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PTSD and Characters



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Wed Jan 14, 2015 12:33 am
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Rosendorn says...



This is meant to be a quick but comprehensive guide for what PTSD is, ideas for how characters can react to it, and the breadth of the illness. It is meant to be primarily a writing guide, and if you are looking for more information than what is provided here, please consult Google.

What It Is

A natural reaction to a traumatic event. The event can affect the person directly, they could have witnessed it, hearing about it happening to somebody close, or receiving indirect exposure to the aftermath via professional ties (EMTs, firefighters, ect). This means simply being in a war zone is enough to cause PTSD, and you don’t necessarily need to have been a soldier. However, this also means you can be within proximity of any dangerous situation that can be traumatic for the person and develop PTSD.

What It Feels Like

I’m pretty sure everybody reading this has been in a situation where something felt dangerous because the situation reminded them of things they knew were dangerous. It’s a little sickening, and a little scary, and you want to get out of there.

PTSD is that feeling on steroids.

When a person goes through a traumatic event, everything about that trauma becomes a potential trigger to remember that trauma. If the trauma happened in the dark, and the person highly associates the dark with trauma, then expect the person to be at least stressed in the dark, if not in a full on panic attack (however, if the dark is not strongly associated with that trauma, then darkness would not be a trigger). These can seem like really innocuous little things, but because they are so strongly associated with trauma in the person’s mind, they become a trigger that gets the person’s brain going “this is dangerous you’ve been here before get out now this will not end well.”

Causes

Literally anything a person finds traumatic can result in PTSD. This can include bullying, abuse (physical/emotional), assault, combat, gun violence, and a whole host of other things. Note: I said anything a person can find traumatic, not necessarily what you find traumatic. This means the variety of causes can span the gamut, and different people will have different causes. Some people can go through events considered highly traumatic and not be phased, while others can develop PTSD by things the average person would consider extremely mild/”unworthy” of such an extreme reaction. People can have past trauma that raises their threshold for what is considered a traumatic event, or their past trauma can make them more sensitive.

Regardless of what you think is traumatic or not, you have to put yourself out of your own shoes and develop the character to the point you know what is traumatic for them.

Diagnosis

PTSD is an extremely complicated mental illness, akin to a jigsaw puzzle. This site has the latest diagnostic criteria. This guide only explains certain points of the criteria and will not directly copy paste unless the wording is particularly relevant.

Number of Symptoms
Many symptom categories for PTSD only require one or two symptoms to be present, despite there being many more symptoms in the category. However, this does not mean people will only have one or two symptoms. Some people have all symptoms in the category, some people have half, or some have the majority. It depends on the person involved.

However, in order to qualify as PTSD, the bare minimum of PTSD symptoms must be present. People can be troubled by events and have some of the symptoms, but it’s not a full out PTSD by diagnostic standards until you hit that criteria.

Severity of Symptoms
This is where things get interesting.

Believe it or not, different people experience the “same” symptom very differently. I’ll break down some sliding scales of possibility for a few of them.

Flashbacks
The textbook PTSD symptom everybody reaches for when they want to show somebody has PTSD. However, they have multiple expressions and don’t always take on “I feel like I am there in that exact moment” edge, and only one type of intrusion is required in order to qualify as PTSD. Types of intrusive memories as covered in Criterion B; terms explained below:

1- You remember the traumatic events repeatedly, without any prompting. This is the “can’t let it go” part, and you rather literally can’t because your brain constantly reminds you of it. However, the length of memories and amount of times they intrude can vary.

2- Nightmares. Fairly self-explanatory, but the frequency and duration of them can vary. Also, the comfort tools people need at night can vary; some people cannot feel better at night no matter who or what is there, while others improve when certain people or things are there.

3- Disassociation. This is the one labeled “flashbacks” and this is the one that has you forget the present and you are back in the trauma for everything from a moment to hours. I tend to specify these as “five sensory flashbacks” when discussing flashbacks, because these are the ones that take over your senses. You are back at the moment of trauma and there’s nothing you can do about it.

