Treatment Tuesday - Posttraumatic Stress Disorder

First off, I'm a guest blogger over at Seekerville today, so stop in and say hello!

Today’s assessment comes courtesy of Heidi. Her heroine got pregnant when she was 17 and had the baby, but her parents forced her to give the baby up for adoption. She is married, but not to the baby’s father, and has lived over twenty years since the incident mentioned above, which has molded her into the person she is today. She blames her parents for the adoption and doesn’t consider herself at fault (premarital sex and all).

Heidi wants to know the following:

1) If someone has PTSD and they are triggered, would they have “panic attacks” or something that would send them to the hospital for a few days? My character has depression more than PTSD, but I need her to end up in the hospital for a night or two to be monitored—what can she have?
2) What would happen if someone with PTSD tried to regulate their medicine, either by not taking it or taking less or none from time to time?

Great questions to get us started, and I like that you already have a working diagnosis! That can and should serve as the framework for the character.

PTSD—or posttraumatic stress disorder—is an anxiety disorder with a fairly high prevalence (about 8% of adults). It is characterized by reexperiencing an extremely traumatic event accompanied by increased arousal (exaggerated startle response, irritability/angry outbursts, hypervigilance, etc). Yes, if she is triggered, a panic attack would be something she could experience. You’d want to incorporate many of the following symptoms into your portrayal of a panic attack to make it very realistic:

1) Pounding heart, increased heart rate
2) Sweating
3) Shaking or trembling
4) Sensations of shortness of breath/being smothered/choking
5) Chest pain/discomfort
6) Nausea/abdominal distress
7) Faint, lightheaded, dizzy, unsteady
8) Fear of losing control or going crazy or dying
9) Parathesias (numbness or tingling sensations)
10) Chills and hot flushes
11) Derealization (feelings of unreality) and depersonalization (feelings of being detached from oneself)

While any and all of these symptoms would be uncomfortable, scary, and upsetting, likely most people would not end up in a hospital because of a panic attack. (There will always be exceptions, however.) My suggestion is to have her pass out from hyperventilation and she could hit her head on something and then that would require monitoring at a hospital.

People with PTSD also avoid anything associated with their trauma. So Heidi’s character would likely avoid talking about adoption, wouldn’t want to be in a hospital (where I assume she was forced to give the baby up) or an adoption agency. So I’d add a few of these telling type scenes to really up the tension factor when she does have to go to hospital. The reader will know this is a big deal.

But since Heidi mentioned her heroine is also depressed, I would be remiss in pointing out an option that would definitely land her in a hospital for evaluation: suicidal ideation. In California, if a person is deemed by a health care professional to be a risk to themselves or others, they can be checked into a mental hospital for observation for 24-72 hours. You might not want to go this dark route, though.

As for your second question about medications, I’m afraid I can’t help you. I’m a therapist, not a psychiatrist (who can prescribe and advise patients on medication). I would refer a patient who was self-regulating her medications back to the doctor who prescribed the medication. Maybe a medical doctor could help you with the physiological reactions you could incorporate into your book. Sorry I can’t be of more help there, but hopefully I’ve given you some other things to chew on.

This service is for fictional characters only, so any resemblance to real life examples is entirely coincidental. Any other fictional character assessment questions can be directed to charactertherapist@hotmail.com.

Character Stereotypes: The Victim

Main Entry: vic•tim
Pronunciation: \ˈvik-təm\
Function: noun

1 : one that is acted on and usually adversely affected by a force or agent: as a (1) : one that is injured, destroyed, or sacrificed under any of various conditions (2) : one that is subjected to oppression, hardship, or mistreatment b : one that is tricked or duped

Think about everything that commonly finds a way into our fiction that falls under that definition: rape, molestation, neglect, robbery, mugging, kidnapping, being taken hostage, terrorist attack, torture, military combat, incarceration as a prisoner of war or in a concentration camp, natural/manmade disasters, severe automobile accidents, carjacking, being diagnosed with a life-threatening illness, or seeing a dead body/body parts. All of these events can be learned about, directly experienced, or indirectly witnessed.

I lifted the above list right out of the Diagnostic and Statistical Manual under the description for post-traumatic stress disorder (PTSD). Not all “victims” have PTSD, but it’s a good disorder to know about in order to inflict our victimized characters with realistic, varying emotional hurdles.

Based on the four most descriptive clinical symptoms for PTSD, I’ll offer a couple overdone and underused scenarios for you to consider for your protagonists.

1) The character has to go through something awful—see above—and respond with intense fear, helplessness, or horror.

Clichéd: Usually fictional victims directly experience a horrible past event; they react with screaming, panic attacks, or “freezing” in place.

Creative: A person can have PTSD simply by seeing something happen to someone else. They can also learn about something awful over the phone and still experience PTSD. Not everyone experiences fear or horror the same way. What if your character laughed nervously when afraid or vomited when horrified?

Click here to read the rest of my article.

Treatment Tuesday - Plot Helps

This week’s character assessment comes from Kacey. She’s writing a YA novel about two friends, Eric and Lane.*

Eric is a 17-year-old who lives with his aunt’s family because seven years ago, he and his mother were attacked by a meth-addicted intruder in their L.A. apartment. His mother didn’t survive the attack.

Eric’s story begins with him and his friends driving at night when his friend hits a man on a bicycle. They stop to see if the man is okay but flee the scene when he starts to regain consciousness. This triggers Eric to remember how he felt after his attack, lying alone, injured, waiting for someone to find him.

* Names have been changed to protect the fictional.

Kasey wants to know several things:

1. Would it make sense for Eric to blame himself for not being able to help his mother in some way and prevent her death? Or would he be more inclined to blame her for the attack somehow (i.e., she should have kept the windows locked so the intruder couldn't get in)?
2. Would the attack affect how he feels about women in general?
3. Would it make sense for him to blame his friend Lane for leaving the man in the street even though Eric was there, too? Would he be more likely to blame himself?
4. After years of therapy, after everything seemed to be going okay, would it make sense for his PTSD to be triggered?
5. Eventually, after Eric and Lane go their separate ways, Eric chooses to turn in Lane to the police. If Eric is experiencing PTSD, would this require too much cognitive functioning to do? Or would someone else need to prompt him to do this?
   

These are some great questions, and very specific, which helps me narrow my psychological focus.

Since Eric lost his mother in such a traumatic accident, it is not at all unrealistic to think that he had post-traumatic reactions to the attack. Your suggestion of putting him through a few years of therapy would also be realistic, as 10-year-olds who are victim to an attack should get counseling, even more so if they lose a parent.

As far as your first question, a young child almost always would blame him or herself for the death. But since Eric is 17, almost of age to be counted as an adult, this rule isn’t as hard and fast. Your decision would need to factor in Eric’s personality. Does he usually blame others, even for his own mistakes? Or does he typically shoulder all responsibility, even when it’s not his due?

Because an adolescent doesn’t have the problem solving and interpretive skills that an adult has, that leads me to think the twist about blaming his mom might make for a more gripping plot rather than the old tried-but-true self-blame. Ultimately your call, of course.

As for your second question, I tried to see how the connection would be made between women in general and his mother, who was the victim of the meth addict’s attack. Maybe you are asking if he would assume all women are helpless or weak? All women would eventually endanger him in some way? Feel free to email me with additional info, as I’m afraid I don’t really have an answer for this one.

