chronic pain syndrome known as Fibromyalgia, and so I read everything I could about Fibromyalgia. Fibromyalgia, I learned, is not so much a diagnosis in and of itself, but is more a final common endpoint to many potential insults (in my case, years of chemotherapy). The first four or five books I read on the subject weren’t any good, but then I found one that clicked, and so over the next week I read it once, then twice, then three times, then four, and then I read it however many times one needs to read something in order to be able to recite it by memory.

Now informed, I put myself on a fanatical regimen of supplements and vitamins, and armed with knowledge of a concept of energy conservation called “pacing” I created an elaborate point system to categorize how much of my limited energy each activity I did used up. Showering: 2 points. Eating: 1 point. Cleaning up after eating: 2 points. Talking: 3 points. Driving: 3 points. Anything outside the house: 3 points per hour.

I calculated I could expend no more than 20 points each day without becoming sick, so I fastidiously scheduled every hour of every day in my planner (finally, I had more things to fill in than “take pill”). I saved a few crucial points each day for weight lifting, and so week over week built my endurance to 22 points, then 24, then 26, then 28, then back down to 26 because I got greedy and tried to do too much, then back up to 28, then 30, then 32 points.

This took about three months.

After three months I could reliably engage in productive activity ten to fifteen hours a week. I know this doesn’t sound like much, but after years of doing not much more than lie in bed, I can tell you ten to fifteen hours a week is nothing to sneeze at. With ten to fifteen hours a week one may not be able to work full time, but one could, theoretically, finish the last few remaining requirements one had left in the final year of one’s psychiatry residency program and graduate. And yes, this is what I did. I finally graduated residency, and at the ceremony I got my diploma and it said UCLA Department of Psychiatry 2010-2017, and yes it took me seven years to finish a four-year residency program, but goddamnit I finished. I came, I saw, and I conquered.

So yes, I graduated, and yes, I was thrilled, but what was I going to do, sell my diploma for groceries? No, I needed money. And more than I needed money, I needed purpose. I needed a job. So I applied for part-time jobs, just ten to fifteen hours a week, because by this point I had enough energy points to work ten to fifteen hours a week AND shower and eat and talk every once in a while.

However, while applying for jobs, something magical happened. I met with a former attending of mine who is in private practice and I asked him for a letter of recommendation for a job and he said, Sure. And then he said, I’ll give you a letter of recommendation, but why don’t you come here instead? Why don’t you start a private practice and use my office (and you can pay me almost nothing for it) and I’ll send you patients (because I have a ton of connections and my practice is full)?

He said, You can do it part time, because when you work for yourself you’re in charge, and you can work when you want to work and rest when you need to rest and you can set it up however you goddamn want to and you’ll make a ton of goddamn money (he phrased it differently). And I said Yes, Yes, Yes, YES, YES.

So that’s how I got to where I am now. A few months ago I studied for and took my psychiatry board exam, and found I remembered much of what I feared I’d forgotten. A few weeks ago I turned 35—an age I wasn’t sure I’d ever reach. I have my own private practice, and I have a little office with a view of the ocean and I see patients and they tell me they suffer and I say, I know. I say, It will change, because I know it will. Time promises one thing—it moves forward. Somewhere along the way we will be changed, even if we don’t try.

You may wonder, Do I feel different now? Do I appreciate life more than I did before? Of course, the answer is Yes. How could I not be changed? How could I not appreciate what I have; how could I not be afraid of losing it again?

What amazes and thrills me, though, is that, sometimes, the answer is No. My life these days is so… ordinary. I go to work and see patients, I play tennis and ride my bike and balance my checkbook, I read books and write words and Google Game of Thrones fan theories. I plan my wedding for the Spring (I’m getting married). I get a cold and complain about it. Sometimes I feel tired and I forget why.

But how wonderful is it to be ordinary, to have the luxury of getting caught up in the petty concerns of everyday life like traffic and money and work? How wonderful is it to have a life so stable you are able to take it for granted? To be able to worry and hope and dream and plan for the future because you believe you will live to see it?

A few years ago I had a conversation with my oncologist, Dr. Eradat, when I was in the worst of my treatment and saw no end to it. I asked him if I would ever feel normal again. “Well,” he said. “It depends on what you mean by normal.”

(Not the most encouraging thing I’ve ever heard, but an honest answer).

So I clarified. “I mean, when will I not feel so… afraid?”

