Showing posts with label Posttraumatic stress disorder. Show all posts
Showing posts with label Posttraumatic stress disorder. Show all posts

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.
Regions of the brain affected by PTSD and stress. (Photo credit: Wikipedia)
(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...
English: Cases of PTSD and Severe Depression Among U.S. Veterans Deployed to Iraq and Afghanistan Between Oct 2001 and Oct 2007 (Photo credit: Wikipedia)

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. 

US Navy 101118-F-5586B-144 Marine Sgt. Brian J...
US Navy 101118-F-5586B-144 Marine Sgt. Brian Jarrell pets his dog (Photo credit: Wikipedia)
* 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.

Thank you so much for stopping by. And thank you for your support. When you buy my books, you make it possible for me to continue to bring you helpful articles and keep ThrillWriting free and accessible to all.

Sunday, September 22, 2013

Criminal Psych 101: Information for Writers


Werner Erhard and Associates v. Christopher Co...
 (Photo credit: Wikipedia)
I have a masters degree in rehabilitation counseling, which means that I worked with people who had mental health issues created by or exacerbated by physical health issues. For example, I had a family whose father was electrocuted while working in the hospital. Because he was on site, doctors were able to save his life. However, he had a complete personality change and became prone to fits of physically-abusive rage. These were aspects that could not be changed, but the family had to deal with.

When I was practicing, I was a court ordered interventionist for families at risk. My population had at least one family member who was involved in the penal system AND displayed serious mental health concerns in the family including homicidal and/or suicidal ideations, and sexually deviant behaviors, among others. 

The following are some things that I think writers might find helpful when constructing their plot lines. I will also offer, that if you have a specific question, you can leave it below, and I will do my best to help.

One of the main things that I want to point out is that clients who are seeing a mental health provider because they want to improve their lives and someone who is court ordered to work with a mental health provider are different. 


* There of their own volition
* Generally honest and working hard to make improvements
* Client's privacy is protected under the law
* End goal is to become a better/happier person

Judicial orders:

* There against their will
* Typically uncooperative and uninterested in progress
* Information gleaned in the therapeutic setting does NOT fall under the same
   patient confidentiality laws
* Client is aware that the information can/will be part of their trial or other legal
   procedure (such as parole hearing)
* Client frequently tries to manipulate the mental health worker to influence their
   testimony and outcome.

So, I dealt with a lot of deception. The two main false presentations were malingering and defensiveness.

MALINGERING - the client pretends to have a mental health issue. Usually they do this to avoid being prosecuted. Malingering runs in cycles closely copying those stories that are found in the news. Clients usually didn't make up symptoms by doing research (in my client case load). Psych disorders and medical disorders tend to be fashionable - right now bi-polar is a big diagnosis. I personally know people who have been given this designation and are medicated for it when I am very clear this is not their issue. I am not digressing - I am pointing out that even clinicians, when not paying attention, can fall into this habit as well.  But if a client presented with PTSD, I would pay very close attention to their symptoms because PTSD is so prevalent in the news right now.

How could I pick out a malingerer? 
* VERY dramatic. Really pushing the envelope on wacked-out (yes, the clinically
  correct word) behaviors. So if your character is malingering, look up the
  symptom list in the DSM V (Should be in your library) and then magnify these
* They drop the symptoms from time to time especially if they don't think anyone is
   watching. It's hard to maintain fake symptoms for long stretches of time. It's like
   constantly telling a lie; the brain is very engaged and becomes tired.

And then just to cloud things a bit, there is pseudo-malingering. That's when someone with a mental health issue pretends to have a different mental health issue because they think that will get them off the hook. Ex. Someone who is a psychopath presenting with PTSD symptoms. The mental health worker has to decide which symptoms are true and which feigned. It's a mess! But would make a GREAT PLOT TWIST!

DEFENSIVENESS - You can read this as the opposite of malingering. It's when a client, with OBVIOUS mental health issues, tries to present as stable. I had a client once who was trying to keep custody of her children. She was diagnosed schizophrenic, was non-compliant with her meds, and suicidal. When she went before the judge, she thought that the best way to keep her children in the home with her was to lie. (She was successful in keeping her six children, and the end result was catastrophic for the kids, I'm sorry to say.)