Your third question can piggyback off the first. If Eric is going to blame his mother for the attack, then it makes sense that he might blame Lane for leaving the hit-and-run scene, as well. However, a lot would ride on how the scene played out. Did Lane make Eric leave the scene? Had Eric wanted to stay and try to offer help, as he remembered his own attack situation? Had Eric felt a familiar sense of dread at the helplessness of his previous situation and wanted to get out of dodge? How you write that particular scene will play a large role in how his guilt or anger comes to the fore later.

And for the last question, it would absolutely be feasible for PTSD symptoms to return after a period of latency where everything seemed fine. Trauma is a funny thing, and people react differently to it. I’m actually just finishing a book about a woman with PTSD who goes symptom-free for over a year and thinks its okay to get back into her former job. But, of course, she encounters a situation that provokes a panic attack associated with a flashback. Totally within reason.

You mentioned that Lane is going to experiment with meth, which you want to feel like a gigantic betrayal, since Eric’s mother’s murderer was a meth-addict. Then you mentioned, “especially coupled with the fact that Lane left a man [run over on his bicycle] in the street at the beginning of the story.” I’m not seeing how the second factor is a betrayal in the traditional sense. Granted, the meth experimentation is understandable. Lane would surely know how this would really tear Eric up. But I just didn’t see the connection with leaving the man in the streets…UNLESS you have written that scene in such a way that Lane forces Eric to leave the man against Eric’s will (see earlier comment above about this crucial scene) or you have some plot twist about the guy on the bike being the meth addict and if they had stopped, they might could have seen the intruder and Eric’s mom’s murdered brought to justice. Hmm…just a thought, though. ☺

Hopefully this has helped with some of these questions. As with any of my assessments, please feel free to email with further questions.

This service is for fictional characters only, so any resemblance to real life examples is entirely coincidental. Any other fictional character assessment questions can be directed to charactertherapist@hotmail.com.

Dear Jeannie: Paranormal PTSD

Dear Jeannie,

My character is named Tex and is the equivalent of a preteen at the time the story takes place. He was raised by an older boy named Johnny who did his best to keep Tex out of harm's way, but ultimately failed when he was forced to leave on short notice when Tex was about 5 or 6. Little Tex had a rough time living on the frontier: malnutrition, inability to find steady work, people taking advantage of his naivety, having to get streetsmart or die, etc. He learned that he possessed the ability to experience emotionally impacting events that occurred in certain places. He found this out the hard way by experiencing the Battle of the Alamo first hand several years after it ended. As a result, Tex now avoids memorials and old battlefields like the plague, fearing something similar may happen. Tex doesn't see Johnny again for 16 years, by which point he promises to aide Johnny in his side of the American Civil War. What kind of emotional baggage might Tex be carrying with him? 
 

Sincerely, 
Stressing in the States

Dear Stressing,

It's pretty clear that Tex is likely suffering from PTSD. One of the key symptoms of PTSD is avoidance of stimuli (people, places, things) that remind you of the trauma. Since he is scared to visit old battlefields and memorials where people died, this would fit. He might also have flashbacks, nightmares or day terrors...you can see my Anxiety Disorders label for more info.

What might be more painful for him is the idea that Johnny doesn't seem to remember him (whether Johnny does or not). I'm sure as a young boy he was wholly reliant on Johnny, and probably worshipped him with hero status. You didn't make it clear whether little Tex knew why Johnny had to leave suddenly, but either way, that event would have devastated him. Seeing him years later, seemingly having moved on, would make him very wary, if not downright pissed. I hope that you have given Tex a very good motivation to want to help him, otherwise that plot point might seem implausible. 

Best of luck to you, and thanks for writing in. 

Got questions of your own? Leave them in the comment section, using monikers like Sleepless in Seattle, and I will post my answers in next weeks column.  The queue is empty, folks.

Dear Jeannie: Depersonalization Disorder and Survivor's Guilt

Dear Jeannie,
 
In my sci-fi book, my character endured sensory and sleep deprivation torture for about 5 weeks before being rescued. He hallucinated a malicious version of himself which taunted him. This character had previously died under similar circumstances before being reincarnated. Due to the similar feelings of isolation, helplessness, distortion of senses and reality, as well as the feeling of dying in both situations, do you think it would be realistic for him to develop Depersonalization Disorder as a result of the second event? Also, what other emotional baggage might he develop as a result of this event?

Lively in London


Dear Lively,

Dissociative disorders are a heck of a lot of fun to write, aren't they? Depersonalization disorder might fit the bill for your guy, but let's make sure.

People with this disorder experience episodes during which they feel detached from, outside of, or lacking control of themselves. They know it's only a feeling, not reality.  However, therapists have to rule out certain disorders before considering Depersonalization. One such disorder which you might want to look at is Acute Stress Disorder. Within ASD, the person can have experiences of being outside of their body, numb, and detached. So be sure to check out that link, and if he fits ASD, that would rule out Depersonalization Disorder.

To throw some more research your way, your character's second experience sounds more like Brief Psychotic Disorder to me. Due to his physical and psychological torture, he hallucinated this mean version of himself. Not knowing the full extent of his first experience, just that it is similar to his second, I feel pretty strongly that one of the anxiety disorders (ASD, PTSD) might be a better fit.

What do you think? Feel free to write responses in comment section below.


Dear Jeannie,

A man is responsible for the death of his family in a vehicular accident and because of depression and subsequent job loss, became indigent. What are some ways survivor's guilt would express itself and what is the shortest time frame it would be expected he would recover without intensive professional help?

Wrecked Two Ways in Texas 


Dear Wrecked,

You've already mentioned one of the ways survivor's guilt rears its ugly head: depression, which subsequently led to missing work and eventually losing his job. But in a previous post I did on this subject, I explained that various other reactions would be feasible. Here's an excerpt:

Survivor's guilt used to be it's own diagnosis in the Diagnostic and Statistical Manual until 1994 when it was subsumed under Post Traumatic Stress Disorder. It carried with it many of the same criteria as PTSD does now, including depression, anxiety, sleep disturbances, withdrawal, nightmares, episodes of uncontrollable crying/laughing, and a loss of interest in things that one brought pleasure. (Very similar to PTSD.)

As for recovery time, that is such an individual variable I couldn't hazard a guess. Given his active guilt in that he was driving the car, I would think it could last a fairly long time. Was he really responsible? Driving drunk? Where there any outside influences on what happened for him to lose control of the car? Some individuals never quite get over this, but some might take years. Therapy is the treatment of choice for this condition, so he could receive help in reframing his belief as being the cause of the accident (if indeed he wasn't) so that he can start seeing himself as a victim.

Any other thoughts or questions, shoot them to me below in a comment.

Got Questions?

Post them anonymously below, using monikers like Sleepless in Seattle.
I'll get to them in future Dear Jeannie columns.

