Wednesday, May 28, 2014

Post Traumatic Stress Disorder in Your Character: Info for Writers

Found publicly on Facebook
The following information is based on the new diagnostic criteria as it is presented for clinical use in the DSM V. The DSM V is the American  bible for those working in the mental health field. If your character lives in a different country, you can understand the symptoms from this article, but you may want to do a quick search to find out if your country concurs. Also please note, the DSM V is the newest iteration and if your story is not being written in present-time then this will not be the exact information used by your mental health professional.

Video Quick Study (5:39) What is PTSD?

What criteria needs to be met for a PTSD diagnosis?

1. Exposure

In order to be diagnosed with PTSD your character need not have be at the event themselves. Indeed the stressor can be experienced in these ways (only one is required for diagnosis):
* Direct Experience
* Witness to an experience
* Indirectly learning that a relative or someone close to them 
   experienced a trauma - If the event involved a death or a 
   threatened death, it would have to have been violent in nature or
   accidental. So for example someone's spouse dying from cancer
   would not qualify for PTSD.
* Repeated and extreme exposure to aversive details of an event. 
   This is the kind of PTSD that affects so many of our first 
   responders. Events might include repeatedly seeing child abuse 
   cases, or horrific car  accident scenes.

   It does NOT include media exposure. So a character would not be
   diagnosed with PTSD from watching the September 11th event 
   on television, though they might experience a form of anxiety
   following their exposure. That anxiety does not fall under the
   criteria for PTSD.

Here are some events that might happen to your character that would cause PTSD (certainly not inclusive of all)
* Rape
* Criminal attack where one is fear for one's life (blog link)
* Sudden dismemberment - such as from a bomb explosion
* Seeing your spouse die of an unexpected violent act
* Being in a car accident
* Battle

Video Quick Study (4:12) Do different traumas cause different PTSD symptomology?

2. Intrusion Symptoms

(One required)
* Recurrent, involuntary, and intrusive memories
* Traumatic nightmares
* Dissociative reactions - such as flashbacks - these are
   experienced physiologically.
* Intense or prolonged distress after an exposure to a trigger. A
   trigger is anything that reminds the character of the traumatic
   event. It can be a scent, a time of day, a way that the body is
   positioned, a sound...

3. Avoidance - The character will make an effort to avoid triggers

(one of these is required)
* Tries to avoid thoughts or feeling associated with the event(s)
* Tries to avoid external reminders. These might include going to  
    the place of the trauma, having conversations about the trauma,
    attempting the same activity, etc.

4. Elevated changes in your characters cognition or mood that began after the trauma or worsened after the trauma 

Regions of the brain affected by PTSD and stress.
(2 of these needed)
* Dissociative amnesia - not being able to 
   recall key parts of the traumatic event.
* Negative beliefs about themselves and the
* Distorted blame of self or others - feeling that
   the trauma could have been avoided.
* Persistent emotions related to the trauma
   including such feelings as: horror, anger, guit,
Video Quick Study (1:52) Feeling shame after a trauma is a normal reaction

These last three can be misinterpreted as depression (blog link):
* Significant change in engagement in activities
* Feeling detached or estranged from others -
    family and friends.
* Unable to experience positive emotions.

Video Quick Study (4:12) What PTSD can feel like
Video Quick Study (11:03) Talks about visible brain changes
RELATED ARTCICLE - Honeycombed brain lesions only found in those who survived IED and explosive attacks.

English: Cases of PTSD and Severe Depression A...

5. Trauma related alterations in arousal and reactivity.

(2 required)
* Irritable and aggressive behaviors
* Recklessness and self-destructive behaviors
* Hypervigilent
* Exaggerated startle responses
* Difficulty concentrating
* Problems sleeping
(these are often self-medicated with alcohol abuse or drug abuse as the result)

Video Quick Study (13:45) Dramatization of PTSD episode. ~ GRAPHIC IN NATURE ~

6. Duration

* The symptoms must be experienced from 2-5 for more than a month.

7. There must be significant distress and impairment to their normal functioning this can be social or occupational in nature.

8. The symptoms cannot be traced back to another issue such as the effect of a medical issue or medications, or substance abuse.

    PLEASE NOTE: There is a different set of criteria for young children

PTSD is a physiological and psychological diagnosis which requires the intervention of trained, specialized health providers. 

* Your character should seek help from a
    proper mental health provider
* Your character's friends and family should be
   educated on the diagnosis and taught what
   helps and what does not.
   `Listening non-judgmentally
   `Not trying to solve the problem
   `Understanding that there is a brain change
    and the character can't "just get over it"
   `Understanding that this can get better
   `Reassuring the character that they are loved,
     appreciated, and important
* PTSD dogs are enormously helpful. They can
   sense the shift in the affected character before
   the character does and can alert the character
   and engage them in a way that lowers stress
Video Quick Study (7:02)

LINK US government Veteran's Affairs overview of treatment options and information about complex cases (more than one diagnosis ex. PTSD with drug abuse and panic disprder)

PLEASE NOTE: PTSD can lead to thoughts of suicide. If you are reading this blog and have these feelings, please seek help. 

In the United States, call:

National Suicide Prevention Lifeline: 
800-273-TALK (800-273-8255)

to reach a trained counselor

(press 1 to reach the Veterans' Crisis Line). 

If you feel that you might act on your thoughts now

PLEASE STOP and call 911.



  1. Excellent and informative article. Thanks!

  2. Thanks for this. One of my characters will be having some PTSD issues a couple books from now, and this will be a good reference.

