Saturday, January 25, 2014

Shame 2.0: The Dissertation

I was talking to my husband the other day about the role of shame in the PTSD response, and I thought it might be a good time to revisit the topic in the ol' blog.

"Shame" has always been sort of a tricky thing for me to parse, especially relative to other similar, overlapping tricky things, like guilt and anxiety.

With which I am also familiar. Hence, I would imagine, much of the difficulty.

As you may recall, I wrote about shame here before, way back in 2011, when I first discussed the theory that PTSD may be, to some degree at least, a shame disorder.

More about that in a minute (because whoa-- did I find some interesting stuff about that).

To quote myself, back then I... um... quoted Dr. Oz:
Dr. Oz says that shame stifles emotion.

I can see how that is true-- instead of feeling what you're feeling, you feel shame for feeling it. The shame swallows or eclipses the anger or the pride or the contentment or whatever it was that you were feeling before the shame spiral pulled you under. It also makes you distance yourself from others, stifling intimacy and preventing you from connecting with others.
Hmmmm. Yeah... no. 

I mean, yes, good, those are some things that shame does to us. But I still wasn't explaining-- to you or to myself-- what shame is, much less how to differentiate that particular monkey from all the other monkeys in my zoo (ooh, what a good metaphor! I'm a walking monkey house, me!).

But I needed a better definition than that, because I needed to get to the bottom of something my husband and I were talking about: the different types of PTSD responses, and the role shame plays in them. 

In some people, it's easy to see. 

Take me, for example.

My husband brought it up because he said he'd been thinking about something I'd said to him recently: that I was slowly realizing how much of my time and energy is spent simply trying to appear normal to others while all of this chaos is going on below the surface.

My brand of PTSD could be called "The Art of Getting By." I bet most people who suffer from it could call it that.

He thought that maybe shame drove a lot of that impulse-- shame over my internal struggles, shame over my perceived inadequacy, shame over my anxiety, shame over whatever.

Sure, I said. That makes sense. Although...

Whenever I try to apply a general statement about PTSD/PTSR to myself, I try also to apply it to the grizzled Vietnam vet ducking at car backfires and screaming at the sky. What I mean by that is that I try to see how he and I could be experiencing similar neurological malfunctions.

Doing that has been a good gut-check for how I figure out what is true and what is not about what's going on in my brain. It's also been what has made me feel increasingly connected to the plight of our veterans with PTSD and the quality and extent of their care.

Anyway, I had trouble with the shame thing. I've felt a great kinship with the hypothetical veteran in the past-- the theory that we are both stuck in a stage of the fight-or-flight response makes perfect sense, and our resulting behavior does as well. 

But it's much harder to see the link with shame.

So I looked it up again, just now, and found something really simple and clear on, one of those websites I might otherwise have skipped, thinking it would have been too generic to have anything useful.


The article first differentiates shame from guilt:
Shame is often considered a "self-conscious emotion" and... occurs when a person evaluates or judges themselves in a negative light. For example, a person might experience shame if they view themselves as worthless, weak, bad, or useless.
Guilt, on the other hand, occurs when people evaluate a behavior or an action as negative. For example, if you borrow money from someone and then fail to pay them back, you might experience guilt because you did something that can be perceived as wrong or inconsiderate. However, if you judge yourself as a bad person because you failed to pay the person back, you would likely experience shame.
Then it tells you why the difference is important:
It is important to distinguish between shame and guilt because they influence our behavior in different ways. Guilt can motivate us to make amends, apologize, or correct a behavior. Doing such things will help alleviate guilt and may increase the extent to which we feel positive about ourselves. In this way, guilt can be a helpful emotion.
Shame, on the other hand, is rarely useful. With shame, people may be more likely to engage in self-punishment (such as through deliberate self-harm) or isolate oneself from others. This is going to do little to alleviate the shame in the long-term and can even intensify the shame. 
And then... the clincher (emphasis mine): 
Why might shame lead to PTSD? The experience of shame following a traumatic event may lead to the use of unhealthy coping strategies, such as alcohol use, avoidance, or self-destructive behaviors. These unhealthy coping strategies can interfere with the processing of emotions associated with the traumatic event, contributing to the development or intensification of PTSD symptoms.
In addition, if people experience shame due to judgments that they are weak or worthless, they may feel more stigma about having experienced a traumatic event. This stigma could then prevent someone from seeking out the appropriate care.  
Coping strategies. Shame is about coping strategies. 


