Putting the science in fiction - Dan Koboldt, Chuck Wendig 2018
Writing mental health in fiction
The brain is wider than the sky
By Kathleen S. Allen, RN, DNP
Like you, I am a writer. I’m also a mental health professional, and I often cringe when I come across mental illness depicted in fiction because it’s usually either not quite right or half-right or completely off track.
It’s fine to use search engines to do research, but there is so much misinformation on the Internet it’s often difficult to discern what is correct and what is downright wrong. It can be damaging to a reader who has a psychiatric disorder when a book writes mental illness poorly. I’m going to dispel myths about several psychiatric disorders in order to help you write mental illness to empower your readers.
During my stint as a psychiatric nurse practitioner I diagnosed patients/clients, wrote orders for patients in a locked psychiatric unit, did admissions and discharges, and prescribed medications and did therapy for adolescents and adults who had depression, anxiety, post-traumatic stress disorder (PTSD), bipolar disorder, obsessive-compulsive disorder, and schizophrenia. I’ve worked with patients/clients who have attempted suicide, were suicidal, or were getting electroconvulsive therapy (ECT), and no, it’s not like One Flew Over the Cuckoo’s Nest. Think of it more like a computer reboot.
I’ve also seen people suffering from a mental disorder due to their medical condition, and that’s why it’s important for psychiatric patients, especially those with first-time symptoms, to be medically cleared before a psychiatric diagnosis can be given to them.
So what does this mean for you, a writer? If you are able to speak to a mental health professional, great! If not, invest in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), a manual that mental health professionals use to diagnose their patients/clients. Each category in the DSM-5 lists criteria for a certain disorder and how many of those criteria need to be met to make a diagnosis.
I believe it is important to write characters who have been diagnosed (or will be diagnosed in your story) with a mental illness to help remove the stigma of mental illness. Stigma can be one of the major reasons why people don’t get help for mental illness along with not knowing resources that may be available to them, having a low (or no) income, homelessness (although not all homeless individuals have a mental illness), and unavailable child care or transportation to treatment.
So, let’s get started with writing a character who has a mental illness in your story.
Facts about mental illness
Depression
Depression can be diagnosed at any age, including as a child. According to the National Alliance on Mental Illness, one in five children will have or has a serious mental illness. Anxiety disorders often accompany depression. This can include generalized anxiety disorder, social anxiety disorder, and panic disorder (with panic attacks).
The most vulnerable groups are adolescents and women. Vulnerable populations are adolescents who are bullied, who identify as being LGBT, who have a history of family with depression or suicide, and who are involved in violence. According to the World Health Organization, suicide is the third leading cause of death for adolescents between the ages of fifteen and nineteen and the second leading cause of death for adolescents and adults between the ages of fifteen and twenty-nine.
Symptoms
Characters with depression can oversleep, not sleep enough, overeat, not eat much, feel suicidal, be irritable, be angry, feel sad, cry too much, or feel numb. They no longer enjoy doing the activities they used to enjoy. Their depression can be mild, moderate, or severe (unable to function in their daily lives). In a severe depression they can also have psychosis and experience hallucinations or hear voices that aren’t there. Characters with depression (moderate or severe) may also be suicidal.
Treatment
Treatment for depression is a combination of talk therapy with a social worker or psychologist who has been trained in cognitive behavioral therapy or interpersonal therapy and medications such as selective serotonin reuptake inhibitors that help balance the neurotransmitters that regulate mood in the brain.
When writing about medications for characters, I find it easier to make up a name of a medication rather than have the fictional character taking the wrong medication for his disorder.
If your character is suicidal, she needs to be hospitalized if she has a plan and intent. If she is feeling suicidal with no exact plan or intent, others need to be vigilant about the degree to which the character is experiencing suicidal thoughts.
Busting Myths About Depression
Please don’t use the word depressed when your character is feeling sad or blue. Being depressed is not the same as feeling down. If your character has depression, it’s not uncommon for him to laugh, smile, or appear happy even when he is in the midst of a depressive episode.
Characters who ask others if they are suicidal will not put the idea in their head. It’s already there, and asking about suicidal thoughts will not force someone to commit suicide if the thought with plan and intent wasn’t already there.
If a character is a cutter (cuts on self to relieve stress or extreme emotional anxiety), it doesn’t mean she is suicidal. Does this mean anyone who cuts isn’t suicidal? No, of course not, but again, ask.
