Character Psychology: PTSD

Posted on October 9, 2008 by arizela

I write dark fantasy. Very, very dark fantasy. My characters go through hell and back on the page, and they genuinely suffer those events. Despite the most recent trend in fiction of the blase hero who shrugs off torture, maiming and psychological terror with a witty one-liner, my characters get to experience the full range of horror, grief, self-doubt, and pain as well as the relief, joy, and love that accompany their travails.

If yours do, too, this is the post for you.

Self-Defense
The human psyche is set up to defend us against long-term dysfunction associated with traumatic events. Factors that modern psychology label “defense mechanisms” – like denial and overcompensating – are meant to prevent us from being overwhelmed by all sorts of nastiness – warfare, muggings, rape, torture, natural disasters… you name it.


Most of the time, the defense mechanisms do their job – they defend the integrity of the person’s mental state until the person has a chance to cope with the problem. But when defense mechanisms fail, or are carried on well beyond the period when acceptance and healing should have begun, mental health problems can set in.

Dysfunction

One of the best tools in the resource bag of an writer whose characters genuinely suffer their tragedies, is PTSD, or post-traumatic stress disorder. Originally used to describe the mental health problems of post-war combat veterans, this term has come to mean an anxiety disorder that comes about following significant traumatic exposure in any age group or population. Examples include folks who experience, have loved ones experience, or observe violent events like mugging, rape, murder, torture, kidnapping, terrorism, natural disaster, child abuse, or any form of significant physical or threatened harm.

So how do you know if your character has PTSD? Symptoms of PTSD include sleeping disturbances (especially nightmares), irritability, loss of pleasure in things once enjoyed, apathy or numbness toward people once close to, jumpiness or being easy to startle, and the potential to become aggressive or even violent.

The hallmark of PTSD are flashbacks – intense, uncontrollable memories of the traumatic event that have the power to remove the person from the here-and-now and take them right back to the moment of greatest trauma. Flashbacks are often triggered by everyday events, sounds, or smells. A backfiring car, the smell of a certain cologne, flashes of light, the sound of a balloon popping, certain phrases of dialogue – anything that triggers a memory can, in PTSD, trigger a flashback. Not every person with PTSD will have flashbacks, but all will suffer from vivid emotional or memory recurrences of the event. Fear, anxiety, and a sense of helplessness are very common.

People with the disorder often describe flashbacks as replaying the event in their minds, of forgetting where they really are and reliving the experience, of being in a bubble of terror. Unlike normal memories, flashbacks trigger not just an emotional response, but a physiological response as well. Release of adrenaline (the fight-or-flight reflex hormone) causes pounding heart, increased blood pressure, sweating palms, stomach upset (up to and including vomiting), a tendency toward aggression, dry mouth, an intense desire to flee…

All writers have some experience with adrenaline to draw from for painting their character’s emotions. Just think of a time when you’ve been utterly terrified, or even nervous. The hormones that control your body’s reaction to these emotions are the same. Maybe asking Susie Q to the spring formal got your heart pounding and your palms sweating. Maybe it was a traumatic event of your own that you have overcome or not yet faced. Draw on these experiences to let your characters experience emotions as real as those you felt when you stood there shaking, pupils dilated to take in more light, heart racing, mouth dry.

The purpose of adrenaline is to get your body ready to either flee from immediate danger, or to fight for your life. With PTSD, it’s just a matter of that hormone being triggered strongly at inappropriate times, for memory rather than immediate threat.

Not every character needs to experience PTSD, but every character should have some reaction to horrible things that happen in their experience. If you think PTSD might be just what your character needs, read on.

The symptoms of PTSD usually occur within six months of a traumatic event, but can take years to show up. Symptoms must last longer than a month to qualify as a disorder under current psychological diagnosing guidelines.

Most individuals diagnosed with PTSD today get relief from a class of drugs known as selective seritonin-reuptake inhibitors (SSRI), which are also used to treat depression. Drugs in this class include Prozac, Lexapro, Zoloft, and Paxil. Individuals not treated medically can see symptoms resolve over time or by ‘working through’ their delayed reaction to the trauma. Psychotherapy and even virtual reality have been successfully employed in resolving PTSD. However, for some individuals, PTSD symptoms can become chronic, lasting years or throughout the remainder of life.

Women are more likely to develop PTSD than men, and individuals who experience traumatic events that were intentionally caused by another person, such as rape, kidnapping, or torture, are more likely to develop the disorder than survivors of natural disasters or events that are not directed specifically at the individual, like car accidents. People who suffer from severe PTSD may have difficulty keeping jobs. Some may attempt to avoid situations that trigger flashbacks or engage in “escape” behaviors like heavy drinking and drug use or attempt suicide.