In case you missed it, that was the light bulb turning on, right there.

So there's the link. In fact, there's the whole damn ball of wax, because without an unhealthy coping strategy, you don't have any PTSD to deal with.

And without that... you and I? We're not having this here conversation, folks.




There it is, then. 

Did I just figure this whole thing out? I did, didn't I. Ha ha. <cracks knuckles, leans back, places hands casually behind head>

Hi. Sherlock here. Have we met?

So, before I go, one more (sort of really big) thing about PTSD-as-shame-disorder. You'd think it would be talked about more openly, considering all the evidence there is for it. 

And there is a great deal of widely-understood evidence. I am hardly the first to make this connection. There's enough that the US military (and many others, I reckon), includes shame-proneness as a variable when looking for candidates for special forces teams and other such intense, high-stress military positions. 

In fact, speaking of the military, I saw an article recently that talked about the newly-emerging issue of women returning from combat positions, and their higher-than-average propensity to suffer from PTSD. I was hoping to see the connection made there.

It wasn't. Shame wasn't mentioned at all.

I think it should have been. Now more than ever, I think it's THE key element to understanding not only how to unlock the mystery of PTSD, but how to properly care for our returning veterans of both genders.

And before I get off this topic, consider this: this article discusses the commonly-held theories not only that women experience more shame than men, but also that men and women tend to express their shame differently: "women 'act in' ... through introversion and self-hate.... [while] men 'act out'... [through] extreme anger and violence."

As that first article states, female veterans are TWICE as likely as their male counterparts to commit suicide. (Acting in: check.)

And as all of these articles state, our veterans are very likely, and getting more likely by the day, to commit suicide.

And as we hear with alarming frequency on the news, sometimes they (as far as my research shows, exclusively men) don't-- or don't only- kill themselves. (Acting out: check.)

And yes, I'm conflating expressions of shame here with expressions of PTSD and/or expressions of clinical depression or whatever other neurological misfires have piled on in any given individual case... but it seems to me that there is useful information here. 

That the roots of these behaviors can be traced to something as simple and malleable as a coping strategy.

That this stuff can be, to some extent-- and maybe to a very great extent indeed--anticipated and mitigated.

Or at the very least, addressed properly, directly, with care and compassion, and without judgement or stigma when the men and women who risk their lives for our country return home, so that they don't end up sacrificing more than they-- and those who love them-- bargained for.

Thursday, January 23, 2014

Update. Idea. Question.

For the past several months, this blog has been largely about migraines, medications, depression, and anxiety.

I haven't talked much about the PTSD directly, because I've been dealing more with some of the major, immediate symptoms and all the hootenannies that come along with them.

If weeks-long migraines and the psychotropic medication-circus can be called "hootenannies."

(And why the hell not? Makes them sound so much more delightful than "horrible death marches to nowhere." Hootenannies it is, then.)

Time for an update, then:

It's all still there.

Still get triggered, still hyper-vigilant, still get that weird cold/numb off-gassing feeling in my legs and arms when I start talking about the accident.

What's different is that I shut down less often. I succumb to the fog less often. I have learned to anticipate when these things will happen and prepare for them. 

I write things down. I take a lorazepam. I breathe deeply. I remind myself that I am alive. I think about how much I understand, now, about what is happening in my brain and body when I'm triggered, and that keeps me grounded in reality.

None of those things are the same as not getting triggered. None of those things mean that I now have authentic emotional reactions to things as often as I want to, or as often as I think I should. 

I don't. I wish I did. Someday I might. Someday hasn't happened yet.

