A few days ago, I spent 24 hours in the ER due to a medication overdose. It was a combination of feeling extremely impulsive and moderately suicidal that led me to swallow the medication. Extreme impulsivity often goes hand-in-hand with Borderline Personality Disorder, and I know it very well.
I quickly regretted it but also didn’t know what else I could have done in my emotional state that would have been better. This is a scary thought because when I am calm and feeling well I can see a great many options that would have been better, but in that moment I felt blinded to anything else but the pills as a solution.
For those who have no idea what this kind of impulse feels like, I present an examination of an impulse. This is a description of what went through my head and the choices I made that led to the behaviour. Keep in mind this occurred after a few weeks of stressors and triggers building, reduced coping skills and growing severity of impulsive acts.
Sometimes I do have these impulses and I very successfully cope with them. Myself, my wife, and my therapist were all actively working to reduce the vulnerability and intensity and very aware of the growing concern, but it just was moving faster than we were. We had identified many possible impulsive acts, but it had not occurred (at least not strongly) to them or me that overdosing on my medication was one of them. I just didn’t think things were that severe yet.
I was alone at the time and it all took about five minutes. This may be painful to read if you know me well, but I am still sharing it in the hopes that you may grow in your understanding of what I and many others experience.
If you would rather not read the following because of a potential trigger for yourself, please consider skipping it. Here is a picture of my adorable cats, Gus and Elliot, so you can take a moment to choose if you should walk away (please do if you think you should!!!).
“I need some water,” I think as I open the cupboard. I was not even thinking of overdosing at this point but I knew I was very stressed and impulsive and moderately suicidal. Moments ago I called Kathryn to tell her this and she is now on her way home. I have told her and myself that I can promise to be safe for twenty minutes until she arrives and I believe that I can be. Water at this point will very much help.
I notice the pills in the cupboard where the water glasses are, and the quietest voice in my mind thinks, “I could take them all.” Instantly I react with an internal firm “No.” I close the cupboard but I do not let go of the knob. I think I should call Kathryn. I don’t pick up my phone which is directly beside me on the counter. Sometimes I think I ignore these warnings because this feeling of being on the edge of impulsiveness can be kind of addictive, like an adrenaline rush, and this thought briefly occurs to me but I quickly ignore it because I don’t want to give up the feeling of adrenaline or the possibility of a solution to the stress I feel, even if I rationally know this version of a solution is extremely flawed.
I re-open the cupboard. I am still telling myself “No, walk away now.” I pick up the bottle, just to see how many are in it – which again I recognize as a signal to walk away and immediately call for help but again, I ignore it. Next thing I know the pills are dumped out on the counter so I can count them. This is almost like a ritualized behaviour that I have done before when I’ve felt impulsive about overdosing – I have still walked away at this point in the past, but it’s getting exponentially more difficult as the impulse and adrenaline build. It is a slow and methodical count, not a frenzied rush. I want to be accurate so I even count again. 76. I know if I do take them, the hospital will ask how many and I want to be sure they know I am not exaggerating. I am clearly aware of the consequences of this action but I still am not walking away.
I don’t know if I really want to be dead, but I think I do. I know I’ve felt this way before and it has gone away, I also know I’ve been very ambivalent about wanting and not wanting to die at the very same moment. I don’t know if this is more about impulse and self-punishment, and maybe alerting others to the danger I am in through a very risky action, or if it is actually about the chance that this could kill me. I think it likely won’t because I’ve done it before and I know a lot about the risks associated with my medication in overdose, but I realize I am playing with fire. These thoughts are not so much conscious words in my head, but I am very aware that this is now a very serious situation.
“I could pick up a few,” I think. I feel the weight of five in my hand, then add five more, and two more and a few more after that until I have 25. I shift them around a bit, consider the size of the handful and wonder if I could swallow them. I am hoping my phone will ring or Kathryn will walk through the door but I still don’t make a move towards walking away or calling for help. With my other hand I pick up a glass and get some water. As I do my hand with the pills moves slowly toward my mouth. The pills are in my mouth and I think, “I could still spit them out. Do I really want to do this?” I avoid imagining what will happen next and I swallow them with water. I feel a decent amount of regret instantly but also some pleasure that comes from the adrenaline of taking a very big risk. I begin slowly counting out 25 more, even though I am incredibly aware that it would be better to stop now. The same thing happens with these 25 and I only now start to grow scared that Kathryn will “catch” me. I quickly pick up the rest with next to no regret or concern for the consequences, shove them in my mouth and swallow.
Panic sets in but I force it away and start thinking about how I will cover up what I did or if I should be honest immediately with Kathryn. I want time to decide, so I put the bottle back, behind her medication so that she is unlikely to notice that it is empty if she happens to open the cupboard, and I go into the bathroom to stare at myself in the mirror.
The look is a mixture of terror, shame, hatred and yes – even pride. I feel courageous at the very same moment I feel overwhelmingly stupid, ashamed, regretful and worried. I consider trying to throw up but that has never gone well for me in the past. I start to run a bath so I can “relax” and appear normal, and have some private space when Kathryn gets home, so I can decide what to do. Having a bath will appear to her like a very skillful thing to be doing so she will be less suspicious of whether I was impulsive. She arrives home within 5-10 minutes and we talk briefly. I know I sound depressed and suicidal, I know she can tell in my voice and demeanour that everything is not okay, but I hope she just thinks it is because I feel like crap and not because I did something.
About ten minutes later I look at her with an honest and scared expression and I can see that she instantly knows I did something bad – we’ve been through this before. I quietly say, “I took all of my pills.” I see the split second moment when she wonders if she heard me correctly and then the fear, panic and even a bit of anger. At first she asks if I am lying, but very quickly she can tell by my behaviour and expression that we are about to be on our way to the hospital…
Obviously this is riddled with examples of distorted thinking and opportunities to intervene. One thing I’ve learned from writing this examination is that I should very strongly consider saying “No, walk away now” out loud, very firmly, even if I am alone. If it feels too hard to give up the plan altogether, delay as much as possible to give more opportunity to call for help or take very small steps away from the plan in the hopes that it will get easier to move away further.
Delaying for me would look like listing all the states I can think of, naming every city I have ever been to, recapping the plot of a funny episode I’ve seen recently out loud to myself. Any emotional delaying (crying or really imagining the consequences or even noisy but kind of anxious yelling) could make things worse, so it has to be calm, based on memory, and something that can involve a lot of unemotional detail (i.e. cognitive distraction). I may not move away from the pills or put them down doing these things, but it’s more likely Kathryn would have arrived or I would have slowly reached for my phone.
For the next several months and maybe ongoing for as long as I’m on medication, I will be given a very small supply of my medication by the pharmacy, as my doctor is very aware of the risks and is incredibly supportive without being punitive. And Kathryn and I have agreed that at least for the next few weeks, maybe longer, the pills will stay in her purse. If she isn’t home, they aren’t home. I only need them at bedtime and it would be extremely rare that she is not home then, and she could always leave one or two if necessary.
The reality is that I will never be able to eliminate all potential triggers and risks for impulsive acts – but absolutely the more safety measures we can put in place, the more we recognize a growing impulsivity, and the quicker I choose to help myself or ask for help, the less likely it will be that I make a decision I will deeply regret. And I absolutely, deeply regret what unfolded on that day.