Dear Jeannie: Dating Choices and Altered Reality

Dear Jeannie,
Annie has been home-schooled by her quirky parents, who have given her a lot of freedom and support over the years. She has an intense, embarrassing crush on a boy she barely knows--a poet who helps her sometimes with her English homework. But he says he has a serious girlfriend. Meanwhile, there is a wild-eyed jock who keeps showing up at her church and hitting on her. Even after his initial shock that Annie is missing a leg, this hottie keeps asking for her number and a date. She can't get him to leave her alone. Annie's much more interested in the poet, but she can't figure out a way to break him and his girlfriend up. Or if she should even try. How can she murder and bury this unrequited attraction before it pushes her into destructive behavior? Or is that likely for a sheltered, reasonably-balanced girl? Does the jock have a chance of wearing down her resistance?
Sandwiched in Sanditon 


Dear Sandwiched,

Home schooling has its advantages academically, as studies show, but socially, there can definitely be disadvantages. You didn't mention why she was home-schooled (perhaps her parents didn't want to subject her to potentially cruel peers?), but it makes total sense that she'd fall for this poet, especially if their interactions have been limited to online. But I'd also think that she'd be two-parts fascinated, one-part scared by the jock. He's attractive, an up-close-and-personal type who has seen her maimed status and still wants to date her. That would be a huge draw for her, I'd think. Her "defective" status wasn't a deterrent, but the fearful part might come in about why he's not deterred. (Very much a catch 22, but that's how I'd see it.) The poet guy is more cerebral--in her mind. Crushes like that can be hard to rid yourself of, unless faced with physical evidence to counter the powerful mental connection (i.e., the picture your online buddy sent you looks nothing like them). I just don't think someone who has been fairly sheltered would really have "destructive behavior" when she has the other, way-viable option of the jock. But that's my two cents. Thanks for writing in!


Dear Jeannie,

Gen is a young woman in modern times, who is very close to her brother. However, she has trouble telling reality from her imagination, and has terrible waking 'nightmares'. Her brain will latch on to small details and turn it into a life threatening situation. Is this kind of thing plausible, or something I'm completely making up? Also, how would it affect her in day to day life, is it likely to hit often, or only occasionally. How will her close friendship with her older brother affect her? 

Trying 


Dear Trying,

Altered reality is a real thing. I've had folks in my office who see and hear the same thing that I do, but state that they saw/heard something completely different. Their perspective is skewed, because their brain chemistry is altered by mental illness. The question to ask is not whether this is plausible, but what kind of background are you giving Gen to have this affliction? I'd venture that something traumatic would have to happen for her to have these waking "daymares." That's a symptom of PTSD for sure. People with PTSD try to avoid anything that might trigger a reaction like this. So it probably wouldn't be be a very common thing, as she's probably grown accustomed to what sets her brain off. I'm not sure I'm understanding your last question correctly (you want to know how it would affect her symptoms?), but her friendship with her brother would likely be one of her calming factors, as he probably could deescalate her quicker than others. If you're interested in additional posts that discuss the nature of PTSD, check out this link. The first two posts are the most informative, I believe.

Got Questions?

I might have some answers! Leave your question anonymously in the comment section below, using monikers like Sleepless in Seattle. I'll post my responses in future Dear Jeannie columns. Since the queue is getting longer, I'll post a mid-week Dear Jeannie column next week!

Treatment Tuesday - Enuresis, Phobias, and PTSD

This week’s assessment comes courtesy of Lynn. She’s writing a historical based on the Kindertransport (evacuation of Jewish children prior to WWII; read more about it here). Her MC is 8-year-old Halina* who goes to live with a Quaker family in London. Her 13-year-old brother is left behind due to no room on the train. Halina maintains contact with her parents until they are sent to Auchwitz. Halina eventually moves to the United States. In 1950, when Halina is 20, she marries and two years later gives birth to a daughter.

* Names have been changed to protect the fictional.

Lynn wants to know how someone would help Halina through her multiple issues, which she listed for me:

1) Survivor guilt – she’s not sure what happened to her brother; friends and family were exterminated
2) Insecurity – how could her parents leave her? Did they not love her? Issues with bedwetting
3) Ostracism – hard time fitting in with British children (different language, culture, religion)
4) Phobias – train stations/suitcases
5) Re-evacuation adjustment to the England countryside when war is declared
6) Flashbacks to the burning of the Berlin synagogue during the bombing of London and burning of St. Paul’s Cathedral
7) Repressing memories as a grown woman; not wanting to share it with family
8) PTSD – depending on when this term was named

Can I just say that Lynn has got her ducks in a row? KUDOS! This was such a fantastic rundown of everything you want Halina to experience and work through. You’ve obviously thought this out and it shows. You practically have your own assessment, which is fantastic!

I think I can help by shedding some additional light on some of the “heavy hitters” you put poor Halina through (meanie!). :)

You have her wetting the bed (called enuresis), which is a realistic response for an 8-year-old who has been forced to leave her parents and brother and essentially moved into foster care. Most likely, she’d have secondary enuresis, which is when a child is dry for at least 6 months and then starts to wet the bed, indicating a more emotional reason, but it could be physical or a change in sleep patterns. If Halina never was consistently dry at night, then she has primary enuresis, and her brain just needs to learn to wake her up when her bladder signals it is full.

Enuresis is typically something children grow out of, but there are practical things her British family could do to try to help her.

• Reduce amount of liquid drunk a few hours before bed
• Reward child for dry nights
• Have them change their own sheets when wet
• Bladder training during the day where Halina would be asked to “hold” her urine when she needs to go so that she stretches the bladder to hold more urine (also called retention control, although probably not back then!)

If I did my math right, Halina would be 8 in 1938. This just happens to be the year that bedwetting alarms came out. Now, I have no idea how expensive they were, but the idea is that the alarm goes off as the child is voiding, and this wakes them up and they can either go to the bathroom or hold the urine until later (negative reinforcement). It’s very effective, but the alarms have a high drop-out rate. Back then there was no medicine for this problem as there is now, so these are your options.

Her specific phobia of train stations and suitcases is appropriate and can be easily done in fiction. Obviously, these things remind her of being taken away from her family, and who she left behind. In particular, I’d think the train station would just be an awful place for her to revisit, since your sketch seemed to indicate her brother was at the train station with her, but unable to accompany her because of a lack of room. So that would be extremely traumatic for an 8-year-old to witness and then being left alone on the train. Halina would stop at nothing to avoid train stations and suitcases. Phobias were known to the mental health field in the 30s, but I couldn’t find out much about treatment. You can see my post here regarding phobia treatment (the part you want is about half-way down). Back then, they might have just given in to her anxiety and made it where she never had to visit those places much. There are perfectly “normal” adults who die with phobias still in tact.

Survivor guilt, which first was diagnosed around the 60s, was removed from the Diagnostic and Statistical Manual of Mental Disorders IV in 1994 and redefined as a significant symptom of Post-Traumatic Stress Disorder. So you won’t be able to mention that until quite some time after she’s married, if you decide to. Her flashbacks would be incorporated into this diagnosis, as would the repressing memories (which is an avoidant response common in PTSD…people don’t want to think about things that give them anxiety).

As to how her husband might could help her through these issues, I’d make him an extremely strong male lead. Halina will need some security after such a traumatic past. You mentioned her husband would be a Holocaust survivor. This could be really good, if you write it in such a way that they bond through a sort of mutual experience (even though Halina escaped the Holocaust, she was terribly affected by it). If you make husband’s issues too strong, then it’ll lose feasibility (in my opinion). Halina has so much on her plate to deal with that I’d think it unlikely for her to fall for someone in worse shape than she’s in. Does that make sense? Might just be a personal thought, but it seems she just needs a strong man.