“Oh,” he said. “Afraid? That doesn’t go away. In twenty years you’ll have a cough and you’ll feel afraid. Your stomach will hurt and you’ll feel afraid. But you’ll need to live your life, anyway.”

There was a point when I had no fear left—when I had lost everything important to me and there was nothing left to lose. Now, I am afraid. I am afraid because I have a life I could not stand to lose; I have a life that, in all its imperfection, is worth the pain of living to keep.

All those years ago what I needed to know was not, Will I ever again be normal? It was, 1) Will I ever again be happy? and 2) If so, when? The answer was, 1) Yes, and 2) It won’t take as long as you think.

I struggled so much against this horrible thing that happened to me, trying to fight what simply had to be endured. In the end I did not need to do anything special to find my way home, because home is more than a place, it is a desire. It will consume you until you have no choice left but to find it; home will grab hold and pull you toward it with a force more powerful than gravity. I just had to be patient. I just had to wait.

I am here, and my feet are planted firmly on this earth. I am alive—I am so wildly alive. I feel each beat of my heart, I sense every sound, the melody of voices so distant you can barely hear them, the gentle hum of traffic outside my window. In the morning it smells of bitter coffee, in the evening of lavender soap. I see every brilliant ray of light, I feel the soft warmth on my skin. The sun glows down on me as if it comes from heaven.

Most of all, I am afraid. I feel that hiccup every time my heart skips a beat. The terror in my throat that chokes me. Every time I cough I feel it, every breath I take I feel it. But I will live my life, anyway.

***

Photo By Nigel Howe

Love… (A Reprise)

October 5, 2016 By Elana 60 Comments

“With wisdom let your mind full of love pervade one-quarter of the world, and so too the second, third and fourth quarter. Fill the whole wide world, above, below, around, pervade the world with love-filled thought, free from any ill will, love abounding, sublime, beyond measure.” –The Digha Nikaya, Buddhist scripture

“Of all of the fires, love is the only inexhaustible one.” –Pablo Nerudo, poet

Last month I took my final dose of chemotherapy in the grueling regimen for Acute Lymphoblastic Lymphoma I have been taking since December 2013. Days before a PET CT had confirmed there was no evidence of cancer in my body. And a few weeks later I stood in front of the ocean and took this photo.

I was in Hawaii for my brother’s wedding—a celebration I was thrilled to share with him, and a symbolic moment for me. It was the first vacation I had taken since becoming sick, the anticipation becoming a focal point over the last few months. I was going to finish chemo and make my flight to Hawaii as if my soul depended on it.

When all this started, almost three years ago, I wrote a post titled, Love Is… (Holy Shit, I Have Cancer). To my surprise it was widely shared on Facebook and the Huffington Post. I never set out to become a “cancer blogger,” and in fact had shied away from writing about such personal things in public forums, but suddenly there were people curious about me and invested in my story. I wanted to keep writing. But how to continue the narrative, as it was happening, with no idea how it would unfold?

And so I have thought about what I would say here—at the end—for so long, turning over words and lines in my head. How would I write a finale to this story? How could I sum everything up in a meaningful way, while not painting meaning onto an experience that, if I’m being honest, was lonely, chaotic, random, and neither romantic nor sentimental?

I do not believe everything happens for a reason (a platitude, in my opinion, too easily offered to those struck inexplicably and unfairly by life’s cruelties)—but I believe we can find meaning in the things that happen. In the middle of the nightmare I clutched desperately onto one hope; the hope that at the end there would be some goodness that made the whole mess worthwhile—a light only this path could have carried me to.

When I was first diagnosed I had been in a long-term (nearly five year) relationship, which unraveled shortly after. And although I was confident it was the right decision, and more preoccupied with the immediate concern of surviving, the anguish sunk my heart into my chest as if the space around it had been eroding for years. The loneliness grew into a consuming void.

About a year later, I saw a psychic. I was tormented by the idea I would be infertile from the chemotherapy, and so I asked her if I would have any children. She said yes—one boy and one girl. I asked her about the man I would marry. What would he look like? What would he be like? How would I know it was him?

She told me he would not be older than me like I had imagined, but would be my age or younger. She told me he would be strong and smart and sensitive and kind, but so unassuming I could overlook him. She told me to pay attention carefully.

Since then I have turned these thoughts over and over again in my mind, each turn further refining the image of this man from a shadow into a clear vision. So when we met earlier this year, it did not feel like the first time we had crossed paths. It was as if I recognized him—as if we already knew each other. He was the one I had seen in my dreams.

