Reading for one of my trauma classes. I’m not summarizing the whole thing, just bits I found especially interesting.

Chapter One: Clinical Features of PTSD. Nothing new here.

Chapter Two: Cognitive and Behavioral Features of PTSD.

Amnesia. People rarely have global amnesia for traumatic events (not even knowing it happened or having no memories of any of it), unless they also had a head injury or other physical damage (ETA: or are children, or there were a whole series of similar events, of which only some are remembered. What doesn't happen often: a sober adult has something horrible happen to them, and later does not even recall that it ever happened.) But partial amnesia is extremely common. A typical example is “weapon focus,” in which a person might recall every detail of the gun but nothing about the attacker’s face.

Taylor suggests that this is caused by “attentional narrowing,” which is a common result of extreme arousal. The apparent amnesia is caused by hyperfocus on certain details and total ignoring of others, so the ignored details were never encoded into memory at all. (As opposed to being forgotten or being present but inaccessible.)

My note: be upfront with people about this – they may never be able to recall everything, and that’s okay. Total recall is not necessary to healing.

Guilt. Trauma survivors tend to have a number of incorrect beliefs about the trauma which cause them a lot of pain and suffering. Helping them identify and argue with these beliefs can be very helpful. Great breakdown of common false beliefs on p. 34-35. I’ll just list a few.

- Hindsight bias. “I should have (magically) known the drink was roofied.”

- Justification distortion. “What I did/did not do during the trauma was unjustified.”

- Responsibility distortion. “It was entirely my fault.”

- Wrongdoing distortion. “What I did during the trauma went against my morals and ethics.”

These come about for the following reasons (I only excerpt a few); unraveling them and making them explicit may be very helpful.

- Judging your actions not based on the reality of the situation, but against an ideal or fantasy that didn’t actually exist. “I should have disarmed and kicked the asses of the men who were holding me at gunpoint.”

- Blaming yourself for not acting on ideas you didn’t get until after the fact. “I should have memorized the license plate.”

- Overlooking actual benefits of actual actions. (ie, you got out alive, possibly because of what you actually did.)

- Focusing only on imaginary good outcomes of actions you didn’t take. “If I’d tried to disarm him, I definitely would have succeeded.”

- Not taking into account that when all options are bad, selecting the least bad is a highly moral choice.

- Not taking time and emotional factors into consideration – what you’d do if you had an hour to contemplate it in the peace of your own living room is different from what you do when you have seconds and a gun to your head.

Beliefs about Symptoms

- People with PTSD often think their symptoms mean they’re “going crazy.”

- They tend to interpret emotions or physiological responses as objective truth. “My heart is pounding and I’m frightened, therefore the situation is dangerous.”

- Physical/emotional arousal has become so entwined with negative feelings that they may avoid all arousal, including that caused by exercise or positive feelings. (Anxiety sensitivity.) Interoceptive exposure (inducing arousal in a safe, controlled manner) is good for this.

Clinician's Guide to PTSD: A Cognitive-Behavioral Approach
I am once again having a failure of imagination. Please pitch in by suggesting a trauma which would plausibly make a character willing to go on a suicide mission. For story purposes, I want this character to be motivated by externally-caused depression rather than solely by idealism.

1. No rape or child abuse. No "terminally ill" or "suicidal because biochemically depressed." I'd prefer to not do "My entire family/significant other/child was killed," but would consider it if the circumstances were interesting.

2. I'm not mentioning the exact setting to avoid giving you all preconceived notions, but it's steampunk in an area where access to steam tech varies widely. Tragedies that could only occur in very rural, pre-modern areas are fine. Tragedies that could only occur in a steampunk context, like tragic zeppelin accidents, are fine. Bullying via Facebook will not work.
My paper for one of my trauma classes is copied below, on the question of including CPTSD (complex PTSD) in the DSM-V . It's 4 pages long, and as per the assignment, summarizes the arguments in a set of papers I read, then describes my own proposal. Quote marks used here as LJ doesn't support block quotes. Also, apologies for the alphabet soup.

Read more... )
This is the third book in a loosely connected series. It doesn't have to be read in order, and requires no more background than what I'm about to tell you. In the first book, Graceling, some people have special abilities, called Graces, which may be magical or may be enhanced versions of real talents, such as acting or fighting. In Fire , set in a different part of the world, some people and animals, called monsters, are overwhelmingly, dangerously attractive and charismatic.

The link between the three, apart from the shared world, is a sadistic, psychopathic serial killer named Leck, Graced with mind control, who takes over a kingdom and rules it for 35 years in the manner you would expect, until he's defeated in Graceling. His ten-year-old daughter, Bitterblue, is installed as queen with a council of advisers to rule as regents until she's old enough to take over. In Bitterblue, she's about eighteen, and starts investigating what really happened to the kingdom during Leck's rule (unsurprisingly, no one wants to talk about it.) The book as a whole seems inspired by things like the Truth and Reconciliation Commission, post-revolution Romania, etc.