People with survivor syndrome have to learn that they are suffers, too. They take on an unnecessary amount of guilt, almost like the tragedy was their fault. Maybe Halina’s husband could be this huge Jewish nationalist who really sees this fact as it is: the Jews were victims. Halina could learn to accept that she wasn’t in any way responsible and this will enable her to move on with her life and grieve the losses she has suffered. When you’re stuck with survivor guilt, the grieving process gets stuck, too. Her husband would need to be persistent, really drawing out her memories and encouraging her to talk about things rather than stuff them inside, which enabling her to come to terms with what really happened. He’ll have to get past her repression some how. A person can convince herself something didn’t happen if they are good enough as repression and denial. Her husband (maybe when he’s a fiancé?) might have to really put some faces to the horrific event by showing her pictures of the camps or some awful scar he has a result…to really bring home that it did happen. Halina has to face it and grieve it.

Okay. This has been a really meaty assessment, but that’s mainly because you gave me SO much to work with, which is great. I wish I could have done a little more research about treatment for some of these things back in the 30s, but maybe you can do some Googling on your own.

Thanks for writing in…really enjoyed this assessment.

This service is for fictional characters only, so any resemblance to real life examples is entirely coincidental. Any other fictional character assessment questions can be directed to charactertherapist@hotmail.com.

Character Clinic: Tanner Sheppard

Today's character on the couch is Tanner Sheppard, the brainchild of author L. Blankenship. Tanner resides in a science fiction book as an ex-pirate (think spaceships instead of ships). He's killed, betrayed, and slaved people. He was sentenced to fifteen years of inpatient therapy under new PTSD treatment modalities (re-recording the memories and taking the stress out of them so they aren't "panic on tap"), but his friend Maggie broke him out after a year.

Louise wants to know: I’ve done a little reading and I got some helpful feedback from an abuse survivor, but when it comes down to it I have zero experience with the kind of sustained, violent (maybe sexual) abuse Tanner went through… I want to represent it honestly, make his progress an honest fight and not a miraculous recovery. So I’m looking for thoughts on what he’s like when he’s still new to wrestling with the idea of being worth something, of being different. And what sort of steps he may be able to take on his own.

Tanner -

Depending on your age when you had the brunt of the traumatic beatings, whether just physical or sexual, that could have some impact on how you present with traumatic symptoms in therapy and in the present day. The tender psyche of a young child going through those types of things can split into multiple personas as a way to protect the main identity. Later, something can trigger these personas to show up (such as the murder of your dad). This is just FYI.

But as to having a particular formula to follow for abuse victims--that'd be impossible. Based on my experience with clients who suffer from sustained violence or trauma, it's a constant battle, one they never "arrive" from. They can be doing really well and then one memory triggers them into their panicked state and damage control is needed to get them back on track.

For Tanner to even contemplate that he's worth something, he'll have to have someone show him through actions that he is. Whether this is Maggie or one of his sisters or some other mentor-type person...they will have to be patient and consistent with him to help him help himself. If they believe it in, then he will have a less-hard time believing in himself (notice I didn't say easier time). It's an uphill battle.

I'm not familiar with the re-recordings of PTSD memories...unless you mean working with trauma survivors using EMDR (eye movement desensitization and reprocessing). This theory is controversial, but some swear by it. I've never used it myself, as it requires specialized training in just that theory. It has similarities with exposure therapy (essentially repeatedly exposing a client to what they fear until they become less sensitized to it) and cognitive-behavioral therapy. The idea is that by reprocessing an upsetting emotion/event while bilaterally stimulating the brain (tapping meridians on both sides of the body on the chest, head, face, etc) moves the upsetting emotion that has been stored in the right side of the brain into the left side, where they are processed differently...in theory, taking the disturbing feeling away from the memory, which doesn't go away, but remains, just processed differently. (Hopefully this makes sense...here's a video that demonstrates it.)

Hope that this helps some. I'll gladly welcome additional questions in the comments section. if you want to take him deeper, click here.

For a chance to win Julie Lessman's newest release, A Heart Revealed, click here!

Treatment Tuesday - Survivor's Guilt 101

This week's assessment is for Jennifer. She wrote in about her current WIP featuring two brothers. The hero feels he is to blame for his brother's death. His brother was driving the car and they were having an argument about the hero's irresponsibility when they got into an accident. The hero's brother died, leaving the hero with survivor's guilt. To add insult to injury, the hero's brother was considered the "perfect" brother, the responsible one--yet he was the one who died. Enter the heroine, who was the girlfriend of the deceased brother. She finds out she is pregnant, and the hero wants to "make things up" to his brother by marrying her and giving the baby a name.

Jennifer wants to know: Would this reaction make sense? Are there any other common factors found in people experiencing this type of guilt?

Before we get to your specific scenario, a brief overview of Survivor's Guilt might benefit my readers. Survivor's guilt is a phenomenon that occurs when a person experiences a traumatic event and lives when one or more people died. This could be war, a car accident, terrorist attack, hurricane--any event where some people die and others do not. The survivor perceives himself to have done wrong just by surviving.

Survivor's guilt used to be it's own diagnosis in the Diagnostic and Statistical Manual until 1994 when it was subsumed under Post Traumatic Stress Disorder. It carried with it many of the same criteria as PTSD does now, including depression, anxiety, sleep disturbances, withdrawal, nightmares, episodes of uncontrollable crying/laughing, and a loss of interest in things that one brought pleasure. (Very similar to PTSD.)

This type of trauma response can result from 1 of 3 situations: (1) individuals feel guilty for surviving or being uninjured when others were killed or injured; [your hero fits here] (2) they were unable to rescue someone or had to leave someone dying in the disaster; or (3) it was not possible to overcome "the bad guys" (Holen, 1993; Simpson, 1993).

Some of the questions your hero will be thinking:

• Why did I live when the he died?
• Should I have died so he could live?
• Would he have had a better life, more to live for? 
• What more could I have done to save him?

What makes your story doubly interesting is that your hero has both active and passive survivor's guilt. According to clinical psychologist Yael Danieli, there is both "real" and "imagined" guilt. She distinguishes between them in that real, conscious guilt comes from an actual act of commission or omission on the part of the survivor that may have contributed to the emotional endangerment/harm/death of the other. The fact that your hero and his brother were arguing in the car might indeed have hindered the brother's driving reflexes in some way.

Imagined (also called passive) guilt is guilt a person's feels when they wish they could have acted differently, maybe more heroically, and as such would have prevented the harm that befell the other person who died. Usually this guilt happens in the absence of having knowingly acted in a harmful manner (i.e., the person didn't do anything that would have hurt anyone else), but not always. Your hero could have been talking about roses on the side of the highway when the other driver hit them and there was absolutely no fault of his in the accident. But because of his passive guilt about the argument, he's moved on to active guilt about playing a role in the actual accident.

[A caveat: one question to ask yourself about your hero is this--is he a control freak? You mentioned he wasn't the most responsible of brothers, which would lead me to the conclusion that he's not a control freak, but I ask this question because those people who are frequently have an even harder time dealing with survivor's guilt. The feeling of utter helplessness in the face of what might seem to be a random, senseless event leaves them unable to cope. They would rather believe that they could have done something differently to counteract their feeling of ineffectualness.]

So he's got this beast called survival's guilt. Would it lead him to want to marry his brother's girlfriend to give the baby a name? Short answer? Sure. Many survivors try to join in the "recovery effort" after a traumatic event--and trying to help others impacted by the loss is a major way to do this. It might be a proactive way he could relieve the guilt, assuming that relief is something he actually wants. But for some reason, this doesn't ring especially true to me, almost as if I'd think he'd rather wallow in the guilt, you know? You mentioned that he was some sort of slacker. Irresponsible. That his brother was the "perfect" brother.