PTSD, in fiction, can be a powerful tool to draw tension and internal conflict (and external if your PTSD sufferer gets violent). As in the real world, it can be devastating to the person’s life and overall well-being. Combat soldiers, particularly from the Vietnam era, have been widely known to suffer PTSD to varying degrees. New therapies have been successful at helping many, but chronic PTSD remains a problem for many.

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On Wet Nurses and Non-Species Specific Milk

Posted on September 27, 2008 by arizela

Someone asked me the other day if a pregnant woman could act as a wet nurse. Short answer – sort of. Pregnant women make a substance called “colostrum” in their milk glands. Colostrum is a thick, golden-yellow, nutrient rich substance that is the precursor to milk. It is powerfully packed with antibodies that help the baby’s immune system, and with enough nutrition to keep the baby healthy until the mature milk comes in, around 3-4 days after the birth, thanks to the fall off of a hormone called progesterone that the placenta manufactures to keep the pregnancy going. Until the progesterone falls off, the body will continue to make colostrum and prepare the breasts for milk production. Colostrum is great stuff. Unfortunately, there isn’t a lot of it. The amount of colostrum in a breast is measured in drops to a teaspoon, not in ounces. Which makes feeding a baby problematic beyond the first few days of life.

Further, it’s a bad idea for a very pregnant woman to try to nurse a baby. Stimulating the nipples releases a hormone called oxytocin that does two things. First, it stimulates the body to release the milk from the breast glands. Secondly, it stimulates the uterus to contract, which means it’s a significant risk of sending Mama into preterm labor. Handy thing to know in a pre-medical society if the pregnancy is overdue and the midwife needs to induce though.

So then what? If the baby’s mother isn’t around to nurse and the pregnant woman won’t work, what about giving it milk from a cow or goat?

Attempts have been made in the past to feed babies milk from non-human species – cows, goats, etc.. Those attempts have mostly failed. There are proteins and substances in human milk that are specially formulated for human babies. Feeding cow’s milk that hasn’t been processed into baby formula is a surefire way to kill the kiddo or at least make her dog sick, as many of the proteins and substances in cow’s milk is formulated specifically to feed baby cows, which aren’t much like baby humans. The same goes for goats, cats, dogs, ferrets, and any other mammal out there. Species-specific milk is the best way to feed a baby in any species, even in today’s world.

Shoot, now what?

In an era before commercially prepared baby formulas, you’ve really got one choice for keeping a baby alive and healthy in the absence of it’s mother following birth – a wet nurse. Like I said in the post on what happens to babies in famines, anybody with nipples can breastfeed, whether or not they have ever had a baby of their own. It’s easier to get things going if pregnancy has already made the changes to the breast that are required for nursing, but even a woman who has never been pregnant can breastfeed if she works at it hard enough. Finding a wet nurse who is already lactating (making milk) might be the easiest option though. Getting supply going is going to require days to weeks of stimulating the nipples, a lot. Babies nurse approximately 140 minutes in a day, and that’s about how much time a woman would have to spend stimulating her nipples to get a supply of breastmilk going. Around the clock, every 2-3 hours for 10-20 minutes at a time. It’s not easy, but if you’re talking the life of a child, it’s worth doing. In the modern age, a double, hospital-grade, electric breastpump is woman’s best friend, but in the age before all those gadgets, grandmothers and aunts and neighbors still wet nursed by getting supply going the old fashioned way – literally milking the breasts until milk was made.Hand expression, the act of “milking” the breast, involves putting the fingers behind the colored portion of the nipple, press toward the chest, then compress toward the nipple, but not down toward the tip. A woman with a good supply of mature milk should be able to shoot milk across the room if she hasn’t fed the baby in a few hours. Point the nipple down into a container, and you can store breastmilk for bottle, cup or spoon-feeding a baby (yes, you can cup or spoon feed a newborn).

Colostrum will “bud” out from several spots on the end of the nipple as droplets and can eventually be collected in a spoon or small cup. When a woman is starting to get a supply of milk for the first time to wet nurse, putting a baby to the breast, even another baby who already is being fed by another woman before the baby eats, will be more effective than hand expression, but with proper technique, hand expression can be more comfortable and more efficient than even the double electric breast pumps used primarily in the US today.

Standford Medical School has an excellent video that shows women with various breast types hand expressing milk for their babies, both well and premature/ill.

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Rare Diseases: Yersinia Plague

Posted on July 28, 2008 by arizela

Yersinia plague is most famously known as The Black Death, a name given to it in the 14th century pandemic that swept away 25 million souls over the course of five horrific years. When plague is mentioned in modern times, folks often scoff – that stuff only happened in the middle ages, right? Nope. Each year, 10-15 cases of Yersinia plague are reported in the United States, and as many as 300,000 deaths world-wide are attributed to the bacteria which causes three distinct forms of plague – bubonic, septicemic, and pneumonic. Asia and Madagascar are currently experiencing “mostly controlled” epidemics, and three major pandemics, the most recent of which began in the 1980’s, have brought this deadly menace to nearly every corner of the globe, with the possible exception of Australia.