But it's all a far sight better than it was, and that's something.

Knowledge is power. If you're of a certain disposition, that adage alone can get you through many a dark night.

I am of that disposition.

Hi. Sherlock here. Have we met?

One thing that helps me feel like I'm moving this whole giant caravan of baggage forward is turning outward and looking for opportunities to connect with other people who might be suffering in similar ways.

I have been able to do that with some readers of this blog who have reached out to me. I have been able to do it with a couple of friends in real life. I am hoping to find ways to make a broader impact with this blog and with the book it will become, and by sharing my experience with people who are looking for guideposts on their own paths out of the darkness.

I've told you before that I'd like to turn this blog into a book at some point, and while brainstorming ideas about how to do that, I thought of this:

What do you think about me looking for venues to do readings from this blog? Who do you think would like to hear it? Where do you think I should look?

I have some ideas, myself, but I'm interested to hear what you might think about this.

One last thing before I go. Mild migraine again, yesterday and today. My triptan didn't work-- my prescribed migraine medication. But once again, you know what did?


So I'm on a new course of research: Why does a benzodiazapine stop my migraine? 

So far, everything I've seen tells me that it doesn't. Benzos are not painkillers. Benzos are not vasodilators. They do not affect the cause of migraine. They are not effective in the treatment of migraine.

BUT THEY STOP MINE. Every time, without fail. So.

What the hell am I supposed to make of that?

Things that make you go hmmmmm...

Saturday, January 11, 2014

A Shade of Awesome

Hi there. Skipped another week due to illness, houseguests, and various other calamities. Sorry about that.

But I'm back with news and things to do.

FIRST: before I go any further, a plea to any of you who read this blog and haven't yet signed up as "followers" in the right sidebar:

Will you do me the honor? Please?

I promise: no spam, no emails, no NSA surveillance drones over your house, nothing. Really, all that will happen is I'll have your little icon there and I'll know you've signed up and people who might look at my blog to see if anyone would want to read it if it were a book will know that yes, indeed, people would.

You're already proof to me. Be proof to them, would you? Conceal your identity-- take on a  super-alias!-- just sign up. Join my club. We're cool.


Okay. So. Down to business.

This was a very, very, very strange week.

When we left off, I was in that weird middle zone, ramping down the Cymbalta, ramping up the Amitriptyline, feeling the worst of one and the barest traces of the other, and stuck in the no-man's land of the PTSD/depression void.

Tired. Forgetful. Vacant. Overwhelmed.

Oh, and bonus: sick with a horrendous head cold.

I stayed in that zone for a while after I posted. Am still there, to a great extent.

And thusly I arrived at the beginning of this week, sick as a dog, with my husband heading to frigid St. Louis on business for four days, my sister and bro-in-law (the adorable newlyweds) in town to visit (and serve as inadvertent life-preservers--more about that later), and an unusually busy and appointment-packed week ahead of me with a brain functioning at about a 2 out of 10.

Overwhelmed to all hell.

The worst part of feeling that way is the certainty that it can never be better. Anxiety overwhelm is something that doesn't lend itself well to cognitive coping mechanisms. There's nothing in there that feels "fleeting." There's nothing in there that sits well with the adage, "This, too, shall pass." 

Anxiety overwhelm is a tidal wave of crushing panic, with a whisper in your ear: forever, forever, forever. 

It is frightfully hard to stand up under that onslaught, and remind yourself that no, actually, a few appointments and phone calls and errands and things to be done and conversations to be had in the course of a normal week are just that: normal, and doable, and manageable in time and space, and not at all insurmountable.

You can break them down by date and time, make a list of materials needed for each one where necessary, and put them in your calendar in separate time slots.

Some time slots are bigger than others. Some lists of materials are longer. Some items don't have lists, and don't take more than a minute of time. 

If you do this, if you write them all down, if you make all the lists and put all the things in your calendar, you can see all these things and know in the intellectual part of your brain (the part that had a career once; the part that earned two masters' degrees; the part that is a full-grown fucking adult human being who has managed to survive all these years somehow without cracking up; what the FUCK) that these things are small, and finite, and separate, and variable, and easily, easily done.

