Mental illness looks strange to most people. People with mental illness behave in ways that violate social norms and appear wild, uncontrolled, and unpredictable. As a result, media is full of depictions of people with mental illness that are often misleading and offensive to those who, in the real world, have to live with a serious mental illness.
Let’s try to be the change that we want to see in the world.
We begin this series with a mental illness that has been in the news lately—and that has been touched on during this month’s posts. It’s a mental illness that struck 3.6% of U.S. adults and 5% of U.S. adolescents in 2017 alone. It’s called posttraumatic stress disorder, but we usually call it by its initialism PTSD.
Who Gets It?
PTSD develops in a subset of individuals who have experienced a traumatic event of some kind. A traumatic event can be physical, psychosocial, or sexual, but no traumatic event is experienced in the same way by any one person. Two people who experience the same traumatic event could have vastly different memories of the same event.
No one knows exactly why some people who experience a traumatic event don’t develop PTSD while others do, but there is very interesting research on resilience that hopes to shed light into this area. What we can say about resilience so far is that it probably has both a genetic and a psychosocial component. That is to say, some of resilience is inherited, and some of it is learned during early childhood development.
People with high resilience are likely to have certain psychosocial factors that inoculate them against developing PTSD. Some of these are listed below. While there are websites on the Internet suggesting that you can easily change yourself to become more resilient, these factors tend to be rather static over the lifetime. Adults have a difficult time learning them without a lot of time, effort, and help.
1. Active Coping Style – The ability to problem-solve and manage emotions that accompany stress. The ability to face fears and learn from them.
2. Physical Exercise – The ability and willingness to engage in physical exercise to improve physical health and mood.
3. Positive Outlook – The ability to use cognitive strategies to enhance optimism and decrease pessimism. The ability to embrace humor.
4. Moral Compass – The ability to develop and live by a set of meaningful principles. The ability to practice altruism.
5. Social Support – The good fortune to find and ability to make developing and nurturing friendships. The good fortune to have resilient role models in one’s life to learn from.
6. Cognitive Flexibility – The ability to find good in adverse situations. The ability to remain flexible in one’s approach to solving problems.
Having said all this, a highly resilient person who experiences a sufficiently traumatic event may still develop PTSD if the stressor is overwhelming enough to make it impossible for the individual to bring their protective factors to bear. Even the most resilient individual may break given enough pressure. One of my most resilient clients—whose information I have altered to protect her privacy—had experienced torture as a survivor of human sex trafficking by the Mexican cartels. She had PTSD, but she coped with it phenomenally well given the stressors that she faced day-to-day.
In short, anyone can get PTSD. Some people can experience the same traumatic event and experience it differently. One person may develop PTSD, while another person with more resilient psychosocial factors may not. Nevertheless, if the stressor is bad enough, even the most resilient individual can develop PTSD.
How Does it Look?
PTSD comes in a variety of forms. No one person’s PTSD presentation is the same. The client from before, who had experienced torture at the hands of the cartels, didn’t have any nightmares or negative self-esteem. She didn’t act out, nor did she hide herself away from the world. Instead, her PTSD presented itself in her hyperawareness of her surroundings. When she entered a room, she kept her back to the wall, and she always knew where the exits were. She startled easily, and her anger would be immediate and as merciless as it needed to be so that she could get away. Safety—for herself and for her family—was her primary objective, and she was willing to dig through flesh with her fingernails to find it.
Another client, who self-described as an “airhead,” was easily distractible and quick to please. She wasn’t worried about exits or strategies for her safety. But with her pleasant demeanor, she kept me at a distance. She didn’t trust men—she couldn’t. So she couldn’t trust me. By struggling to remain as fun and as sweet as she could, she was attempting to placate and soothe me. In the same way that Orpheus lulled Cerberus to sleep by playing his lyre, she was trying to get this interaction with a man over with, so that she could go back to being her smart, focused, and fearless self.
Someone else could experience terrible nightmares, which makes him hate going to sleep. Another person takes Ambien to make the nightmares go away. Another one drinks or smokes weed to the same effect. Between 50 and 67% of people with PTSD also struggle with a substance use disorder, usually to stop the re-experiencing symptoms from happening again…and again…and again.
The PTSD Formula
As described in the DSM-5, in order to be officially diagnosed with PTSD, a character must have been exposed to actual or threatened death, serious injury, or sexual violence in one or more of the following ways.
1. Directly experiencing the traumatic event.
2. Witnessing the traumatic event as it happened to others, in person.
3. Learning that the traumatic event happened to a close family member or close friend. When the event involves actual or threatened death, the event must have been violent or accidental.
4. Experiencing repeated or extreme exposure to averse details of the traumatic event, as when first responders have to collect human remains or when a social service worker is repeatedly exposed to the details of child abuse.