    1. You are definitely not a pants-er. Great planning! When you get there, let me know if I can be any help.


  3. Great post Fiona, thanks. I've done a lot of research on the subject, the main character in my first novel suffers from PTSD. Your infromation, especially the video links, may help add further realism in the editing/rewrite.

  4. Great post Fiona. I have done much research on the subject, the main character in my first novel suffers from PTSD. Your post, especially the video links, may help add more realism during the edit/rewrite.

  5. One of the situations people don't realize can cause PTSD is repeated hospitalizations with life threatening diseases. For example, recurrent sepsis, recurrent abscesses, sickle cell disease with vasooclusive crises (pain crises).
    Just something to add. Otherwise, this is an exemplary post!

    1. I have had a couple of people mention this to me - so I'm going to respond from a clinical POV rather than an experiential POV.

      PTSD has a set of qualifiers that are listed above that come from the DSM V which is the diagnostic bible for clinicians.

      PTSD has the qualities of being sudden, unexpected, violent in nature and (with the exception of the repeated exposure of first responders and soldiers, etc.) also the quality of being over.

      In the case of medical issues, including issues that are life-threatening and high-pain, they are typically diagnosed with one of the other forms of anxiety disorders. That is not to say that the individual is not experiencing all of or some of the same reactions as an individual with PTSD, nor does it speak to the severity of the person's experience. It is merely a way to document the the affects of the presented condition and a base on which to build a treatment plan.

      My very best to you. It sounds like you've had quite a difficult road to travel. I am so sorry and wish you well.

  6. Hi Fiona! Thanks for posting an *inclusive* post about PTSD--there are many misconceptions floating around, one of which is that only war vets have/can have PTSD. Having suffered four+ years with PTSD despite never having so much as donned a military uniform (nor will I ever), I can attest to the FACT that this is not true.

    In my second book of my wip (Spheres), my protagonist suffers from PTSD. It's a lot different than my 'type'--I've never struggled with flashbacks, and the fantastical element(s) allow a different form of expression--but the point is, I want others to 1) be more aware of PTSD/its symptoms and causes/how to 'help' rather than hinder, and 2) to recognize that PTSD can *feel* insurmountable, but doesn't need to actually BE insurmountable.

    1. Thank you so much for your input, Lynanne. I'm so sorry that your experience with a traumatic event has had lasting effects on your life.

      Wishing well,

  7. Good stuff! Thanks for the helpful blog on PTSD.

  8. Great article. Three of the characters that I have in my books had suffered from PTSD, one from her infant son dying, second was a rape, and the third was a kidnapping and rape which led to a drug addiction. Thank you for sharing

  9. Poor Batman :(

    I have one character in my WIP who's handling her PTSD through subtle retaliation against her attacker (her brother) and another whom no one around him is sure whether or not he's suffering.

  10. Thank you so much for sharing such excellent information!

  11. This post contains so much valuable information!

    The main character in my next-to-be-published book develops PTSD by the end of the novel. Some of it stems from growing up in a chaotic household, but the main cause is her abusive skating coach. Like many PTSD sufferers, she is preoccupied with survival while the traumatic events are actually happening; the symptoms show up once she escapes to a safe place. She doesn't know what to do with herself in a safe place! Her main avoidant behavior is her refusal to speak her native language. But as she learns English, she refuses to speak it correctly because doing that isn't "safe" either.

  12. Fiona, thanks for another helpful info-site. I want to add that PTSD is very individualized. If a "family" is responsible for horrible abuse, they are not the ones to be entrusted with a diagnosis. If your parent is the perp and has died, you may have to get creative in dealing with the residues of long-term PTSD. Some counselors are specially trained. Safety is a big issue. Thanks for including this. Mary Ellen

  13. Just for clarification, PTSD is a medical diagnosis made by a qualified health professional. The person experiencing symptoms will be treated with an array of interventions including medication and therapy. Confronting the cause of PTSD is rarely part of the therapeutic program.

    What works for a client is indeed extremely individualized as is their treatment goal plan. If you are writing a plotline that includes someone with PTSD, it would be a good idea to find a professional who works in this area to give the salient points you've written a once over. For example, I wrote a book which included a character with schizophrenia. While I have a masters degree in counseling, I had little interaction with clients exhibiting this diagnosis. I hired an editor who has a PhD in psychology to make sure I represented the character correctly.


  14. Exellent article.I have PTSD myself from several months of being sexually harrased and you hit the nail on the head.
    (I know it happens WAY more freqently to women, but being a guy had a lot to do with it. Didn't know it was a thing until, you know, it happened.)

  15. This is exactly the kind of article I have been looking for for quite some time now. I am planning a series of stories which involve several characters dealing with mental health issues. One suffers from panic attacks, with which I have personal experience, but I have no personal experience with PTSD and I worry about not representing it correctly.

    However, this article seems to be more focused on authors writing stories set in the modern world. My story will be set over 1000 years in the past, where diagnosis and treatment would have been completely different. Indeed, PTSD would not even have been recognised for what it is. I am still struggling with which aspects of an article like this to include, i.e. which would be most historically believable. Any advice on that front would be incredibly useful.

    1. Hi Ellen,

      If it were me writing this (I have a history degree as well as psych degrees), I would plan for my character's internal (feelings, inner dialogue, what he does in private) and external (what others see - his facial expression, his eating patterns etc) based on the information that is listed as the criteria for diagnosis.

      THEN, I would decide how you think his group would handle things. Remember what we perceive as traumatic may not be traumatic at a time when violence, illness, pain and suffering were much more part of the everyday experience. Once you know the norms for your group, you can decide how that impacts the traumatized character.

      Best of luck - it sounds like an interesting project.