Getting It Right: Writing About Post-Traumatic Stress Disorder | Part I

So your character has Post-Traumatic Stress Disorder... but what does that actually mean for them? How might their symptoms manifest and affect their lives? Let’s take a closer look at Criteria A to C.

No one wants to read about a character with an easy life. Victories without a struggle aren’t meaningful. They aren’t inspiring. They don’t leave you thinking about them for days, weeks or months afterwards, your fingers still tingling from the magic on the page.

The solution? Put your characters through the wringer. And sometimes that wringer involves subjecting them to traumatising experiences. In cases such as these, your character could go on to develop Post-Traumatic Stress Disorder (PTSD).

What does it take to be diagnosed with PTSD? All was revealed in the previous Psychology & Storycraft post, How to Tell If Your Character Has Post-Traumatic Stress Disorder. Knowing the list of symptoms found in PTSD isn’t enough on its own, however. I did my best to make the diagnostic criteria as understandable and applicable to writing as possible, but there’s something impersonal about reading off a list of symptoms—and writing is all about creating that personal connection.

What exactly do the criteria mean? How can they affect your character’s life? How do you write about PTSD in a way that’s not neutral and analytic but emotive? That’s the subject of the next two posts.

To Keep in Mind:

The information in this post comes from the DSM-5 (see ‘Further Reading’). Please do not use it to diagnose yourself or others. It isn’t intended to be a substitute for professional advice so do consult a qualified clinical professional if you have any questions about the diagnosis criteria. Feel free to use this information to diagnose your characters, however.

Before you tuck into the ‘translations’ of the diagnostic criteria, please absorb the important phrase I’m about to throw at you.

Everyone is different.

Absorbed it fully? Great. Now what does it mean?

As you may have noted while reading the Psychology Segment, Criteria A to E are each made up of several symptoms, of which your character must experience at least one or two. That means there’s a lot of variation in the symptoms that someone with PTSD might experience. One person could have predominantly fear-based intrusion symptoms, like those in Criterion B, while another may have primarily arousal- and reactivity-based symptoms, like those in Criterion E. The two may present very different symptoms and yet both be diagnosed with PTSD.

So what does that mean for your writing? That Post-Traumatic Stress Disorder doesn’t affect everyone in the same way. There is no one ‘right’ way to portray it in your writing, no rigid set of symptoms for you to check off a list. Therefore, I’d recommend you go a step further in your research and read firsthand accounts of people living with PTSD.

The diagnostic criteria only give you a brief overview of what the symptoms of PTSD are; the story of day-to-day life for someone living with Post-Traumatic Stress Disorder will give you the reality behind it. The emotion. And it’s the ability to create an emotional experience that makes readers connect with you and your characters.

But before you go off looking for those firsthand accounts, familiarise yourself with what the diagnostic criteria look like in context. I’ve created a more understandable ‘translation’ of the criteria outlined in How to Tell If Your Character Has Post-Traumatic Stress Disorder, with a focus on what they actually mean and how you can write about them in your story. After that, the rest is up to you, dear writer.

Please note: For the sake of simplicity and easy reading, I’ll be referring to the trauma as an ‘event’ (singular) throughout this post, but please be aware that the original trauma could have occurred several times or across several events, not just the one.

Criterion A: Stressor

This criterion concerns the traumatic event that caused your character to develop Post-Traumatic Stress Disorder. The trauma could have happened to your character directly, they may have witnessed it happen to another, learnt of it happening to a close family member or friend, or been repeatedly exposed to traumatising details of the event. Let’s break those down into sections and look at what could be classed as a traumatising event.

Criterion A1:
Your character experienced the event directly.

The traumatising events could include (but are not limited to): exposure to war, as a combatant or a civilian; threatened or actual physical assault, such as mugging or physical abuse; threatened or actual sexual assault, such as rape or abusive sexual contact; being kidnapped, taken hostage, tortured or incarcerated as a prisoner of war; experiencing a natural or man-made disaster; or being involved in a severe vehicle accident.

Life-threatening illnesses or debilitating medical conditions don’t necessarily count as a traumatising event, unless the medical incident was sudden and catastrophic, such as waking up during surgery or going into anaphylactic shock.

Criterion A2:
Your character witnessed the event happen to others.

The traumatising events could include (but are not limited to): witnessing threatened or serious injury, unnatural death, physical or sexual abuse of another person due to violent assault, domestic violence, war or disaster, or a medical catastrophe in their child, such as a life-threatening haemorrhage.