4- Basically, being extremely uncomfortable after any reminder of trauma from intensely feeling wrong for a short period of time to a prolonged period of various types of distress, including anxiety, depression, and other urges for or acts of self-destructive behaviour.

5- You react to stimuli around you more intensely than somebody without PTSD after being reminded of trauma related stimuli.

Note- You can have only one of these, or you can have any number of them in any combination. Your character might not have any disassociation at all, or might have them in combination with something else.

Disassociations Without Flashbacks
This is only a maybe for some PTSD survivors, but it does exist. It’s a general feeling of not being in touch with either yourself or reality, sometimes both. These are not psychotic, schizophrenic, or any other hallucination based mental illness.

More often than not, these are coping mechanisms for very intense feelings. When in a triggering situation, sometimes it is easier to disconnect to either the world around you or yourself. These periods can be short, or extremely long if the person is in a triggering situation for a prolonged period of time. Some people experience a "crash" back into negative feelings if they spend too much time in a situation they disassociate from.

Emotional Effects
Somebody with PTSD will often report mood changes. These are covered in Criterion D, which has two required for the criteria to be met. These can result in personality changes or sometimes form a duality; a few personal stories involve people believing they had type II maniac depression instead of PTSD.

Also, PTSD survivors can have unusual and unexpected reactions to stimuli. At times, they can appear detached and robotic from horrors around them, while others they can be hypersensitive to what appear to be small things.

The word “appear” shows up in both sentences because the inside and outside world is very different. Becoming detached is often a survival mechanism, a sort of “shut down and stay safe” technique that allows some semblance of continued functioning; meanwhile, hypersensitivity can be an indication of a highly triggered state.

Reactivity
Primarily covered in Criterion E. I touched on this in the last point, but this criteria is about reactions to the area around you. Only two need to exist, but more than that can exist. They can be contradictory symptoms, or they can be consistent symptoms. The way symptoms manifest depend on the person who’s expressing them, with each symptom having definitions relative to the person affected. “Self destructive” behaviour can be everything from drugs and alcohol to eating disorders and a messed up sleep schedule. Think about your specific character and how they can most easily self destruct, because in the end it is about availability and best use of the symptoms.

Comorbidity
Aka “a bunch of illnesses show up together and they interact.”

PTSD has multiple common comorbids, including addiction, depression, anxiety, and eating disorders. Insomnia is not uncommon, as well, especially if the person has nightmares. Nightmares can result in people who stay up until they’re about to collapse, then they sleep for a few hours and repeat the cycle. This means if your character has PTSD, you’ll have to at least entertain the possibility that they have more illnesses. You’ll have to consider whether or not they have comorbids, and if so, which ones they have. While doing this, keep in mind each one of the comorbid illnesses has multiple expressions, such as addiction spanning from thrill-seeking to drugs (to a whole host of things you can be addicted to), and eating disorders spanning starving to binging.

A note on CPTSD
CPTSD is a subset of PTSD that results from a very specific traumatic situation: long term captivity/entrapment. When somebody has been abused for an extended period of time in a space where their abuser completely controlled their environment, they can develop CPTSD. This type of PTSD is debated and not included in the DSM 5, but that doesn’t mean the illness itself doesn’t exist.

The primary symptom that differs from PTSD is a loss of self. Because of the captivity, people don’t know who they are outside of abuse. It leads to people not really knowing how to hold onto who they are, even after they’ve left abusive situations. People with CPTSD can throw themselves into what other people are doing, or into what they feel like they should be.

Wikipedia has a good overview to start your research.

Overall
If you take one thing away from this article and one thing only, I want it to be this:

PTSD is different for everyone, which means it should be different for your characters.

While abuse does change who you are, it doesn’t change you the same way as the next person. Abuse survivors do share commonalities (they have to, in order for diagnostic criteria to exist), the end result for how those commonalities express themselves can and often are wildly different among people. It depends on what they have available, what the abuser/trauma allows, what they can get away with. If you’re going to have a character with PTSD, you have to build in their whole history from pre trauma, the trauma itself, and post trauma. In the case of parental abuse, pre trauma might not exist, which makes it even trickier to figure out how their personality would’ve manifested (it’s likely the vast majority of their personality would be reactive, as a result of trauma).