This is hugely and admirably ambitious. As an allegory of personal and political trauma and recovery, it's largely successful. As a fantasy, and especially as a fantasy set in the same world as the other two books, it doesn't make a whole lot of sense. It doesn't read like a fantasy. It doesn't feel like a fantasy. The concepts and language are extremely modern, as in America right now, and don't match the Renaissance-ish time period. There is nothing Leck does with magic mind control that couldn't have been accomplished in non-magical ways. With minimal rewriting, the book could have been set in either an imaginary country in our world, or a completely different and more contemporary fantasy world.

I liked this the best of the three novels, but, as a much more ambitious work, it also had more glaring flaws. I didn't like the romance at all, though thankfully that's a relatively minor part of the plot. There was a lot of repetition of ideas, revelations, and plot points, making the book feel over-long and in need of editing. Bitterblue comes to essentially the same realizations repeatedly, when she only needs to do so once. There's no humor whatsoever - at one point a man turns up with the Grace of turning his head inside out. I laughed and laughed, and then realized that it was actually supposed to be horrifying, not funny. And the names continue to be terrible, such as "Gracelingian" as the name of the language and a man named Thigpen, which I can never not read as Pigpen.

Still, the strengths are quite strong. Bitterblue is a very sympathetic character. I rarely encounter novels on this subject at all, and considering how hard the subject is, it's pretty well-done. Oh, and there are several important gay and lesbian characters in the supporting cast. Warning for disturbing material appropriate to the subject matter, including sexual violence, child harm, and mass murder.

Spoilers are enciphered )

Bitterblue

My favorite novel on the subject of personal and political trauma and healing is this: Where She Was Standing, by Maggie Helwig. It's not fantasy.
The compassionate Maisie Dobbs, once a nurse in WWI, becomes a private investigator ten years later, relying on her understanding of psychology to crack cases. Her first one, naturally, involves the damage done by the war, both to the people who served and the ones they left behind.

This well-written, thoughtful book works better as a novel than it does as a mystery; the sleuthing is very basic and the villain barely concealed. Some of the details of Maisie's history are a bit much - she began life as a servant but was lifted into a higher class because her employers were just that bowled over by how amazingly smart she was, and her thoughts about psychology sometimes sound more New Age than period - but all the parts dealing with the war and the wreckage it left in its wake are perceptive and moving. I'd read more in this series.

Maisie Dobbs
I'm writing a paper on PTSD and combat-related berserk states as depicted in pre-1650 sources and comparing it to the current understanding of both. Ideally, I will be able to reference substance/alcohol use and abuse in relation to this.

Can you recommend me some sources to check out? I am definitely going to be using Shakespeare's Henry V, Part I. I have already thought of Macbeth (possible PTSD), and The Iliad and The Mahabharata (berserk states). Nonfiction is also fine.

NOTE: No Civil War memoirs! I'm trying to find sources from before PTSD was really conceptualized as such, and it had been conceptualized as "soldier's heart" by then.
rachelmanija: (Book Fix)
( May. 20th, 2012 12:52 pm)
What would I like to do today? Curl up with any one of the delicious-looking books which have just arrived in my home!

Code Name Verity, by Elizabeth Wein. WWII girl pilots and spies, female friendship, and did I mention that they're WWII girl pilots and spies? This is by one of my favorite authors, and people are saying it's amazing. Please do not spoil. I am sure it has many twists.

Everybody Sees the Ants, by A. S. King. I have no idea what this is other than Sherwood highly recommends it, it was nominated for the Andre Norton Award, and she said that it is very psychological and the less you know before reading, the better. Please do not spoil!

Shadow Ops: Control Point, by Myke Cole. Contemporary military fantasy by an author who did three tours in Iraq. I expect the military details are all very accurate. This looks very enjoyable. Bonus: black protagonist is actually on the cover.

Hiding the Elephant: How Magicians Invented the Impossible and Learned to Disappear. Fun-looking nonfiction.

Unstrange Minds: Remapping the World of Autism. Written by a man with an autistic daughter, it promises to pull in personal accounts, science, history, and culture to explore the increase in or increased awareness of autism.


What do I actually need to do?

Complete an online course in Trauma-Focused CBT. By the way, the course seems very comprehensive, as far as comparatively brief online courses go, and it is free if you register. If you complete it, you get a certificate. It's intended for children who have gone through a traumatic event, but could be adjusted to work with adults. I have to complete the course, produce the certificate, and demo a section in front of the class.