But if you are in the middle of anxiety overwhelm, with the last of the Cymbalta digging in its claws and leaving bloody trails as it slips inexorably out of your system; and with the brief, bright bursts of Amitriptyline still too few and far between to build a day upon, those tasks, from the phone call to reschedule the doctor appointment to the day-trip to the City, all look exactly the same.

They have the same weight and heft. They require the same time, effort, energy and planning. They tax my system in the same way. They trigger the same fear, fight, and flight. They are all too big, too difficult, too far beyond my ability to manage, and they are all extremely urgent, all at DEFCON 1, and all need to happen RIGHT NOW.

When the overwhelm is really bad-- and in this in-between state I've found that it can get very bad indeed-- the cognitive tricks don't work as well as they should. My inner Sherlock can't be convinced, despite the evidence, and for a while I am all lizard brain. 

To paraphrase some every misogynistic movie from years past: no matter how much my mind says NO, my body just keeps saying YES YES YES.

This actually happened to me this week. My sister Liz sat down with me and helped me talk out everything I needed to do, and we made a list of everything that needed to happen and when, and I put everything in my calendar, and I could see it all laid out and that there was plenty of space and time for everything and that it was all well under control.

And yet.

Even as I did it, my fingers were tingling. Then my arms. Then my legs and feet.

Why, you ask? Is it that PTSD thing, that energy off-gassing thing?



It was me, hyperventilating. HYPERVENTILATING. Hyperventilating, because I had to reschedule one doctor's appointment and attend two, take my kids to school three times and gymnastics once, let someone into my house to spray for ants, let another person into my house to fix windows, write a check, pay a bill, make a phone call, validate a credit card, and just generally keep everyone fed and clothed and non-bleeding.

Over the course of five days.

With help.

No kidding, if Liz had asked me, during that session, when I wanted to work showering into my schedule for the week, I probably would have either burst into hysterical tears or lost consciousness.

I am shaking and anxious just describing this to you, and it's several days later and it's all been done (successfully!) and I've had a Lorazepam.


The extremely capable, overachieving part of me is absolutely appalled at all of this. The unfortunate thing about being in this state is that you don't get to trade your inner critic for a new, nicer one in the interim.

Nope, she's still holding me to the same standards, even though those are wildly beyond my abilities at the moment while my brain tries to sort out its little chemical romance. Soooooo helpful. What a bitch.

And speaking of that, this whole brain chemistry experimentation stuff is for the birds. Jesus.

But I'm officially done with Cymbalta-- I stopped my ramp-down early. I'd made the shift from 20mg every other day to 20mg every 3rd day, and I think the third time I did that, I felt notably worse after I took the pill than I'd felt before. It knocked me out and made me feel sluggish and awful. So I decided that the time had come to part ways, and that was that. 

So Monday of this past week, the Day of Great Overwhelm, was the first day I should have taken Cymbalta but didn't. 

Makes sense it was a worse-than-usual day. It was. As was the next. But the day after that? Better. And the next? Better still. And then: Pretty good. And today: Not bad at all. So. It was the right thing to do. 

It was just a thing to be gotten through.

Still, the reality of what I'm doing to my brain and body is hard to escape when its displayed in such extremes. Not that I have a choice about it-- life with this chemical assistance is so, so, soooo much better than without, right now-- but that doesn't make it any less terrifying or humiliating.

And it is. Both. It's terrifying to feel this out of control of myself, and humiliating to... well, to feel this out of control of myself.

Hi. Sherlock here. Have we met?

So this week, as I said, was a strange one. We hadn't planned it this way-- it was all sort of coincidental that my husband was leaving AND my sister was arriving AND I was stopping my meds AND my other meds weren't yet on the scene AND I had a more-taxing-and-triggering-than-usual schedule.

But guess what happened, mid-week, as Cymbalta's last talon tore itself loose?