Yersinia plague is caused by the bacteria Yersinia pestis (see photo). Y. pestis is a rod-shaped bacteria that has developed a solid reservoir among wild rodent populations, including prairie dogs, squirrels, and chipmunks but most famously associated with rats. In fact, it is speculated that the plague originated in Egypt and was introduced to the rest of the world by the black rat stow-aways on trade ships. It is very rare indeed for a human to be infected directly by a rodent, however. Much more commonly, the fleas that pester the infected rats spread the disease among humans. Y. pestis closes off the throat of the fleas, making them unable to swallow food. The poor starving parasites go on a feeding frenzy and with each bite and unsuccessful suck, spread the bacteria into their intended snacks – other rodents, wild animals, and humans.

Bubonic Plague

The most famous form of Yersinia plague, the bubonic plague, is also the least fatal of the three forms. Initial symptoms include the development of large, painful “bubos” (see photo below). The bubos are actually very swollen lymph nodes which served as points of initial infection and most often show up in the groin, under-arm, or neck. They tend to be red with a bruise around them and the tissue may die, turning the characteristic black color. Other symptoms make the common flu look like a kiddy ride – high fever, nausea, vomitting (possibly bloody), severe muscle/joint pain, sore throat, headache, debilitating weakness, chills, and a general sense of feeling so miserable you’d gladly lay down in front of a steam roller for a little relief. With modern antibiotics, if given quickly, the relief is more likely – only 15% of patients treated with antibiotic therapy and supportive therapy die, as opposed to 40-60% of people who go untreated. Bubonic plague can lead to septicemic or pneumonic plague.

Septicemic Plague

Septicemia is a severe, generalized infection – the bacteria circulate through the blood stream and can impact any organ in the body. Septicemic plague can occur after the formation of bubos or without bubos (rare) and the symptoms listed under the bubonic form of the disease. In addition, septicemic plague can cause symptoms throughout the body depending on which areas are affected – diarrhea (often bloody), constipation, severe belly pain, cough (often bloody), muscle pain, stiff neck, bleeding from just about anywhere, gangrene of the fingers, toes, penis, or nose, seizures, confusion, delirium, or coma. Untreated, septicemic plague is 100% fatal and can lead to pneumonic plague.

Pneumonic Plague

Pneumonic plague can be contracted two different ways – from the advancement of bubonic or septicemic plague or from coming into contact with another person or animal who has pneumonic plague. This form of the disease may include bubos and bloody cough, along with general symptoms of the plague and signs of pneumonia. The difference here is unlike bubonic plague and septicemic plague, pneumonic plague is extremely contagious person-to-person. While the other forms of Yersinia plague can pass person-to-person with close contact and exchange of bodily fluid, stepping within a few feet of a person suffering pneumonic plague and taking a few unprotected breaths can be quite literally a death sentence. Survival if treated with modern antibiotics within the first 24 hours of infection with pneumonic plague is often effective at preventing death, but left untreated, this form of the plague is 100% fatal.

The pandemics that swept through the pre-modern world drastically altered the face of the world, not just in terms of the depopulation, but in political, scientific, and religious terms as well. Volumes have been written which point to the Black Death of 14th century Europe as the single most important disease event in shaping the face of the modern world, creating the infancy of modern medicine and ending the dark ages.

Modern sanitation, pest control, and antibiotics have reduced this one-time mega killer to a smaller stature on the scale of world threats, but modern man might yet feel the real bite of this beast. In the age of terrorism, Yersinia plague in aerosol (airborn) form is considered one of the most feared as a potential biological weapon. And unlike small pox and polio, this deadly disease has host colonies the world over and will very likely continue to be a threat looming over us forever.
Posted in infection, Plague, Rare Diseases | Tagged , , | 2 Comments

What would happen to a nursing baby in a famine?

Posted on July 18, 2008 by arizela

The answer: nothing, if the mother was smart enough to just keep nursing (assuming baby is under 6 months old).

Breastfed babies die in famine situations all the time though right? Yep. Because the mother is so desperate, so unable to believe that she can provide adequate nutrition when she herself is wasting away, that she will feed the baby anything. Women have been known to chew tree bark and grass on the side of the road and feed the nutrition-less pap to their babies because of that insecurity.

The truth is, nature is a smart cookie and survival of the species is a pretty strong genetic need. Baby gets the choicest nutrients and the composition of breast milk changes to give baby the best chance of survival, even over the mother. Nursing takes so few calories from the mom that even if she is skeletal and malnourished, baby will be fat, healthy, and happy if nursing continues. Women even managed to nurse babies and keep them alive in the Nazi concentration camps, under the absolute worst conditions.