ETA: Also, the therapist and the child can play a game where different names of emotions are written on individual pieces of paper. The therapist and the client take turns picking out one of the pieces of paper out of a box (without showing the other) acting out the emotion and having the other person try to guess the feeling.

My emotions upon imagining myself doing this exercise: horror, embarrassment, anxiety, panic, hysteria, inappropriate laughter, denial, disbelief, doom. Well... I know which section I WON'T be demonstrating to the class!

Please taunt me by discussing the books I have mentioned. No spoilers, please. I will select one to reward myself with when I'm done.
rachelmanija: (Gundam Wing: Sane against the odds)
( Feb. 14th, 2012 11:27 am)
This is about triggers in the technical sense, of the "cues" mentioned by the DSM-IV in its criteria for PTSD: "intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event."

I have a much more detailed explanation of triggers here. (Warning: uh, triggery in that it contains descriptions of PTSD and abuse.)

In LJ/DW culture, people often use "trigger" in a much more colloquial sense, to mean "a thing which is upsetting/disturbing/unpleasant." But in the technical, trauma-related sense, this is what a trigger is:

Triggers are not merely upsetting in general. They are things which bring back memories or feelings associated with trauma.

Triggers are highly, highly idiosyncratic. (There are exceptions to this, which I'll get into in a moment.) They don't have to directly relate to the general nature of the trauma. In fact, they are at least as likely to relate to some random thing associated with the trauma, not with the nature of the trauma itself.

For instance, a person who was raped in a car would be at least as likely to be triggered by hearing the song which happened to be playing on the radio during the rape, or by the feel of a vinyl car seat, as she would be by fictional depictions of rape, discussions of rape, or the word "rape." (Some people, of course, do end up triggered by all fictional depictions of rape, etc. I'm just saying, not all people, not always.)

I suspect that the reason for this is that "rape" is a very general thing. But a specific trauma is specific. A fictional rape may bear very little resemblance to one's real rape, and so not touch off any specific memories. But the song, the vinyl seats, the smell of the man's cologne, and so forth, are real things which get burned into the very cells of one's brain, and the fibers of one's nervous system. They may bring up reactions which happen before you even know why you're reacting.

ETA: Forgot about the exceptions to the "idiosyncratic" thing. There's two big categories of those:

1. Most people whose traumatic reactions reach the level of diagnosable PTSD will be physically triggered by sudden loud noises and unexpected touch. It has to do with how our nervous systems are wired. Those things are inherently startling, and if your startle reflex is cranked up past a certain point, inherently startling things will provoke the same level of physiological/emotional reaction people normally have when, say, someone suddenly leaps out of a dark alley and sticks a gun in their face.

2. When similar sorts of traumatic things happened at the same time, in the same space, to large groups of people, you can take a pretty good guess at what triggers will affect many or most of them simply by looking at notable features of the trauma or the area in which it took place. For instance, some insensitive landscape designer stuck a bamboo grove on the grounds of the Veteran's Administration. Unsurprisingly, you can tell who the Vietnam vets are by which ones are taking a very wide path around the bamboo. In the unlikely event that burning papers start fluttering down from the sky, the people who have very strong reactions are probably the ones who were present in New York during 9/11.

End ETA.

People often warn me about fictional depictions of child abuse. I am not triggered by that, or by fictional anything. I was tied up and abused. I'm not bothered by rope bondage in fiction. (Feel free to rec me rope bondage in fiction!) But I did have something trigger me yesterday, and I'm writing it up because it was such a great example of how triggers actually work - and can be dealt with.

Cut for length; also, kind of navel-gazey. )
If I get through all this tonight, I will go eat dinner and watch some Flashpoint. Really dense material below - but interesting.

Summary:

- PTSD is largely a matter of conditioned physiological changes, which are very hard to change via insight and introspection alone.

- Many people face trauma, but not all develop PTSD. People are wired to respond to fear with action (fight/flight.) If they are immobilized and helpless, literally or metaphorically, during a trauma, they are likely to develop PTSD. This may have a biological basis. If they could take action - complete the fight/flight response - they may be able to decondition some of their PTSD reflexes.

- Traumatized people often freak out when meditating due to its internal focus's tendency to send them straight into traumatic memories. But meditation or mindfulness would probably be helpful if they could manage it. Wonder if movement-based meditative practices are less likely to cause freak-outs? If so, that would explain why so many survivors find movement practices helpful. Maybe the movement provides a balance between interior feelings (scary/bad) and external focus (move left arm to block), thus decreasing interior focus and making it more tolerable.

If the trauma is partly caused by the interruption of the fight/flight response and people being forced, physically or by circumstance, into helplessness or inaction, then maybe movement lets them work through the fight/flight (action) response they needed, thus rewiring conditioned responses.

Lots of detail below cut.

Read more... )
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