My gut tells me that your hero would have many dormant feelings of worthlessness or not being as worthy as his brother emerge after the accident. Old messages of him never "measuring up" or not being as good as his brother might have been triggered, which would possibly illicit all manner of self-condemnation, inner turmoil, or acting in such a way as to prompt rejection or disdain from others so that his internal feelings and external factors gel.

So for a guy like this (if I indeed pegged him right), marrying the girlfriend would have to serve some greater purpose. You didn't mention anything about love in the character sketch, and a pregnancy is time-limited, so it appears that the marriage would be very close to the death of the brother--within the year. I got to thinking that if he had loved this girl all along that would make the marriage all that more bittersweet and tormenting, like he finally got what he wanted--but at the expense of his brother. That's emotionally intense!

How would your character make an arc that leaves the reader satisfied that he'd dealt with the guilt and moved on?

Aaron Haas wrote about survival guilt in Holocaust survivors in his paper (found in Lemberger, 1995). In it, he writes, "Guilt is the penance one pays for the gift of survival." Psychologist Donna Marzo wrote that instead of having a person focus on their guilt, they should focus on the gift of survival. In your book, that could mean a gift for your hero to change his ways, mend his relationships, be better than he was. It's a second chance. Let his internal arc swing this direction to give your reader a nice cathartic conclusion as he embraces life and living.

Good luck with this! Any other questions, leave them for me below. Hope this helps.

Don't forget to enter the giveaway for Janice Thompson's new release, Stars Collide. Click here!

Dear Jeannie: Futuristic Castaway Love Story

Dear Jeannie,
Mark has a problem. As a mature, kind person, he's been asked to help a foreign castaway adjust to his people's culture and language. The castaway is growing on him. She's sweet and smart and eager to please. But she, and the rest of Mark's society, are aware that her own people are coming for her. It may be next week, it might be ten years, but they will find her. The more of a claim Mark has on her, the greater the risk of disaster. His own people are concerned about Mark. Conception is difficult among their people, and he is wasting the best years of his life tutoring this little foreign girl when he could be married and starting a family. Problem is, he doesn't want anyone else. What factors are going to weigh heaviest in making a decision about this? Can he justify picking her over his own people? They like her fine, but she's not kin and she brings trouble. Should he choose her, what might influence them to agree?
Torn in Toronto 


Dear Torn,

The answer to your question depends on a few things. How entrenched is Mark in his own culture? He doesn't seem to be a rule breaker by nature, or he wouldn't have been chosen to help the castaway. But the smart, introspective types have strong moral values and opinions, and are very prone to follow their heart purposefully. However, the more influence he has in his world, the more likely the others might be able to accept her, which would make his choice easier. Especially if he were to impart some knowledge to her that would end up benefiting the townspeople in some way, say, during a battle. You mentioned that he was mature, and that others thought he was wasting his prime years on the castaway. But does Mark a long history of girlfriends? Something tells me he doesn't. And that the reason he doesn't is that he is picky, perhaps. That would factor into his decision to choose the girl over his culture, because he might reason that no one in his culture has made his heart pound. Anyway, hope this helps. Thanks for writing in!


Dear Jeannie,

Owen's military father developed PTSD and an alcohol addiction which led to him abusing his wife and slapping around Owen and his two younger siblings during his worst episodes. After 10 years, his mother, a kind, loving woman, got a divorce and left with the younger two children. Owen loves the military and is ferociously loyal to his father, he's furious at his mother for (what he sees as) abandoning his mentally ill father and stealing the children. His mother wants to reconnect with Owen, but Owen absolutely despises her. He's a kind and generous individual, and I would like him to repair his relationship with his mother, but I cannot figure out how. He has brutally rebuffed all of her attempts to communicate, and he absolutely won't listen to his siblings discuss it. His father is likewise bitter at her for 'turning the other children against him,' and he encourages Owen's rebuffs. Any ideas?
Mystified in Mississippi 


Dear Mystified,

Owen might need to see another family with a similar dynamic, one in which he'd be more aligned with the mother and the abused children, to be able to see the dynamic in his own family. When people are entrenched in a certain viewpoint (and Owen definitely is that), they can't see beyond that. To expect him to without some sort of outer intervention (i.e., a letter from his mom written before the divorce, or something similar you've seen in movies and read in books) or exposure to the harmful effects in another family would be like expecting an insane person to suddenly become sane. If he could grow close to a woman, perhaps older (not romantically, though he could be interested in the eldest daughter...that sort of thing) and could begin to see evidence of her husband's abuse and how it is negatively effecting his love interest and the maternal security he feels from this woman, he might be able to see his father for what he was, rather than idolizing him and putting him on pedestal. I'm happy to entertain any other questions below in the comment section about what I've suggested. Good luck!

GOT QUESTIONS? 

I might have some answers. Leave your question below, anonymously, using monikers like Sleepless in Seattle. I'll post my response in future Dear Jeannie columns.

Dear Jeannie: Sci-Fi Exclusive

Dear Jeannie,

Dahlia has spent her young life focused on escaping the mining outpost where her family lives so she can get an education and spend more time with fewer aliens (sci-fi alert). She was taken over by a parasite who hijacks her body and dominates her words and actions, even to the point of forcing her to commit crimes. She is eventually rescued from her attacker/parasite, but she spends the next several books coping with the rape-like trauma. I'm concerned about her relationships post-rescue. She formed some friendships while the entity had her, and I'm not sure how she's going to interact with them in the aftermath. Distancing herself? Codependency? Promiscuity and/or social marathons (this would be extremely out of character for the old Dahlia)?

Whiplashed in Space

Dear Whiplashed,

This makes me think of The Host somewhat. Having your body taken over by something else would probably have some traumatic symptomology not unlike PTSD, yet Stephenie Meyer doesn't address this at all. Her heroine is just peachy when the alien is taken out. But for your book, the biggest question is should she be fully aware or not when she's "not herself." If she's not fully aware (i.e., dissociated), then she wouldn't even know who the friends are she made while the parasite had her. I think there's more tension if she is aware, because then she'll have to deal with more angst afterward, having been privy to everything she was "forced" to do. I think she'd stay away from these friends, given that the Dahlia they knew isn't who she is. Even more so, they would remind her of this traumatic period in her life that she's trying to move on from. Not sure how to answer your promiscuity question...was she promiscuous with the friends? At any rate, people who have experienced trauma generally try to avoid anything that could connect them with that trauma. Hope this helps!

Dear Jeannie, 

Conner and Sierra are from the same world. Conner was sent to Earth as a baby by his father in an effort to save his life. He grew up as an orphan and has always felt like an outcast, especially when he develops powers he can't control. Sierra is developing her skills as a Light Mage in Conner's old world. She's told she needs to summon a Guardian Spirit to help protect and defend her. Inexperienced, she inadvertently summons Conner from Earth. Since Conner is used to being on his own and not growing close to others (mainly from fear of abandonment and being used by those he came to trust), how would Conner react to suddenly being thrust into this new world where he is magically bound to protect this girl he doesn’t know? And would it make sense that Conner grows close to Sierra and comes to realize he loves her, or would he be distant to her for fear of her abandoning or using him?