If, however, mom decides to supplement baby on whatever food can be found, then baby will likely become as malnourished and skeletal as the mom and may die rather quickly. Artificial baby formulas aren’t a safe bet either, in modern famine situations. Diarrheal illness is widespread during famine, and without clean water, refrigeration, and proper handling, formula can be every bit as deadly as famine.

Older babies >6 months need some supplemental nutrition, but breastfeeding is still vitally important, as mom’s immune system continues to help baby to fight off any pathogens mom is exposed to – including those diarrhea producing bacteria that can rage through refugee camps and the like.

In your fantasy stories, if mom is lost, baby can still survive these conditions if someone is willing to become a wet nurse. Anyone female with breasts will do for starters – any woman can breastfeed. However, pregnant women will only produce colostrum – an immature milk in tiny volumes that won’t support a growing baby’s needs fully. Establishing a milk supply in an individual who has never been pregnant is a little harder than in someone who has made milk before, but it can still be done. Putting baby to breast frequently, stimulating the nipples, and some herbs (with limited efficacy) have been long-known to restart or start lactation. In modern times, the American Academy of Pediatricians recommends that adoptive mothers of young infants breastfeed. However, wet nursing and milk exchange is highly discouraged in the US today because of the risk of spreading diseases like HIV.

Posted in Disasters, Infants | Tagged , , | 1 Comment

Rare Disease Column: Tetanus

Posted on July 18, 2008 by arizela

Ever gone to the ER for a few stitches in a minor wound and had the nurse ask you when your last tetanus booster was? Oh great. A shot.

Well, don’t be too hard on her. Tetanus might seem like no big deal now in the age of the vaccine, but it is still a deadly menace. The number of cases reported in the US has fallen considerably since the invention of tetanus toxoid, which primes the body to immunity against the bacteria that causes this highly infectious (but not contagious) disease – Clostridium tetani (see photo).

Tetanus, known as Lockjaw prior to the 1920’s, was described as early as Biblical times, and no wonder. The C. tetani bacteria can live for years in soil or animal carriers and is widespread. While it seems to prefer geographical areas that are warm, moist, and which have high levels of organic matter, it can live just about anywhere and in the inactive spore form can survive most chemical antiseptics as well as autoclaving (heating to sterilize) to 112C or 249.8F for 10-15 minutes. CDC

The real danger of C. tetani is in the toxin it produces – an exotoxin which is one of the most powerful neurotoxins known to man. Less than 200 nanograms of C. tetani‘s deadly neurotoxin is enough to kill most humans. The generalized form of this disease is among the most dramatic and cruel non-contagious diseases out there. The toxin produces progressive spasming of the muscles, starting with the jaw, which locks tight and prevents opening the mouth or swallowing. Sometimes the illness ends here, with the person having difficulty breathing and a quick death, but most often, the stiffening, uncontrollable muscle spasms progress down the body – the neck stiffens and hyperextends over the back, the arms and shoulders begin to posture and so forth. The spasms themselves can be so powerful as to snap bones, and for those who survive, paralysis from broken spinal cords may be a reality. ~30% of cases will not survive, however, and many will end up looking like this poor soldier (see portrait) who died shortly after this posture was seen.


So how does one get tetanus? A common misconception about the disease is that you have to step on a rusty nail, but in truth, any deep puncture, cut, or chronic wound can become infected, regardless of what caused it. Nails and tools that are left out in soil have an obvious advantage in this regard, as the soil is one of the main places C. tetani is located. However, consider the fiction implications of cultures who thrust their great swords into the dirt prior to battle (please don’t try this with your katana or rapier, as your character is more likely to suffer death by virtue of having a broken weapon in battle than to inflict it upon the enemy via tetanus).

In modern times, treatment consists of managing the original wound – keeping it clean and bandaged, plus updating tetanus boosters if appropriate. In individuals who’ve never had a 3-dose series (which is a standard for children in the US), passive immunity can be confered by giving an injection of antibodies from another human host who is immune. Once symptoms start, the anti-toxin is of limited use, but is often still given to keep symptoms from worsening. Supportive therapy for airway, draining the bladder, providing nutrition, etc are the mainstays of treatment. Each year in the present-day US, approximately 20-100 people still develop tetanus infections, with about 10% dying, most often related to not updating boosters every 10 years or IV drug use (particularly heroin, which is sometimes contaminated with C. tetani).

Another nasty little note about tetanus – surviving it once doesn’t protect someone from getting it again. Also, infants can develop tetanus from infection of umbilical cords, particularly if they are cut with non-sterile instruments, but only in mothers who are not vaccinated. The incidence of this worldwide is still relatively high, but in the US, only 2 cases have been reported in the last couple of decades.

For more information on tetanus:

Centers for Disease Control
MedLine Plus, National Institute for Infectious Disease

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