Now, while I am a counselor, typically the two titles seen in the legal system are:
Forensic Psychologists and Forensic Psychiatrists.

Forensic Psychologists 

* Have masters or PhD in psychology
* Can do psych testing
* Can offer expert testimony
* Can provide treatment and evaluation of progress  CANNOT prescribe
* Can attempt to establish a motivation in a crime
   Was it do to a substance abuse issue?
   Was it do to something that had happened to that person in the past?
   Was it do to a mental health disorder such as PTSD or Schizophrenia?

Forensic Psychiatrists

Regions of the brain affected by PTSD and stress.
Regions of the brain affected by PTSD and stress. (Photo credit: Wikipedia)
* Have medical degrees and residency in
* Can do everything that a psychologist
   can do
* Can prescribe medications
* Can decide if the client is a danger to
   self and community leading to an
   involuntary mental health hospital stay
* Can establish if the crime was based
   on a medical issue - one such issue that
   is coming up in the news lately are the
   brain injuries sustained in football,
   and tumors growing on the brain.

Counselors, Psychologists, and Psychiatrists all:

ASSESS - evaluating people using psychological tests

Mental health workers do NOT get to make a judgement. They are only offering their expert opinions. For example, I could not declare someone insane and have someone placed in a medical facility involuntarily. I would present my information and the judge would rule about the sanity/capacity of the client.

Testing is used to help the courts understand the person being assessed
Test Examples:
General personality inventories Myers-Briggs
Beck Depression Inventory 
Rorschache Test Video Link to original test (9:05)
Weschler Memory Scale
Weschler Adult Intelligence Test Video Information Link (13:38)
Robert Hare's Psychopathy Checklist Animated List - Link (2:43)
Rogers Criminal Responsibility Assessment Scales Informational Link
English: At sea aboard USNS Comfort (T-AH 20) ...
 (Photo credit: Wikipedia)

Psychiatrists can add physical exams:
Blood work
Toxicology reports
Cat Scans

TREAT - psychotherapy like talk therapy, art therapy, music therapy,
 behavior modification

* Civil - family members of custody, guardianship, JD, medical do-not resuscitate,
   disability and loss in workers comp cases and social security cases
* Criminal - 
   Ability to stand trial
   Treatment of incarcerated criminals

One of the things that Forensic Mental Health Workers are trying to decide upon is competency. Someone could have been legally insane at the time of the crime. That does NOT mean that they are insane now. So the assessment looks at what was the mental health capacity in the
* past
* present - what is their mental health standing now? 
   Can s/he give testimony? 
   Stand trial? 
   Can this client understand what is going on? 
   Can they participate in their defense?

It's during the trial that the judge would decide the level of sanity during the crime. Only about 1% of cases attempts an insanity plea. 1 in 1,000 are considered insane.

An American judge talking to a lawyer.
(Photo credit: Wikipedia)
Guilty but Insane:

If the defendant did not or could not understand what he or she was doing, or they knew it was wrong, at the time of the crime, they are considered not guilty by reason of insanity.

* Mens Rea - Guilty mind 
  You can't have a crime WITHOUT  mens rea and if you are
   criminally insane you CANNOT have mens rea and therefore you CANNOT
   be guilty

* Actus Reus volitional and conscious and/or omission to act. Ones mental
  state  can effect actus reus.
  Sleep walking disorder
  Car accident with stroke
  You don't owe the duty to go to someone's aid if they are imperil (unless by
   contract/law/or relationship)
  VIDEO QUICK STUDY (5:25) go to 1:30 to start.

Guilty but Mentally Ill:
After John Hinkley shot at Reagan the courts developed a new designation. Guilty but Mentally Ill happens when the suspect knew what he was doing was wrong BUT could not help or stop the actions because of his mental health status.

Diminished Capacity - you had the intent to commit the crime but had a mental reason for not being held completely responsible. VIDEO QUICK STUDY (:48)

See how this article influenced my plot lines in my novella MINE and my novel CHAOS IS COME AGAIN.

Thank you so much for stopping by. And thank you for your support. When you buy my books, you make it possible for me to continue to bring you helpful articles and keep ThrillWriting free and accessible to all.