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

When trauma strikes, it can have long-lasting and far-reaching consequences. If your story features said trauma and its consequences, you may find yourself writing about characters with Post-Traumatic Stress Disorder (PTSD).

PTSD is a trauma- and stressor-related disorder caused by a very distressing, frightening or stressful event and can affect anyone, not just military combatants. You can find out exactly what its symptoms are and how it’s diagnosed over in How to Tell If Your Character Has Post-Traumatic Stress Disorder, then dive in to the more detailed ‘translations’ of those symptoms in Part I of Getting It Right: Writing About Post-Traumatic Stress Disorder.

Read those two posts? Then it’s on to Part II of the diagnostic criteria ‘translations’. Find out what Criteria D to H mean and how to write about them accurately, respectfully and emotively in today’s post.

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.

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.

With that in mind, let’s dive straight back in with the translations of Criteria D to H.

Criterion D: Negative Changes to Thoughts and Mood

Symptoms within this criterion relate to negative changes to your character’s thoughts or mood associated with the traumatic event. These changes begin or get worse after the trauma and should include two or more of the following:

Criterion D1:

Your character is unable to remember important aspects of the traumatic event.

It’s important to note here that this amnesia is usually caused by psychological factors, not physiological ones, like a head injury, alcohol or drugs. You can find out more about dissociative amnesia in I Forget… What Can Cause My Characters Amnesia? and in the ‘additional specifications’ section at the end of How to Tell If Your Character Has Post-Traumatic Stress Disorder.

Just because your character can’t remember aspects of the trauma doesn’t mean there’s no effect on their behaviour, however. They could have intense emotional responses and not know what’s triggering them thanks to these blocked memories—and that can have some interesting applications in your story.

Criterion D2:

Your character has persistent and exaggerated negative beliefs or expectations following the trauma.

They might now believe that the consequences of the traumatic event are permanent and unchangeable, and that their future is negative. Their beliefs about themselves, others or the world may also be tainted by negative emotions and expectations. Let’s look at these one at a time.

Beliefs about themselves: Your character may feel shame or guilt, that they’re no longer able to trust themselves or their instincts, or see themselves as bad or even evil. For example: I’m a bad person. I’ve always had terrible judgement. I’m so ashamed of myself.

Beliefs about others: Positive beliefs your character had about others may become negative after the traumatic event. For example: I can’t trust anyone ever again. They’re out to get me. People just take advantage of each other.

Beliefs about the world: Your character may now expect the world to be an unsafe, unpredictable, untrustworthy or frightening place and feel powerless, helpless or incompetent as a result. For example: The world isn’t fair. It’s dangerous out there. Bad things could happen that I can’t control.

Consider the primary features of the trauma your character went through—these could indicate themes for their negative beliefs or expectations. For instance, if betrayal is a major feature, trust may now be difficult for your character. If violence, particularly if it was sudden or unexpected, was involved, then the safety and predictability of the world may now be thrown into doubt.

Criterion D3:

Your character has persistent, distorted thoughts about the cause or consequences of the traumatic event, which leads them to blame themselves or others.

Note here that these thoughts are distorted or erroneous—in other words, your character may be mistakenly or unfairly placing the blame for what happened on themselves or others—for example, believing that it was their fault they were abused.

Bear in mind that people place blame differently. One person may blame themselves while another may blame external factors, like other people, the world or fate. For instance, if your character was involved in a serious car accident, they could blame themselves for not being properly in control of the vehicle or for reacting too slowly. Alternatively, they could place the blame on the driver of the car they collided with, or blame the world, because the wind suddenly picked up and blew an obstacle into the road. Who or what your character blames could also affect how they forgive (or fail to forgive) what happens to them.

Criterion D4:

Your character has a persistent negative emotional state.

This unshakable negative mood state could feature feelings of fear, anger, horror, guilt or shame, and either begin or become worse after the traumatic event. If writing scenes from this character’s perspective, let the negative emotions they feel permeate their thoughts, their behaviour, the tone of their narrative, so that it creates the impression of consistency. Be careful not to overdo it though—while this is a persistent mood state for your character, it can become annoying to readers if you mention it every few lines.

Criterion D5:

They feel a noticeable decrease in interest or participation in significant activities.

Your character might feel a markedly diminished interest in activities they previously enjoyed and no longer take part in them, which could be due to feeling more emotionally numb or wanting to avoid anything associated with the trauma. If your character experiences this symptom, they may feel a decreased motivation to take part in these activities, despite knowing that they should enjoy them.

Criterion D6:

They feel detached, alienated or estranged from other characters.

The emotional numbing your character feels could lead to them withdrawing from others, feeling less attached to the people around them and less motivated to connect with loved ones. The isolation and alienation they experience may be worsened if the people around your character don’t understand them.

Criterion D7:

Your character has a persistent inability to feel positive emotions.

This is particularly the case for emotions such as happiness, joy and satisfaction, as well as those associated with intimacy, tenderness and sexuality. Your character might feel as though they “have a wall up” or are blocked from feeling positive emotions, even when they’re in a situation in which they know they should feel them.