PTSD symptoms usually begin immediately after the traumatic event and persist for at least one month after the event. PTSD symptoms are made up of four different domains: Re-Experiencing Symptoms, Avoidance Symptoms, Arousal Symptoms, and Cognitive Symptoms. We’ll talk about each domain in turn.
Also called intrusion symptoms, re-experiencing causes the person experiencing PTSD to literally re-experience the traumatic event in one or more of the following ways.
1. Memories – The person experiences intrusive memories of the traumatic event. The memories can cause distress, even when they are just memories.
2. Nightmares – The person relives the trauma within their dreams. Sometimes the dream can be explicitly related to the traumatic event. Sometimes the dream is a metaphorical shadow chasing you, covering you, and suffocating you.
3. Flashbacks – The person relives the trauma again because something reminded them of it. It could’ve been a topic of conversation, a red car, the sound of a horn going off, or an odd scent, but something elicited the memory, and now you’re beginning to feel and act as if you were there. In the midst of it all.
4. Distress – The person begins to feel prolonged psychological distress after being confronted with a cue that symbolizes or resembles an aspect of the traumatic event. A blue button, an off-putting word, an odd look, can cause you to feel as if you’re in danger again.
5. Physiological Reactions – The person begins to feel marked physical reactions in response to a cue that symbolizes or resembles an aspect of the traumatic event. That same blue button, that same word, that same look, and now your palms are sweating, your stomach’s in knots, you want to pee, and maybe you’re having a heart attack, too. You can’t tell, but you have to get out now.
Avoidance causes the person experiencing PTSD to strive, sometimes at high cost, to want nothing to do with anything that could elicit a re-experiencing symptom. A person experiencing PTSD generally experiences avoidance in one or both of the following ways.
1. Physical – The person stays away from places, events, or objects that could serve as reminders of the traumatic event. Since that car accident that took your mother’s life, there’s no way you’re getting back in a car. Not now, not ever.
2. Emotional – The person avoids thoughts or feelings related to the traumatic event. You’d rather cut someone out of your life than hear them talk about their damn baby one more time. Every time, it’s like a knife in your gut, exactly where that monster made that incision…
Arousal symptoms are constant stressors to a person experiencing PTSD. They keep people on guard, untrusting, and isolated from others. It’s like walking on eggshells, and it can make a person with these symptoms easily stressed and irritable. High arousal can make it hard to do simple tasks, like eating, sleeping, and even concentrating. These symptoms usually come in two or more of the following forms.
1. Irritability – Frequent angry outbursts with little or no provocation. You don’t why, but you’re suddenly so mad you could break something. And before you knew it, you had. Both people or objects can become targets of this aggression.
2. Recklessness – The person becomes self-destructive and careless. You’re already broken. What could anything else possibly do to you, right?
3. Startling – The person becomes easy to startle, and their response is usually exaggerated in its intensity. An arm falls on your shoulder. What does it want? You don’t have time to think. You have to attack.
4. Concentration – The person struggles with concentration. It’s difficult to focus on any one thing. Any distraction is like a freight train’s screech.
5. Sleep – The person struggles to fall or to stay asleep. Or the person experiences restless sleep that leaves them feeling exhausted by morning. You got your eight hours, sure. Two hours of tossing and turning, an hour of cold sweats, you guess you must have passed out at some point because then your alarm started going off, and now you’re tired, annoyed, cold, and soaked in your own sweat. And it’s time for work.
Cognition is your ability to gain knowledge and understanding through thought, experience, and the senses. If your ability to concentrate is impaired, you can have make cognitive errors, where you acquire understanding that does not accurately reflect reality. It’s uncanny how much time we spend thinking to ourselves about our day-to-day experiences. Imagine being unable to do that normally. These symptoms usually come in two or more of the following forms.
1. Memory Problems – Importantly, the person’s difficulty remembering their trauma must have nothing to do with other factors, such as head injury or drug use. You remember flashes. Bits and pieces. A dangling light fixture. Stretching shadows that danced with the sway of the light. The sound of the boards creaking. But you can’t remember his face. It’s like he’s a blur and the rest of the world is crystal clear. You know who he is, but why can’t you remember his face on that night?
2. Negative Beliefs – The person experiences negative beliefs or expectations about themselves, others, or the world. You know it wasn’t your fault that the vampires raided the club that night. But you were a bouncer, and you hid. You lived, but maybe you should’ve died. Maybe you only lived because bad people get to live. Bad people like you. Cowards.
3. Cause Distortion – Persistent, distorted thoughts about the cause or consequences of the traumatic event that lead the person to blame themselves or others. You know it wasn’t your fault that the vampires raided the club that night. But you’re a dancer, you moonlight at a vampire club on Mondays, and you flirted with a vampire the other night. Did you lure them here? Could all of this death your fault?