I had been dating for six or so months prior, with variable success. On those early dates I would hold back until halfway through, when I would anxiously and apologetically reveal I was a cancer survivor. “I’m still on chemo, but don’t worry, I’m in remission and everything is fine,” I would say, dismissively.

I was truly surprised no one seemed to care or hold it against me. The reactions ranged from, “Oh, interesting” to “Oh, do you mind if I ask how it happened?” to “Oh, my cat had leukemia so I know what that’s like” (really).

I became more confident revealing my story, and soon decided to state it overtly in my dating profile: “I’m a cancer survivor, with the renewed appreciation for life and awesome short hair to prove it.” Some men even contacted me explicitly because of my short hair, and when I joked it had grown out a bit since I had taken my photos, they would say, not kidding as much as you’d think, “Well, that’s what scissors are for.”

But still, while a potential date might appreciate my super stylish short hair, I assumed when he got to know me the jig would be up. I would subtly dissuade any man from getting close to me; if describing my cancer-related physical and emotional instability was not sufficient to send him on his way, I would emphasize other red flags. “I have a lot of baggage” I’d say. “I’m pretty sure you don’t want to date me.” I felt sure no one could really love me after everything I had been through. And if he did, it would be despite my history, and certainly not in any way because of it.

When I met this man, though, I felt understood in a way I didn’t know was possible. On our first date we sat across each other over nachos, and he asked me, eager and curious, about the experience—not so much the specifics of what had happened, but what it had meant to me.

(He later admitted that after that first evening he went home and told his brother, “Yeah, she’s super smart and beautiful, but even more I really like that she had cancer.” He said he admired how I seemed wise from the experience and talked about it thoughtfully. He said, “I don’t know how to explain it… but the cancer thing is really fucking sexy.”)

On our second date we sat next to each other over drinks. Midway through the evening, he paused. “Do you know what I really like about you?” he said. I thought he might mention one of the superficial qualities others sometimes compliment me on, but that I don’t value too much in myself. But instead he pointed out something most people rarely notice, and fewer have admired me for. He said, “I really dig that you’re an introvert.”

On our third date we lay on the grass at Will Rogers State Park, looking up at the sky. It started as a midday picnic but ended late into the night. We ate Tender Greens and drank wine and played guitar. And as we became closer, I shared with him the rest of me—all of the pain, all of the ugly parts—but it did not dissuade him. It made him love me even more.

After not much longer we were sitting on the couch and he looked me in the eyes. “I am going to marry you,” he said. It was more statement than question. He said, “I know what I know.” It was the first breath of air as I lifted myself to the surface of the ocean. It was the light only this path could have carried me to.

—

Someone recently asked me if, in retrospect, there is something I would have told myself at the beginning to help me get through it. I shook my head; there was no possible way I could have understood how bad things were going to get—nor should I have had to.

I would have said, though, do not try to hedge against the suffering because there is no point—this will be a horror that can not be fought, and must simply be endured—although enduring it will not be simple, nor static. I would have said the pain will make you utterly unrecognizable to yourself, and it will be so terrifying, and so beyond anything you have ever experienced, that it will astound you it can be survived. But it can be survived, and you will survive it.

Most importantly, I would have given myself the reassurance others desperately wanted to give me, and I desperately wanted to give myself, but that none of us knew was true until now. I would have said, It will end. I would have said, You will live, and the happiest moments in your life will be not before cancer, but after.

So, now, what could I tell you about love?

I would say love is my past, and it is my story, and my story can not be taken from me. I would say I hope love is my future, although no future is guaranteed.

And I would say love is my present, and while the present is brief, it is what holds my heart up the strongest. Love is here, right now.

And I was put here for love, and I survived this for love, and I will live this day fully, for love.

Elana Miller aka E. Diddy Presents The Cancer Rap

June 27, 2016 By Elana 39 Comments

I got cancer and all I have to show for it is this stupid rap.

…Just kidding.

But seriously. I did it… I wrote a rap about cancer. I think when you’re able to reflect back on a difficult experience and and turn it into something as ridiculous and hilarious as this rap is it means you’re headed in the right direction 🙂. I’m not totally out of the tunnel yet, but I’m close.

Shout out to all of my cancer friends out there reading this and to all the people I love who’ve been there for me. If you know someone who’d enjoy this, please share (I have no problem making a fool of myself if it’ll make another person laugh).

Also, feel free to call me E. Diddy from here on out.

(If you’re reading this in your email click here to see the video on my blog and here to see the YouTube link)