Trauma is not something you can simply throw onto a character. You have to build it into them. Do your research into it, talk to people who have PTSD, and talk to people with the specific type of trauma you’re using. Understand the illness is not a monolith, and even two people with exactly the same cause can express different symptoms. They can have different comorbids. They can have the same comorbids that manifest different ways.

It’s messy. It requires a lot of thought. And you owe the people who actually suffer from PTSD the respect of doing it.
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Wed Jan 14, 2015 10:23 pm
RacheDrache says...



*claps*
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Sat Jan 17, 2015 3:45 am
ThereseCricket says...



This is great, Rosey. Thank you for it. <3
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Sun Jan 18, 2015 1:40 am
TheCrimsonLady says...



Love this.
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Thu Jan 22, 2015 6:44 pm
BellaRoma says...



This is so like my character (especially the long term captivity thing). Many of the traits are similar, which makes sense in the context of my novel.
It's been really helpful.
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Fri Feb 20, 2015 12:04 am
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Carlito says...



Very well described!

The only thing I would add is that PTSD (along with most mental health disorders), is very treatable. There are TONS of different treatment modalities, and I'm not going to try to explain all of them. The most common (and arguably the most effective) is Cognitive-Behavioral Therapy (CBT) or Cognitive-Processing Therapy (CPT). I'm not sure if the internet can give an accurate description of what those are, so if you're curious I am happy to share!

One of the biggest pet peeves I have when I read books that have any element of mental health in them, is how horribly inaccurate the symtomology or treatment looks. This is a disservice not only to the field, but for the millions of people that are affected by these disorders.

I am in a clinical psychology graduate program. All of this stuff is very complicated, so PLEASE ASK if you're not sure. :)
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Fri Feb 20, 2015 12:42 am
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Rosendorn says...



@Carlito

An addendum to that.

PTSD's treatability depends on quite a few factors, including the severity of PTSD, how long it's gone untreated, the type of PTSD, and the resources available to the person suffering from it. There's also whether or not you end up with a validating therapist who knows what they're talking about (a surprising number of therapists know nothing about how to handle patients), don't actually have PTSD relating to therapists themselves, and how much mental energy you have to put into therapy. There's also how some people are medication resistant, can't afford either therapy or medication, and how everything therapy wise is a shot in the dark that not everybody wants to try. Some people don't even realize they have PTSD, even if they express all the symptoms.

Also, this guide applies to fantasy, science fiction, and historical novels, all of which can have no mental health care system to speak of. Some places in the modern world also lack these mental health care systems, or do not use Western psychology as we know it (forcing therapy programs that aren't culturally adjusted to non-Western areas often fail and are critiqued for being colonialist). Plus, as I mentioned, not every therapist is physically capable of handling PTSD symptoms, or might not handle the PTSD subset the individual has. They could dismiss the experience on their own prejudices and refuse treatment. The patient could have other factors (sexual orientation, race, gender, disability) that make the therapist doubt the reality of PTSD.

Not everyone can go to therapy for the reasons above. For some, it's too expensive. For others, they cannot afford to take time off to properly recover. Some are still in the situation that gave them PTSD in the first place (such as those still living with abusive parents). And yet more can and have been highly abused by the health care system to the point they have absolutely zero trust in it for completely good reason. Many individuals have PTSD regarding therapists from this abuse.

While the points you raised are important, please do not assume that every and all case of PTSD can be treated. Also, even with treatment (one of my friends has gone through a very successful, therapist-shocking recovery period), people can and do still express the symptoms (which she does). They simply become manageable. Treatment is not a get out of jail free card for the illness going away. Some people can and do recover completely, but that is not physically possible for everyone. This is both between the amount of resources they can allocate to recovery and how severe the PTSD is. Some people who can dedicate all their time to recovery still can't improve simply because the PTSD runs too deep.

These are all things to keep in mind, and before you even consider if your character has gotten treatment and what type of treatment they go through, you have to consider if they can in the first place.
A writer is a world trapped in a person— Victor Hugo

Ink is blood. Paper is bandages. The wounded press books to their heart to know they're not alone.

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