4. Negative Emotions – Persistent, negative emotional state. You can’t shake the feeling of disgust that you have with yourself. Why did it have to be you? It’s probably something about you. Something gross that you can’t dig out. Or you’re constantly angry. You don’t know at what. Maybe it’s at the world. Maybe it’s your parents for having given birth to you. Maybe it’s you you’re maddest at.
5. Diminished Interest – The person has a markedly diminished interest in engaging in activities that they used to find pleasurable or were otherwise significant. You’ve stopped going in to work. They keep calling, but you can’t even bring yourself to answer the phone. “It’s been two weeks. If you need time, we can work things out, but I need you to talk to me.” You’re very lucky to have such a nice boss, but right now, all you can see is the empty space in bed next to you.
6. Detachment – The person starts to feel detached or estranged from others. Your wife used to be your world. But ever since you saw her face in the bathroom mirror—with those black, soulless eyes—you can’t even face her. It’s like she’s an entirely different person. She hasn’t changed. So what if she’s—whatever she is. She’s still the same mother she was yesterday. The same friend. She still makes you the same Get-Well-Soon waffles you like so much when you’re not feeling well. Still, you can’t shake the feeling that things aren’t the same. And you’re starting to feel that same distance when you hold your daughter. It’s like your heart is closed, and you lost the key somewhere that night.
7. Lack of Positive Emotions – The person becomes unable to express feelings of happiness, satisfaction, or loving feelings. You kiss your wife good night, but you don’t do it on the lips anymore. You barely turn your head. When she told you she was getting you tickets to see your favorite show, you forced a smile—because you knew it’s what she wanted to see.
How Do You Fix It?
You’ve given your character PTSD, and now you want to fix it. Before your character actually starts to do any fixing, your character is going to need help. PTSD symptoms can be managed with medication, which is why, as I’ve said, so many people with PTSD turn to alcohol or illegal substances. It’s highly likely, unless your character has many protective factors, that your character has been self-medicating with something before they get help. They may not be addicted, however, but that’s a conversation for another day.
Your character may or may not need help getting help. That is, your character may have to have another person point out how they’ve changed since their traumatic event. A friend, a stranger, even an antagonist could do this. Your character may or may not be reticent to seek help for themselves. They may or may not need to be dragged. They may go unwillingly. They may be eager to learn that something can be done about what they’ve been going through. Your characters’ reactions could vary wildly.
As I’ve said, no one experiences a traumatic event the same way. No one experiences PTSD the same way. Likewise, no one heals the same way. I hope I’ve made that clear by now.
In fantasy or science fiction settings, it becomes possible to heal PTSD with more active measures. A large component of PTSD comes from a person’s memory of a traumatic event. Lose the memory, theoretically, lose the trauma. Memories can be lost in a variety of ways in these settings, and you are encouraged to come up with your own.
Note, however, that chronic trauma is trickier. When a person has been exposed not to one or two, but many traumatic events over the course of their lifetimes, their memories often become jumbled together—good and bad. These memories become the core of the individual’s personality, in some cases leading to a personality disorder. In these complicated cases, none but the most powerful magi or the most talented advanced alien neurosurgeons could manipulate memories in a way that avoids doing irreparable damage to the individual’s personality.
Also note that there is no place in the brain where memories are “stored” after they are “lost.” Every time a memory is accessed in the human brain, it is rewritten with a memory of the memory. This is key to how healing occurs in PTSD. If the human brain is the only place where memories are “stored” in your setting, then lost or stolen memories are gone forever.
Non-speculative healing is done primarily with a psychotherapist. There are many well-researched treatment modalities for PTSD, but all of them work on a similar principle: remember and rescript the traumatic memory.
A traumatic memory, it turns out, is very much like an earworm in that it plays again and again in your brain. It becomes stuck, and so does the individual. Just like an earworm, which you can get rid of by playing the song in full over and over until the earworm is gone, a traumatic event is usually healed when a person, with professional assistance, goes over the event until their brain has fully processed what it means for the individual and their future.
Some people do heal on their own from PTSD over time, but this time is measured in years—even decades. The only way to do heal from it in a shorter period of time (anywhere from a year to a few years) is to undergo some type of professional treatment. Medication, whether provided by a doctor, a drug dealer, or a convenience store clerk, will only alleviate the symptoms of PTSD for a time. In many cases, the latter two only make things worse.
It’s difficult to be thorough when it comes to as complicated a topic as PTSD, but I’m willing to answer questions. Just comment on this post below, and I’ll happily answer any questions about any material I failed to cover. Come back next month, when I discuss depression!