Muddled in Missouri

Dear Muddled,

I like this plot line...reminiscent of Emma's story in Once Upon A Time. Conner has grown up extremely distrustful of others. Most system kids are, whether orphaned or fostered. Adults are synonymous with unsafe and untrustworthy. The only thing Sierra would have going for her is that she's his age. You didn't mention whether Sierra's father was in the picture, but it's also in her favor (and by that, I mean Conner won't be turned off by her) that she's somewhat orphaned as well. This will make them kindred spirits underneath all the awkwardness and confusion about mages summoning mages and being bound to protect her, something no one did for Conner (that he can remember). He's going to be resistant, resentful, and fearful, though he'd never admit it to anyone. But yes, love can develop amidst the most extreme circumstances, so that shouldn't be a problem. But let them get to it slowly. Thanks for writing in!

GOT QUESTIONS?

Post them anonymously below using monikers like Sleepless in Seattle, and I'll post my answers in next week's column. The queue is EMPTY!

And if you haven't taken my writer's survey about whether your partner is supportive of your writing, please do so now! I'm closing in on 100 responders!

Holidays and Trauma: Making Connections

Holidays can be a really tough time for people who don't have mental health challenges, much less those who do. In fact, the holidays themselves often bring about trauma for many people.

Christmas in particular is one of the toughest holidays for some to soldier through (pun sort of intended). Perhaps because it's a holiday where expected family interaction is coupled with presents, unlike Thanksgiving. Whatever the reason, Christmas can actually usher in a reexperience of pain for people with Post-Traumatic Stress Disorder.

These individuals might feel like Ebeneezer Scrooge instead of Santa's Little Helper. Holidays can reinforce the feeling of being "outside and looking in," like you're watching a movie filled with happy, smiling people while you're stomach is twisted into knots as past events swirl around in your head instead of visions of sugar plums.

Of course, this further isolates the trauma survivor. A typical reaction of family or friends who don't "get" trauma might be, "What's wrong with you?" Even worse, trauma survivors might not even be able to verbalize what's wrong with them. Instead, they feel humiliated and wish they hadn't shown up at the holiday event or party.

For those of you who have family members in your life (or characters!) who have PTSD, be cognizant of how you offer to include them, as well as sensitive to even subtle cues from the person that they aren't comfortable. Survivors may need to create new rituals to help in their healing, and it's important for people in their life to support this by being open to change as needed.

Let's analyze: What have been your traumatic experiences over the holidays, either your own or someone you know? What helped to overcome those feelings?

Character Clinic: Joe Cooper

Lorna's character Joe is on the couch today. He's a high school senior quarterback whose biggest dream is to play for the NFL--preferably the San Francisco 49ers. He has a girlfriend Rebecca who he loves dearly. One night, he was texting Rebecca and not paying attention to the road. He hit and killed a jogger. To make matters worse, he ran from the scene and didn't tell anyone. The jogger just happens to be the uncle of Cheryl, the head cheerleader at his school who has always had a crush on him. She's vowed to find out who is responsible for killing her uncle. Yikes!

Lorna wants to know: What is Joe thinking or feeling as he goes through his life after the accident? Will he have trouble in school or make mistakes playing football? Anything important I need to know?

Joe -

You've killed someone. Unless you are an unfeeling, uncaring person (which your intake form would suggest otherwise), then you are definitely going to be affected--seriously--by this traumatic event. The guilt, at times, might be unbearable.

The nightmares you mentioned are evidence of post-traumatic stress, as would any flashbacks while you're awake, avoiding the scene of the crime, perhaps even avoiding your car (opting to ride your bike to school, etc). People with PTSD generally try to avoid any and all reminders of the event, which might mean suddenly Cheryl makes you uncomfortable (besides the fact that she's after you and doesn't know it) because she reminds you of her uncle. Or it might play out in your life by the fact that you don't want to text your girlfriend anymore. Texting reminds you of that split second when you heard your car crunch into something on the road.

It's different for everyone, but *normal* people would probably act different enough after an event like this that even the casual observer would know something was "up" with them, whether they could figure out what it is or not. You'd likely be more withdrawn. Your grades might suffer. Your game might suffer. Life might suddenly crowd you out.

You'll probably be mentally hounded by questions, like, "Could I have done something to save him?" "Should I turn myself in?" "Should I have died too?" "Is my life worth living after having done this?" This will be excellent inner tension for him.

I feel that I must say that any reader is going to want him to come clean by the end of the book, or not only will the book be unsatisfying, it will also be espousing a moral premise that is inherently false. So I hope you've got a great arc planned for him to see this through. Best of luck!

Character Clinic: Bridger Heidemann

I've got Liberty's character, Bridger "Brick" Heidemann on the couch today. Lucky for me, I've already assessed the love interest in the futuristic sci-fi romance. Brick is sort of an anomaly in his convictions for his day and age where everybody is sleeping with everybody else and there are few moral standards adhered to. He's a private investigator, hired by the heroine Tamryn to track down her best friend, who's missing. Brick values remaining chaste, but he's drawn to Tamryn, despite their different backgrounds and moral codes of conduct. Brick gets kidnapped near the end of the book to be part of an "active sperm donor" business for women looking to get impregnated. (Yikes, Liberty!)

Liberty wants to know: How do I play out dynamics between two very different leads in a believable way? What kinds of mental issues will Bridger face following the kidnapping, especially if there is some physical abuse (i.e., kicking, punching, stabbing) to go along with it?

Liberty -

What we've got here is opposites attracting. Nothing new, but the angle of morality that you are taking is a different twist. I'm not sure how much this is played up in your book, but it sounds like remaining pure is a big part of Bridger's identity, and this is a value Tamryn doesn't hold.

One thing's for certain, his or her stance on morality doesn't have to play a part in physical attraction. Sparks between people can often be surprising, given the different poles they come from. So writing some very real scenes of them trying to deny that chemistry will give your romance readers something to appreciate.

Tamryn will likely want to take things to the next level, riding the wave of her baser desires and instincts. This will be the initial cause of conflict, I assume, and it needs to shake Bridger up a bit....that he could get so close again to "doing the deed," this time with his full faculties about him (i.e., not half asleep). But it will be his lesson in how strong physical attraction can be, and you can subtly get a point in with readers that our mental capacity to stop can overcome the pleasure principle (if you so desire).

Bridger will be wary of her, as she embodies and represents a sensual side of himself that he's either refused to acknowledge or has kept buried because it's safer. But he'll be drawn to her anyway b/c of the attraction. Great place for him to feel that tension...which is great for page turning in a romance.

An aside about your idea to have them both ask to marry each other at the end...Bridger seems to be a pretty traditional sort. Comes from a traditional family, remaining pure, etc. If Tamryn beats him to the punch, even if he has the ring in his pocket, I'd make sure that it was the completion of a character arc for both of them. Bridger possible needing to relinquish some of his iron-tight control, and Tamryn forging ahead into a commitment with a man that up until then she's tried to evade. Something like that. Otherwise, it won't be satisfying to the reader (in my opinion) for the original/traditional role of the man asking the woman to marry him to be usurped.