Bipolar Disorder
Bipolar disorder means a person with this mental illness experiences both depression and elation during different times. There is a spectrum of bipolar disorders and not everyone experiences extreme lows or extreme highs, although some can. Some have rapid cycling, meaning their periods of ups and downs can occur like a rollercoaster over several days or weeks, and some can have depression for months before they have an upswing.
A character with bipolar disorder can be diagnosed as an adolescent and sometimes as a child. At risk are those with an immediate family member also diagnosed with it.
Symptoms
A character with bipolar disorder can exhibit manic signs such as not needing sleep, having increased energy, eating less, having grandiose thoughts or ideas, talking too fast, or talking nonsense. He may engage in high-risk activities such as spending too much money or other risky behaviors. When he is not in a manic state he can experience signs of depression including being suicidal. He can also experience psychosis.
Treatment
Bipolar disorder is treated with medications called mood stabilizers and therapy. It is a myth that everyone who has been diagnosed with bipolar disorder will have extreme highs and lows. It isn’t uncommon for some to have extreme highs and lows, of course, but not everyone does. Some only have a slight spike in the high end; some might experience a low mood. It all depends on their baseline, which is why a good history is so important.
Schizophrenia
Schizophrenia is usually diagnosed between the ages of eighteen and twenty-five when someone has a “first break” and exhibits signs of psychosis. That’s not to say older people can’t have a first break, but it’s not as common.
This mental illness is characterized by having auditory, visual and/or olfactory hallucinations. People with schizophrenia can also be delusional and have thought disorders.
Treatment
Schizophrenia is treated with antipsychotic drugs. Other medications such as those for depression may also be used if the patient is also depressed. There is no cure for schizophrenia, but symptoms can be minimized with the right combination of medications.
Busting Myths About Schizophrenia
A character with schizophrenia will not stop hearing voices or having hallucinations overnight. It takes weeks for antipsychotics to work and sometimes months to find the right combination of medications. Delusions are difficult to dispel and may not respond to medication.
A character with schizophrenia is no more violent than a character without it. She may be delusional if she is untreated and be hard to reason with, but a character with schizophrenia is not more violent than one without schizophrenia.
Post-Traumatic Stress Disorder (PTSD)
PTSD can happen after a traumatic event occurs where the person believes his life is in immediate danger. Soldiers in combat often are diagnosed with PTSD, but it can happen with any trauma such as surviving a sexual assault, surviving a disaster such as a plane crash, or from being in an armed robbery situation.
Symptoms
A character with PTSD can have flashbacks of the trauma, nightmares, be hypervigilant, be startled easily, avoid loud noises such as fireworks, and experience signs of depression such as not eating or sleeping enough. She may also avoid the area/situation of the trauma, such as avoiding being in a car after a car accident.
Treatment
PTSD is treated with therapy and medications to treat the symptoms. PTSD can happen after a trauma, so getting psychological help immediately after a trauma is imperative. The symptoms vary by individual, but not everyone who has been through a trauma will experience PTSD.
Dissociative Identity Disorder (DID)
People with DID may experience symptoms such as losing time, waking up in a different outfit or in a different place, experiencing memory loss or a gap in memory, or feeling like they are out of their body. They may also have an awareness of two or more personalities. An extensive history by a psychiatric professional should be done. Treatment for DID is usually psychotherapy and although medications can be used if someone is experiencing depression or anxiety, there is no medication specifically for DID.
This psychiatric disorder is rarer than it is shown in novels, on TV, or in movies. If your character has DID, a mention about how rare it is should be part of the narrative. A character with DID will not kill when he isn’t in his core personality state. In other words, if he kills when he is using an alternative personality, he would also kill when he was in his core personality. He will not have amnesia after killing someone, so it wouldn’t be a surprise or something to be revealed.
There you have some common mental health disorders you might want to have your characters experience. The most important takeaway is DO YOUR RESEARCH. There are other mental health disorders I didn’t discuss (such as eating disorders, attention-deficit hyperactivity disorder, or anxiety disorders) but again, do your research and speak with a mental health professional to get your story right so you don’t lose readers or perpetuate damaging stereotypes.
Resources for learning about mental illness
National Alliance on Mental Illness: www.nami.org
World Health Organization: www.who.int
National Institute of Mental Health: www.nimh.nih.gov
University of Michigan Depression Center: www.depressioncenter.org
WebMD: www.webmd.com
Mayo Clinic: www.mayoclinic.org