Criterion E: Hyperarousal and Hypervigilance

This criterion features changes in your character’s levels of alertness and their reactions, starting or worsening after the trauma. It could be in two or more of the following ways:

Criterion E1:

Your character has angry outbursts or irritable behaviour.

These quick-tempered responses could be caused by little or no provocation (e.g., feeling unusually aggravated by unwanted noise, like car alarms) and typically feature verbal aggression (e.g., yelling at people) or physical aggression towards others or objects (e.g., getting into fights or destroying furniture).

Criterion E2:

They behave recklessly or in a self-destructive way.

Your character might turn the emotions they’re feeling following the traumatic event inwards and behave in a way that’s harmful or reckless, such as driving dangerously, drinking excessive amounts of alcohol, taking drugs, self-harming or behaving in a suicidal way.

Criterion E3:

Your character is hypervigilant.

In other words, they’re tense and on guard, alert to potential threats in the environment, especially those related to the traumatic event. If the original trauma involved a vehicle accident, your character might be sensitive to potential danger caused by cars or trucks. If the trauma involved other people, they might sit with their back to the wall and face the door in a public place so that they can scan for threats, or they might go through checking rituals, such as making sure the doors and windows are locked on a night. They might also be sensitive to dangers that are unrelated to the traumatic event, such as being fearful of suffering a heart attack.

Criterion E4:

They have an exaggerated startle response.

An exaggerated startle response—unsurprisingly—means that you startle easily when something unexpected happens. Your character may often feel jumpy, starting when a phone rings, for example, and could have difficulty calming down afterwards.

Steven Taylor highlights two examples of interpersonal and dangerous consequences of an exaggerated startle response. Firstly, combat veterans experiencing this symptom might become physically aggressive when startled, almost like a reflex, which can have some serious consequences for their relationships with others. For those whose PTSD stems from a traffic accident, an exaggerated startle response could have potentially life-threatening repercussions. One woman was startled by a truck roaring past her while driving and reflexively stamped on the brakes, causing her car to spin and almost cause an accident.

When writing about this symptom, think not only of its physiological effects but also of its social and safety-related ones. These could provide sources of internal, external and interpersonal conflict in your story.

Criterion E5:

Your character has problems concentrating.

These problems could stem from your character's preoccupation with intrusive thoughts relating to the trauma (like those in Criterion B1), or from constant scanning of the environment for threats (like the hypervigilance described in Criterion E3). As a result, your character might easily lose focus (e.g., losing track of a conversation), have difficulty remembering things (e.g., their phone number), leave activities incomplete, or need to put in more effort to concentrate on reading or watching things. Tiredness caused by disturbed sleep (Criterion E6) can also make it more difficult for your character to concentrate.

Criterion E6:

Your character has disturbed sleep.

This could mean trouble getting to sleep (initial insomnia), difficulties staying asleep (middle insomnia) or sleeping restlessly throughout the night. Memories of the traumatic event might find their way into your character’s dreams, as mentioned in Criterion B2, which could be causing the middle insomnia. Worries about safety or heightened alertness are other potential causes of middle and initial insomnia, in addition to worries about sleep, such as being afraid of nightmares.

Related Post: What Happens to Sleep Deprived Characters?

Criterion F: Duration

To be diagnosed with Post-Traumatic Stress Disorder, your character must experience Criteria B, C, D and E (called the ‘disturbance’) for more than one month, not just the once then never again.

It’s also worth noting that these symptoms don’t all have to appear immediately after the traumatic event—in cases of delayed expression, the criteria might not be met until at least six months after the event. The onset and expression of some symptoms might be immediate, whereas others might take weeks or months to develop to the point where they can be diagnosed. Keep this in mind while writing about characters with PTSD.

Criterion G: Impact

The effects of the disturbance must cause your character significant distress—these symptoms are negatively affecting their lives in a big way—or must impair them in a social, job-related or some other important way.

For example, if your character developed PTSD after a serious traffic accident, they may experience symptoms while driving, which could have dangerous consequences like those highlighted in Criterion E4, or they may avoid driving altogether. The latter could affect their social lives (they’re no longer able to reach their destinations easily) and their ability to work (they could struggle to get to work or, if their job involves driving, they might not be able to work at all). You can find out more about the effects of PTSD on a person’s life here.

Criterion H: Exclusion

Finally, to be diagnosed with PTSD, Criteria B-E can’t be caused by another medical condition or by the physiological effects of a substance, such as medication or alcohol.

A Few Final Points to Remember

Everyone is different. It’s very rare for someone to experience all the symptoms of Post-Traumatic Stress Disorder, so one person diagnosed with PTSD may experience markedly different symptoms to another. When deciding which symptoms your character will have, consider:

• How the symptoms relate to the original traumatic event. Ask yourself: does it make sense for my character to experience this symptom as a result of the trauma?
• How the symptoms fit in with each other. Ask yourself: could one symptom link to or exacerbate another, like Criterion E6 potentially contributing to E5?

The Next Step

Find articles, accounts and stories from people with PTSD and learn more about the reality of living with the disorder. Do your research, write accurately and be respectful and sensitive in your representation of Post-Traumatic Stress Disorder, and you won’t go far wrong.