A Quokka Dreeds its Weird

This is purely for study purposes (mine) and entertainment (yours and mine). I cannot actually diagnose any real person.

Young Miles

Presenting Problem: Miles Vorkosigan is a 29-year-old white male who appears older than his reported age. He is of below-average height and weight, and has visible disabilities affecting his legs and back. He wore a military uniform, and his grooming and hygiene were above average (normal for Barrayaran military.) His speech and movements were very energetic, and he appeared restless and fidgety. Upon initial questioning, he appeared cooperative but irritated.

The client relaxed when he was assured that the contents of the meeting were not only confidential but top secret, and was quoted back (by advance permission) Imperial Security Chief Simon Illyan’s comment, “I don’t want to fix him. I just want to know what makes him tick.”

The client then confirmed that he was present due to an experimental pilot program bringing in Betan therapists to assess and, if necessary, treat members of Barrayaran Imperial Security. He rapidly diagnosed himself as “a bit bipolar, hyperactive, split personality, and megalomania,” then laughed when it was pointed out that the last two are not diagnoses.

Client stated that he has a history of depressive episodes and combat-related flashbacks, but neither interferes with his job performance. He stated that he has satisfying relationships with his family, is happy with his work, and has ongoing romantic relationships. Upon closer questioning, he admitted to a suicide attempt as a teenager and frustration over being unmarried. Client denies current suicidal ideation.

Personal History: Serious physical disabilities. Social prejudice due to ableism. Satisfying and very successful military career. High-stress life, but client stated that he enjoys this. Client seems very invested in his secret identity.

Family Background: Good relationship with parents and extended family. History of conflict with deceased grandfather. Recently learned of existence of clone-brother, but clone-brother cut off contact, to client’s regret.

Psychiatric/Treatment History: No previous diagnoses. Client said that he has never been treated for a mental illness, and speculated that he is probably allergic to all psychiatric medications.

Differential Diagnosis: Described manic and hypomanic states to client, and asked if he was having one now. Client stated that he is “always like this” except when he is having a depressive episode. Acquired client’s permission to call his mother, who agreed that client’s baseline met all the clinical criteria for hypomania, except for the existence of a non-hypomanic baseline. Client’s mother described client’s behavior as a child, which met the criteria for Attention-Deficit/Hyperactivity Disorder, Predominately Hyperactive/Impulsive Type. Client and client’s mother stated that the client has never had a manic episode except while under the influence of a substance.

Symptoms of PTSD are concentrated on the reexperiencing and increased arousal axes. Avoidance symptoms are missing, but reexperiencing ones (dreams, flashbacks, psychological distress, and physiological reactivity) are sufficiently intense as to justify the diagnosis.

Rule out Dissociative Identity Disorder. Client’s over-investment in his secret identity is common in military operatives, and there is no amnesia present.

Rule out Narcissistic Personality Disorder. Client’s grandiosity and sense of specialness don’t seem unrealistically inflated given his circumstances, and he shows no more entitlement and arrogance than is common among wealthy, high-status people. Other symptoms are not present.

Recommendations: 1. Individual therapy services to address his PTSD and Major Depressive Disorder. Recommend a cognitive-behavioral approach.

2. A complete medical examination to rule out possible physiological or medication-based causes for his conditions.

3. A medication consultation. NOTE: See extensive list of allergies. Be aware that while the therapist did not diagnose Bipolar II, it could be present in a non-diagnosable form.

4. Individual therapy services from a Jungian perspective to address issues of Persona and Self.

Axis I (clinical disorders): Major Depressive Disorder, Recurrent, With Catatonic Features. Posttraumatic Stress Disorder.Attention-Deficit/Hyperactivity Disorder, Predominately Hyperactive/Impulsive Type.

Axis II (personality disorders and mental retardation): : No diagnosis.

Axis III (general medical conditions): : See attached files.

Axis IV (psychosocial and environmental problems): : High-pressure occupation. Ongoing search for wife.

Axis V (GAF: Global Assessment of Functioning): : 65 (Some distressing symptoms, but generally functioning well.)

Rachel's note: What do you think? Do you need the existence of a non-hypomanic baseline to diagnose Bipolar II? Or should I have gone ahead and diagnosed it anyway? (Or guessed that brief non-hypomanic, non-depressive periods probably existed but had gone unnoticed?)

I am taking a class on Treatment and Assessment. Yes, MFTs can diagnose. (We can't prescribe medication.)

To help familiarize myself with the DSM-IV and the process of diagnosis, terminology, etc, please recommend a fictional character I am familiar with who you think might have a mental illness, and I will attempt to diagnose them according to the DSM-IV criteria, as time permits. It would be helpful to note some incidents or traits which make you think they may need treatment.

For this go-round, please don't throw characters at me who you think might have something obscure, like (checks index) Mixed Receptive-Expressive Language Disorder. The class is currently focusing on mood and anxiety disorders, but I am also reasonably familiar with psychotic, dissociative, and personality disorders from my recent class in Abnormal Psych.

This is purely for study purposes (mine) and entertainment (yours and mine). I cannot actually diagnose any real person.