Criterion A3:
Your character learnt of the event happening to close relatives or friends.

The traumatising events could include (but are not limited to): violent personal assault, suicide, a serious accident or injury. In this case, PTSD may be more severe or long-lasting if the event was intentional and was caused by another person. The traumatic event must have been violent or accidental in nature (for example, death from natural causes doesn’t qualify).

Criterion A4:
Your character was exposed to extreme or repeated traumatising details of the event.

For example, police officers repeatedly exposed to the details of child abuse, first responders collecting human remains at the site of a disaster, or firemen, police officers and medical personnel witnessing people die in traumatic accidents.

Criterion B: Intrusion Symptoms

This criterion is all about the intrusive re-experiencing of the traumatic event, which should happen in one or more of the following ways:

Criterion B1:
Your character has recurring, involuntary and intrusive memories of the event, which they find distressing.

Rather than simply ruminating over the memories, it’s important to note that these distressing memories are involuntary and intrusive. They can be triggered suddenly, without your character meaning to remember them, and they happen repeatedly, not just the once or twice.

Criterion B2:
They have recurring distressing dreams, which relate to the traumatic event in content or emotional tone.

The event itself may be replayed again and again in your character’s dreams, or they may have recurring dreams that are thematically-related or representative of the major threats involved in the event. For example, if your character was assaulted, they may have recurring nightmares about being chased by an unidentifiable malevolent figure, in addition to dreaming about the attack itself.

Criterion B3:
Your character experiences dissociative states, in which they feel or act as though the traumatic event is happening again.

These dissociative states (i.e., your character feels detached from themselves or their surroundings) can last anywhere from seconds to hours—or even days. During this time, they might relive aspects of the original event and behave as if the event is happening right then and there.

The feeling of detachment that your character experiences can range from mild to extreme. At one end of the spectrum, they might have brief visual or other sensory intrusions related to the trauma, in which they don’t lose their sense of reality. At the more extreme end of the spectrum, your character could lose awareness of their present surroundings completely. The latter, often called a flashback, is usually brief but can cause your character prolonged distress or heightened alertness.

Related post: I Forget… What Can Cause My Characters Amnesia?

Criterion B4:
They feel intense or drawn-out psychological distress when exposed to reminders of an aspect of the traumatic event.

This feeling of intense distress can be triggered by something internal, like a physical sensation (e.g., a rapid heartbeat in a previously traumatised child or dizziness in a survivor of head trauma), or something external, like a reminder in the environment. External triggers could relate to an aspect of the trauma directly or symbolically—for example, windy days after a hurricane or seeing someone who looks like their perpetrator could trigger intense distress in your character.

Criterion B5:
They feel noticeable physiological responses to internal or external reminders of the trauma.

For example, your character may feel a surge in their heartbeat or an increase in sweating after being reminded, symbolically or otherwise, of the traumatic event.

Criterion C: Avoidance

This criterion concerns avoiding anything associated with the trauma, whether they’re direct memory cues or things that resemble or symbolise the traumatic event. Your character could do this in one or both of these ways:

Criterion C1:
They avoid or attempt to avoid distressing memories, thoughts or feelings about the traumatic event.

If your character experiences this symptom, they’ll always (or almost always) try to avoid thoughts, memories, emotions or talking about the original trauma or anything related to it.

One way they might do this is through distraction techniques that let them avoid these internal reminders. Alternatively, if their memories are triggered by bodily sensations, such as a raised heartbeat or shortness of breath, they may avoid physical exertion, which could cause a similar bodily response.

Criterion C2:
Your character avoids or attempts to avoid external reminders that trigger distressing memories, thoughts or feelings.

Whereas Criterion C1 concerns avoiding internal reminders, C2 is all about the ones that come from outside—people, activities, objects or situations that trigger memories of the traumatic event.

For example, in Steven Taylor’s Clinician’s Guide to PTSD, he highlights how military combatants might avoid watching news coverage of wars and how victims of a hold-up might avoid banks. Avoidance can take subtler forms too. Survivors of domestic violence might speak in a whisper and avoid eye contact with people who seem too assertive to avoid provoking them.

Phew. That’s a lot of information all at once. Take a little time to think about which symptoms are best for your character’s circumstances and their story and how you could integrate them into the narrative. Then pop back for more ‘translations’ of Criteria D to H (and a free workbook), in Getting It Right: Writing About Post-Traumatic Stress Disorder | Part II.