Really quick about the abduction: He's going to be traumatized, especially given the nature of what he's being abducted for. It would be like his worse nightmare...almost like forced prostitution, even though the end result is impregnation rather than debauchery. Still...to him, it won't be much different. So even if he doesn't actually have sex with anyone before he's rescued, that would mess with his head. (In my weird, psychocrazy way, I think this is awesome, btw.) If he's abused, he'll probably have the usual PTSD responses of flashbacks, nightmares, exaggerated startle response, hypervigilance, etc. I've done many posts on this subject, so I won't go into it here.

Hope this helps, and thanks for being so patient!

Let's Analyze: What are some great examples to point Liberty to of books that have dynamic heroes and heroines who are POLAR opposites?

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Treatment Tuesday - Abuse Cycle Elements

This week's assessment comes from Hayley. She's writing about Alana*, a girl who has experienced a fair share of neglect and abuse from a very young age. She eventually ran away from home and became a beggar in a major city before she fell in with a gang, where she is grouped with Corban*, the antagonist who is 10-years older than Alana. Corban takes a liking to Alana, but when she doesn't reciprocate, he pursues her more forcefully, and his intent grows from an infatuation to an obsession over several years.

Alana finds herself in an abusive relationship with Corban as progressive incidents of physical and verbal abuse maker her increasingly complacent. She adopts a survival mentality, accepting a lesser pain to avoid the greater and to cooperate rather than anger him. Her addiction to alcohol increases as a means of escape, as well as occasional use of opiates. She hates him, is terrified of him, yet he holds an incredible sway over her image of self-worth now. When Corban nearly rapes her, she flees at the age of 17. The novel starts 2 years later when she circumstances force her back to the city and get her involve with the gang and Corban again.

* Names have been changed to protect the fictional.

Hayley wants to know several things:

1) Does it make sense that Alana tries to avoid, fight, or resist Corban in their scenes together, but also has a level of complacence after several years of his abuse? 2) What are the side-effects of this type of abuse? 3) Do the presence of drugs/alcohol make sense? To what degree? 4) Is it believable for Corban to still have so much influence over Alana after two years apart, and how difficult would that be to overcome during the course of the novel? 5) Would it be believable for a romantic subplot to take place during all of this, helping her towards greater self-worth and showing her such treatment isn't normal?

This is a lot to cover, so I'll jump right in. What you're writing is tricky, mainly because you are making it clear to the reader that Alana doesn't want to be with Corban. In order for the domestic violence (also called interpersonal violence now) cycle to work, there is that vital link of the abused actually being co-dependent on the abuser that's implied, yet that's missing from what you've described. She doesn't want to be with him at all, but he's pressed her into submission anyway?

My initial thoughts for question #1 are this: either you're going to have to have Alana's motivation to stay in the gang be so compelling that she'd rather deal with Corban than the awful, dangerous, life-threatening alternative waiting for her outside the gang, OR you'll need to write in an initial attraction of Alana to Corban (which I think would work because she's young and impressionable, and he's older, maybe handsome...) that changes a bit when she realizes that he's not very stable with his emotions.

The situation as you've described it is totally appropriate for domestic violence (DV) situations, given that the abused actually CARES for the abuser in a co-dependent kind of way. Let's just say Alana actually did have feelings for Corban initially, but they get buried in fear as he becomes increasingly possessive and aggressive. You can set the story up for a traditional DV situation with just one little tweak. There are a few things missing for this to fit into Stockholm Syndrome, as well, because generally, victims/hostages with Stockholm come to love/respect their abusers, and you don't have Alana doing that, either.

If there isn't something added or tweaked, the reader might be suspicious...I mean, why the heck doesn't she just LEAVE him if she doesn't have some sort of residual feelings/attraction for him? (Let's face it...this is the question we always ask of women who are in DV.) The important difference being for Alana is that you have her not liking Corban at all with no reciprocation of his feelings...so it would bound to raise this question in the reader's mind as it did in mine. One-sided relationships don't quite fit the bill for the cycle of abuse, of that makes sense.

You did write that she "still responds if he's kind." In the cycle of abuse, women generally want to believe the abuser when he swings back to the honeymoon phase. When he says he'll never hit her again, or destroy something meaningful to her, she believes it because she desperately needs to believe it. By doing so, she gives validation to her remaining with him as long as she has. If there isn't some redeeming factor about the guy, women probably would leave quicker. As it is, the national statistic is that women leave an abusive relationship an average of eight times before they leave it for good.

So that sets up the situation of Alana coming back to the city/gang/Corban very nicely (question #4). He's still have a great influence over here, even after 2 years. Women who have been in these type situations never forget the feelings of inferiority and helplessness. It'd be akin to shrugging into a coat of oppressive memories again, and all too easy to slip back into that mindset.

The side effects (#2) of abuse to this degree are serious. Women who are abused as a child often end up in abusive relationships, accepting this type of treatment as the norm. Using alcohol and drugs (#3) to escape their present circumstances and past trauma is totally feasible and psychologically appropriate (in that it makes sense, not in that I'd recommend it to a client!). They have trouble with long-term relationships a lot, as well as with intimacy once they've found a great guy. Lots of PTSD can be involved in their day-to-day lives, flashbacks, avoidance of certain places, etc. (And men who have been abused in their childhood are more likely to become abusers as adults...so not sure how Corban lines up with this, but of course, this isn't 100% necessary.)

As to question #5, whether it's feasible for a romantic subplot to happen, my answer is that it's feasible, but probably not within the same novel. Maybe you could hint at an attraction to someone else, an attraction she's scared of, but I'd save delving into it for a sequel. In reality, it takes a while for women who have been abused to trust again. But a hint or two wouldn't at all be inappropriate, because the reader will want to have some hope that she will eventually see that there are better ways to be treated and that she won't settle for something less. After leaving Corban, she needs to have a strong inner resolve that she'll never settle or get involved in something like that again. Once she returns, this resolve will be tested, but perhaps interactions with this other man will fortify it? You could go different directions here...just think about it.

Okay...all for now! Any other questions, please ask! You have a lot going on in this story that a lot of women will be able to relate to, which is great. Good luck with it!

This service is for fictional characters only, so any resemblance to real life examples is entirely coincidental. Any other fictional character assessment questions can be directed to charactertherapist (at) hotmail (dot) com.

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T3 - Therapy Basics: The DSM

One thing all therapists, psychologists, licensed clinical social workers, psychiatrists and whoever else might provide mental health services has in common is the DSM. (Oh, and health insurance and pharmaceutical companies, too.)

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (or DSM-IV-TR for short) is called the therapist's "bible," although I'm not thrilled with that association. (I've only got ONE Bible, thank you.) It's put out by the American Psychiatric Association (APA) and the list price of it is about $89, but you can get it from Amazon for $72.

The DSM lists the criteria for mental disorders. Each disorder is given a specific code (i.e. 301.13) and this code is recognized by health professionals everywhere in the US. (Like, I know 301.13 is Cyclothymic Disorder).