I will make a filter for this shortly. Until then, cut to spare you, and also for sexual content including some hilarious romance novel excerpts. These are my brief notes, for my own benefit with the exception of the throbbing pistons which are for yours, on today's reading.

( Read more... )

I don't want to spam people, and will eventually make a special "psychology" filter. Please comment if you especially do or don't want to be on it. Otherwise, I will take my best guess. I will not be hurt if you don't want to be spammed with billions of notes on scholarly articles!

I'm reading an essay by Arthur Kleinman, "How Is Culture Important for DSM-IV," dissecting its extreme cultural biases and blind spots. Great stuff.

Brief notes follow - note that this is all simplified and primarily meant as notes to myself.

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Another one of the books assigned for Human Sexuality, which I was nearly done with before I learned that the teacher had been reassigned. I finished it anyway, of course.

I have a lot to learn about trans issues, so please feel free to correct me if I use wrong/outdated terminology, or for any other reason.

Adding “in the modern western world” to the end of the subtitle would have been a good idea: the book does not even touch upon pre-modern or non-European/non-European-descended American concepts of transgenderism. I am certain that a more wide-ranging book exists, and I wish one had been assigned; I kept thinking, “Are you ever going to mention hijras? Two Spirit people? Sikhandi?” She did not.

As a history of transgender (and intersex) activism and history in modern Europe and America, though, it seems reasonably good, not that I’m an expert. Rudacille, a cisgendered woman (a term which never appears in the book), includes a number of interesting interviews with trans people. They are, however, similar kinds of trans people: all American, at least in their thirties, and people who strongly identified with a single gender and, to some degree or another, medically transitioned. Race was not stated for anyone, and was not made clear from the interviews; unless I missed something, there was no one clearly identified as non-white. Neither are there in-depth interviews with anyone who identifies as genderqueer or anything non-gender-binary, anyone really young, anyone who decided not to physically transition, etc, though some such people are quoted.

I couldn't help wondering if Rudacille, probably unconsciously, selected her interview subjects according to who she felt comfortable talking to (and who felt comfortable talking to her,) and so ended up with a bunch of people who were demographically similar to her and who more-or-less shared her beliefs. Irritatingly, sometimes she'd give a nod to diversity by quoting someone for one line, prefaced with something like, "So-and-so, 19, who self-identifies as a Radical Faerie trannyboy," and then not follow up with an interview.

Rudacille has somewhat biologically determinist and stereotypical views about gender, in the sense of believing that certain qualities, like compassion, nurturing, adventurousness, analysis, are inherently masculine or feminine. She also comes down heavily on the “nature” side of questions like “why are boys more aggressive/better at spatial relations/etc,” not to mention on the “oh hell yes” side of questions like “Is it even true that boys are more aggressive?”

The trans people she interviews mostly hold at least somewhat similar beliefs, citing their gender non-conformist behavior in childhood as an early indication that their true gender didn’t match their bodies. (It’s more complicated than that in some cases; some of the people she interviews are intersex.)

Rudacille concludes with a chapter making a case that DES and other environmental estrogen-affecting chemicals may affect fetuses, causing them to be transgender. I kept waiting for her to add, “Though of course, while that may be true for some people, it cannot be true for all, since transgender people pre-date the existence of any of the chemicals I’m talking about.” Alas, no.

I suspect that a subjective sense of gender is inborn, and that some people have it more strongly than others. I know people, male and female, who don’t have a strong sense of their own gender, and others who do. This seems to have nothing to do with whether or not you match a gender stereotype. But I would guess that the stronger the sense of your gender, the stronger the distress if you have a body which doesn’t match it.

I have always had a very strong sense of being female, but I was so gender-nonconformist as a child that it was a significant source of conflict. I liked “boy stuff.” I had “masculine attributes.” I liked to dress “like a boy.” But I never wanted to be a boy; I was just into stuff which (bizarrely, in my mind) was labeled “boy stuff.” I was so convinced that I was female, despite everyone telling me that I was in no way a proper one, that I decided that none of the things I liked could possibly really be boy things. I was a girl, and I liked to climb trees. Q.E.D., climbing trees was also a girl thing.

I mention that as an example of how biological sex, gender stereotypes, and the internal sense of gender seem to me to all exist independently of each other. They may all line up. Or some of them may. Or none of them may.

There must be some trans people who stereotypically fit the gender they were assigned at birth, and yet still feel that it’s the wrong one. (Say, a female assigned at birth who loves looking pretty and shopping, but knows that in his heart, he’s a man – a man who loves looking pretty and shopping.) I wish Rudacille had interviewed a couple of them, because that might have shaken her annoying beliefs in the inherent masculinity and femininity of abstract traits.

Any recs for something a bit more radical, less gender-stereotype-essentialist, and/or with more pre-1800 history and perspectives other than European and American-minus-Indians?

The Riddle of Gender

This book, one of the required texts for my 10:00 AM Monday Human Sexuality class, suggests that the class, while possibly lacking in academic rigor, will not lack in amusement value. I am picturing a cross between a 70s encounter group and a "Let's all draw our vulvas, watch a video of women ejaculating, and then make an offering to the Great Goddess!" workshop.