Psychopharm doubled my Amitriptyline dosage (from 25mg to 50mg, which is actually just the lowest therapeutic dose, typical being 50-100mg, so not that big a deal). Coincidentally, I hit week 6 of the 6-8 weeks it takes to reach full potency in your system, and, right on schedule, I'm beginning to feel some positive psychotropic effects.

They're mild, because I've been ramping up on a very low dose. But they began to pick up right when I needed them. Thursday of this week, as if to celebrate my survival of all the appointments and errands and panic-inducing calendar items.

So far, Amitriptyline feels like... creativity. Thursday night, I went on a Pinterest spree and found patterns for about 50 new handbags that I want to sew on the new, two-wall-spanning desk I want to build in the office I plan to paint in the house that I am once again excited to be designing and decorating to its best potential.

The fact that these effects coincided with the doubling of my dosage is indeed, I'm sure, a coincidence, but it bodes extremely well for when I begin to feel the effects of the increase.

A manic spree of creativity, I will gladly welcome with my whole heart. I'm sort of kidding about the mania thing-- I'm about as in danger of a manic phase as I am of flying to the moon-- but creative inspiration AND motivation together are, for me, the surest signs of a well-functioning antidepressant, so I'm a little thrilled to see how much further this will go. 

I'm a terrific idea girl, and not so great with the follow-through (see Overwhelm, above). I've got a few really enthusiastic women on my team right now (Hi A, A, and L!) who are ready to rock on some of my projects, so if I (and Amitriptyline) can get myself together to the tipping point, my world is about to get a whole lot more active and interesting and aesthetically awesome. 

So I'm still sort of in the in-between zone, in that I'm not yet sure if what I'm doing will be enough, or if there's another combination out there that will be better for my particular brand of crazy, but as of two days ago, I think I can say I'm past the worst of it and things are looking up.

And the Amitriptyline, a drug I'd never heard of before, is a bit of a rock star in ways beyond the psychotropic, for me, so at the very least, it will be part of my arsenal, ongoing. It helps me sleep, for one, which is awesome. And it seems to have closed the gap that the Topomax was leaving with the migraine propholaxis, and I've just gone a month and a half with only two half-hearted and quickly-extinguished attempts by a migraine to make itself known, including during a menstrual cycle AND a 2-week sinus-heavy cold. NOTHING. NO MIGRAINE. NADA!

So. THAT'S a win.

The rest is just figuring out what works and if what works works better than what doesn't work doesn't. If that makes sense.

If the benefit of the benefits outweighs the cost of the costs. Because with these drugs, there's always both, I'm learning, and you just keep comparing all the tics in the Pro and Con columns and hope, at some point, so come to some satisfactory balance. 

told my sister the other day that I feel a bit like you feel after you've been dyeing your hair for years and years and years-- so long that you have no idea what your real hair color is anymore.

I'm feeling like that about my brain now. Who knows what "back to normal" is?

I'm learning that "back to normal" isn't the goal for people like me, and we're just setting ourselves up for heartbreak if we keep insisting that it is. 

And anyway, with what I'd done with my normal, why on earth would I want that again, anyway?! I'd like to raise the bar on normal, please. Supernormal. Ultranormal. 

UBERNORM with a side of fries!

Yeah, forget reverting to what I once was, whoever that girl was and when she existed is lost to the ages now, and as lovely as she might have been, she didn't know the things I know. She hadn't seen the things I've seen. She'd never loved who I love or been who I've been or done what I've done or lived what I've lived.

Wishing to revert to her feels like regret to me, and if you've learned nothing else from this blog, I hope you've learned that despite it all, I don't regret what happened to me or the life I've had because of it.

And despite the times of struggle, I always manage to end up back here, on the way up, feeling charged with purpose to keep on fighting, keep on moving, keep on working for the new me who I know is evolving out of all of this.

And I don't have to settle for any old normal. I can make her whoever I want.

I'm just going to pick a shade of awesome that appeals to me and aim for that.