In addition to the criteria (list of symptoms to look for in a patient), the DSM provides a lot of other helpful information about each disorder. (Psychiatric terms in bold italics)

1. Diagnostic Features - this is the criteria written out in paragraph form, often with illustrative examples
2. Subtypes and/or Specifiers - gives whether there are different types of a disorder (like there are several types of schizophrenia); specifiers simply give more specifics on the disorder, like when the onset was, or if a certain feature is more prevalent over another
3. Associated Features and Disorders - this gives clinical features that are frequently associated with the disorder, but aren't required to make a diagnosis, as well as associated medical and physical examination findings (i.e., people with an eating disorder are likely to have dental erosion or alcoholics typically can have cirrhosis of the liver)
   
4. Specific Culture, Age, and Gender Features - sometimes people present a disorder in a way that doesn't completely add up with the description on the page, and the reason could be one of the above listed, i.e., their developmental stage or cultural setting
5. Prevalence - the section gives known information for prevalence, incidence and lifetime risk; when it's known, this information includes different settings - community, primary care, outpatient mental health clinics and inpatient psychiatric settings
6. Course - gives the typical lifetime patterns of the disorder: how it's presented, how it evolves, typical age of onset, mode of onset (was it abrupt like PTSD or gradual like Alzheimer's?), whether it's in episodes (episodic) or a continuous course, a single episode v. recurrent, the duration of the disorder, as well as the typical length of the illness and it's progression over time (stable, worsening, improving)
7. Familial Pattern - looks at the frequency of the disorder among first-degree biological relatives compared with the general population
8. Differential Diagnosis - probably one of my most favorite sections, as it gives possible other diagnoses that might be similar as far as presentation and then how to differentiate between the two (or three or five)
   

Not every disorder will include all of this information. Sometimes the information isn't known, and it might be included in the next version of the DSM (to come out in 2012, tentatively). Many times this information changes from publication to publication, as data is gathered from ongoing studies. New diagnoses emerge and some diagnoses get the chopping block or get absorbed into others.

There is talk of including internet addiction, compulsive shopping, or premenstrual dysphoric disorder--that's right, ladies. The real name for PMS, and it's not actually a diagnosis right now!--as well as getting rid of schizoaffective disorder and possible gender identity disorder to reflect the changing times. Major changes within editions usually make the news, the biggest being in 1974 when the APA took out homosexuality as a disorder. As you can imagine, new editions cause LOTS of controversy between professionals in the field as well as political and religious leaders.

But one thing remains the same: this is the therapist's manual. I never see a client when I don't break out this really large book of almost 1000 pages. You can see how this would be helpful in writing, right?

Q4U: Which of the eight sections do you think would be most helpful when writing?

Join me next Thursday as I discuss the multi-axial format of the DSM and why this is extremely useful.

Character Clinic: Bradley Morgan and Gender Identity Disorder

If you haven't taken my Personality and Plotting Survey, PLEASE DO SO NOW!! (2 minutes, tops.)

Today's character on the couch is courtesy of E.S., who is writing a literary fiction novel about 20-year-old Bradley. Bradley was physically and sexually abused at the hands of his father from the ages of 5-18. He's in a relationship with Curtis, who is supportive, but Bradley has an aversion to sex and often has nightmares/sleep terrors when sleeping alone. Also, Bradley likes to wear women's clothing, mainly at home. Sometimes he feels more comfortable when he's cross-dressing.

E.S. wants to know: Bradley feels like everything he owns and everything he does is marred in some way by his father. How can Bradley take his life into his own hands and escape the hold his father always had over him to make his life feel like it belongs to him, not his father? How can he stop being as utterly terrified of his father as he is and work up the courage to let himself be genuinely happy with his life and who he is? Also, what steps should he take with regards to his aversion to sex?

E.S. -

What you've got here is a homoerotic character-driven novel, but without much plot. You've raised some incredible issues that literary fiction could help shed light on, and I wish you well with it. But what I didn't see from your intake form for Bradley was much of a plot, so while you've got this angst-ridden anti-hero or sorts, I didn't read much that you are planning on doing with said angst-ridden anti-hero.

He's coming from a traumatic, shame-filled past, and his current narrative or life script is focused on how he felt as a young child. The regression he shows at night (almost child-like, needing to be held, etc) might be evidence of this, as well as a PTSD reaction, due to the fact that the abuse most likely happened at night. Bradley is going to need some therapy at some point in this novel to address these issues. It's unlikely that his relationship with Curtis, no matter how supportive, is going to be all he needs to "get past" his past.

As for getting past an aversion to sex, many sex therapists suggest to couples to try sensate focus. The link I've included goes into detail as to how a therapist might structure sessions, so I won't do that here. Needless to say, this is a therapeutically very popular way of handling aversion or discomfort for couples.

You mentioned that you think Bradley might have Gender Identity Disorder. I wanted to take a moment and hijack this mini-assessment to share with my readership a little more about this disorder and some other terms closely related.

Gender Identity Disorder can be exhibited in children or adults, with minor differences in what to look for. Basically, someone with GID might state over and over their desire to be the other sex. Males want to wear female clothes, and vise versa. These individuals generally embrace the stereotypical aspects of the opposite sex, such a man doing all the cooking and cleaning and a woman doing yard work. (Sorry! I said stereotypes.) And FYI, the American Psychology Association is looking to change the criteria for this disorder...and a few others...when the DSM-5 comes out. Check it out here.

However, I'm not sure that Bradley fits all the criteria for this particular disorder. Does he essentially want to be a woman? I realize he's attracted to other men, but that wouldn't preclude him wanting to a woman. Cross-dressing is just that, dressing in the clothes of the opposite sex. Taken to the most extreme, this could include one wanting to be a transexual, (someone who at the far end of the spectrum wants to undergo surgery to make the outside of their body match with the inside). But it could just be that Bradley is a transvestite - someone who cross-dresses (although cross-dresser is the preferred term). Another caveat would be if Bradley gets a sexual enjoyment from dressing in the clothes of the opposite sex. Then it would fall under a transvestic fetishism.

This can actually get pretty confusing, with all these terms! And trying to figure out which are politically correct, etc, can be overwhelming. If you have additional questions about this, just ask below.

Hope this has been helpful E.S.! Good luck to you.

Mental Illness in the Presidency

Happy President's Day to you! Hopefully you're off work, laid back in your recliner, and getting some serious writing and social media networking done. 

In honor of our presidents, I thought a post on mental illness in the Oval Office might be appropriate for my blog readership. Duke University psychiatrists Jonathan Davidson, Kathryn Connor, and Marvin Swartz teamed up in 2006 to diagnose our fearless (or not-so-fearless, in some cases) commanders-in-chief from 1776 to 1974 using biographical information.

37 presidents were researched, and 18 (49%) suffered from some sort of clinically diagnosable disorder. The most common disorders were depression (24%), anxiety (8%), bipolar disorder (8%), and alcohol abuse/dependence (8%) were the most common. 10 of these presidents (27%) suffered a disorder during their presidency, which in most cases probably impaired job performance.

So which president had what? Some of the more notable ones are below:

Abraham Lincoln: depression (more than the others, this was widely known)
Franklin Pierce: PTSD/depression from witnessing his son's violent death in railway accident
Ulysses S. Grant: alcohol abuse/dependence; social phobia
William Taft: sleep apnea (often dozed off during important meetings)
Theodore Roosevelt: bipolar (showed signs of manic energy b/c he was indefatigable)
Lyndon B. Johnson: bipolar
Richard Nixon: heavy alcohol abuse/dependence (especially through Watergate--go figure)
Calvin Coolidge:social phobia; depression (after teen son died of an infection); hypochondria
Thomas Jefferson: social phobia

Interestingly, the contemporaries of Grant, James Madison, Rutherford Hayes and Woodrow Wilson who knew them as young men wouldn't have thought that either of them would grow up to do very much based on their seeming mental problems/deficiencies. 

Just goes to show you that you can't judge a book--or a president--by it's cover too early.