Its arrival this week was perfect timing, given that the month to date was the sort which, to completely misquote Emma Bull's War for the Oaks, left me grasping for straws of comfort like, "No matter what else happens today, at least I still like my clitoris."

This is the sort of book which has an anatomical drawing of a clitoris, and a woman pointing to it and exclaiming "WOW!"

The book has some interesting information about clitoral anatomy (the little button part is just the tip of the iceberg; a large portion of the female genitalia is made up of clitoral tissue and structures.) But most of the book is basically, "Wow! A clitoris!"

There is a long chapter on female ejaculation, in which women enthusiastically describe their gushing orgasms, with slightly terrifying details like, "And then I had to mop the floor!" The author then notes that you too may be able to teach yourself to ejaculate, if you don't already. Personally, after I am done having solo or partnered sex, the last thing I want to do is mop the floor.

Despite some dubious history and a cringe-worthy discussion of the Tao and Tantra, this book is mostly harmless. I expect it would be delightfully eye-opening to any women who aren't already familiar with their anatomy or the possible range of their sexual response. But for a graduate course... seriously? This is the best you can do? If anyone knows of more academically rigorous or up-to-date or more culturally sensitive books on female sexuality, please rec them to me, and I will rec them to the school.

I also boggle that this apparent typo in chapter one didn't get corrected through many editions: From as far back as the Kinsey report in 1953, intercourse has not been found not to be the most effective means for women to experience the full range of their sexual response, and yet, penis-in-vagina sex remains the ne plus ultra of sexual activity.

And I boggle more at this: During full-blown sexual response, clitoral tissues expand enormously. The erectile tissues fill with blood, causing the clitoris to protrude enough, as one woman put it, "to fill my cupped hand."

The Clitoral Truth: The Secret World at Your Fingertips

( Hilariously pornographic cheery illustrations below cut )

10:00 AM on Mondays. That's what I call starting the week with a bang!

Awesome: One of the required texts is The Clitoral Truth: The Secret World at Your Fingertips.

Less Awesome: It also requires a course reader costing $140. WTF!

Before I spend the next two years plowing through textbooks, please recommend me some books on psychology: therapy, memoirs of therapists, memoirs of people with mental illnesses, theory, anecdotes, treatment, classics which are still relevant, cross-cultural and non-western issues and theories, etc.

No holds barred! I am particularly interested in trauma, but on the other hand, that's also the area where I'm best-read. So anything goes. (Should I read Jung?)

Yesterday tanyahp and I were talking about the American diagnostic manual of mental illnesses, the DSM-IV, and how some of the listings are pure pathologizing of “weird” (usually sexual) behavior, some seem to represent recent culturally based phenomena (which doesn’t necessarily mean they aren’t “real,”) and some others have a far longer history.

I mentioned that there’s a speech in Shakespeare’s Henry IV, Part I, written around 1597, in which Lady Percy speaks to her warrior husband, who’s often away fighting and is about to go lead a rebellion, and that she hits virtually every one of the DSM-IV’s diagnostic criteria for PTSD - in iambic pentameter.

For your amusement and/or enlightenment, here’s Lady Percy’s complete speech, annotated with the DSM-IV criteria.

( Insomnia, exaggerated startle reflex, recurrent dreams of battles, lack of interest in formerly pleasurable activities, and more! )

telophase reminded me of a conversation we had a while back, and I thought I'd throw it open for discussion (especially as there are a couple of psychologists reading this.)

We were talking about the mind and how it perceives its own processes, and how, if you ever grill people about how they see their own selves and the way they imagine their minds, they will come up with metaphors and concepts that seem extraordinarily weird to anyone who is not them.

Walter Jon Williams has an excellent sf novel called Aristoi, in which some of the high tech is psychology. People have learned how to induce multiple personalities in themselves (which they call daemons) in a very controlled manner, so that rather than having any kind of disorder or deficit, they can tap into the almost unlimited potential of their own selves. He makes it sound really fun, too: call up the physically adept daemon to help you with a fight, or the aesthetically-minded daemon to add to your appreciation of a work of art.

I once mentioned to Walter that I wished I had daemons. He looked rather surprised, and said, "But you do."

"Well, sure, in a sense," I replied. "But I mean I wish I had them the way they're depicted in your book, so they really feel like other people, not just portions of myself."

"The daemons in Aristoi were my attempt to write down the inside of my own mind, the way it feels to me," replied Walter.

"...really?" I said.

Or some such; this conversation is obviously not verbatim. Unfortunately, I did not a get a chance to further quiz him on what he meant by that.

But that's something else that makes me wonder whether the line between what are generally considered to be (a few-- not all!) mental illnesses and quirky but normal thinking processes is merely whether or not the person in questions interprets "other personalities," say, or "I am not human" as metaphor or fact.

Is there really something very different about the mental state of Otherkin, or do they just interpret the very common sense of being different from everyone else, and the also quite common identification with non-human beings, as metaphysically real rather than metaphoric?

Is that also the difference between Walter and Sybil?

Thoughts? Fascinating personal disclosures? Musings on delusions/ideas which are socially normal vs. weird, when they're actually quite similar?