Mental Health Monday–Character Analysis: I Hear Voices…No, Really


Stina Lindenblatt asked me to give a run down of treatment for her character. He hears voices, but they are real (in a paranormal way). They end up driving him to cut his wrists. And Stina wants to know what would happen next.

In the state of New York (where I live), someone can be admitted to a psychiatric facility on an Emergency Admission. Also known as an Involuntary admission, people who are a danger to themselves or others can be admitted for treatment, even if they don’t want to be. (We also admit people voluntarily, of course.) I bring this up because not all states have this law.

So, if Stina’s character showed up in my ER, let’s say, and has cut his wrists and reports hearing voices, I’d recommend inpatient hospitalization for his safety and stabilization. Treatment would include keeping him in a safe environment (in the hospital), offering him medication, individualized therapy, and group programming.

Medication varies by diagnosis and symptoms, but someone experiencing auditory hallucinations (voices) would be given an anti-psychotic. “First-generation anti-psychotics” (so called because they were identified and produced first) include Haldol, Thorazine, and Prolixin. They are fast and effective, and though Stina’s character would likely be sleepy for the first few days he’s on them, he’d also note resolution of symptoms within a few days to a couple of weeks. “Second=generation anti-psychotics” (so called because they were developed after the first generation ones and were touted to have less side effects (despite causing other side effects like metabolic changes)) include Risperdal, Seroquel, Zyprexa, and Abilify. Also quick-acting, these agents would resolve Stina’s character’s symptoms within a few days.

One may assume cutting of wrists indicates a suicide attempt and therefore means the person is depressed. (This isn’t always the case, but let’s go with that assumption here, okay?) So, in addition to the antipsychotic, Stina’s character would be offered an anti-depressant like Zoloft, Prozac, Celexa, Wellbutrin, or Effexor. These medications take several weeks to kick in. A person doesn’t have to stay in the hospital for that length of time, by any means. We just need to see their mood begin to stabilize out.

Before leaving the hospital, it would be important for Stina’s character to have follow up treatment with a psychiatrist and counselor scheduled. This would allow for outpatient monitoring of his medications and symptoms. Antipsychotics (if symptoms are resolved and thought to be part of a depressive episode) can be discontinued within a few weeks or months. Anti-depressants should be taken for at least a year to fully treat the current episode and prevent future ones.

If someone has chronic symptoms and history of depressive episodes, they’d more than likely need to stay on medications long-term. If someone has chronic psychosis, they’d need to stay on the medications long-term as well.

Stina’s character is 17, which may alter his management a bit…however, in this case, he’d likely be given the same medications as an adult.

Based on Stina’s description of her character’s clinical presentation, I’d diagnose him with Psychotic Disorder Not Otherwise Specified (he doesn’t necessarily meet criteria for DSM-IV diagnosis) and perhaps Depressive Disorder Not Otherwise Specified.

Other potential diagnoses include: Brief Psychotic Episode, Schizophreniform Disorder, Schizophrenia, Schizoaffective Disorder, and Major Depressive Disorder with Psychotic Features. Any medical conditions or drug use would have to be considered as well.

I hope this is helpful, Stina!

I’d be happy to answer any follow up questions as well. There’s a lot of information in this post and I could certainly go on, but I won’t cause your eyes will start crossing soon. πŸ˜‰

Be sure to check out Lydia’s Medical Monday post about what plant in your garden could kill you.

Remember, these posts are for WRITING PURPOSES ONLY and are NOT to be construed as medical treatment or advice. Happy writing!

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18 comments on “Mental Health Monday–Character Analysis: I Hear Voices…No, Really

  1. Sarah says:

    Yay! I sent Stina in your direction because I knew you could answer this question! I direct a program for kids at risk for psychiatric hospitalization or who are being discharged from the hospital, so I guess I’d just add that because he’s a minor, it would probably be easier to hospitalize him whether he wants to be there or not, as long as his parents are in favor of it. In addition, the second generation anti-psychotics are definitely what we see (Risperdal seems to be a favorite!)–I almost never see a kid on one of the first generation drugs, probably because those wouldn’t be prescribed unless nothing else worked (?), and kids are usually right at the beginning of the process.

  2. Doris says:

    Ahh…. I’m in my element!

    Great explanation, Laura, considering the space limitation.

    Have a great week.

  3. Ciara Knight says:

    I remember taking Psych and thinking everything is Not otherwise specified. πŸ™‚ Great explanation. I might be sending you a character question soon. πŸ˜‰

  4. Lynn Rush says:

    LOVE this question. I’ve always wondered how an involuntary admission worked like that. And the meds. First generation/second generation. That’s great info along with potential sleepiness that would be important for us to mention about our character to make it more real. LOVE it!

  5. Nada says:

    And there’s the psychiatric system in a nutshell.

    * Assumption of cause.

    * Diagnosis unspecified.

    * Medicate to the point of stupor.

    * Saddle the patient with a “history of being treated for mental illness” and “history of anti-psychotic medications” that will follow him/her for life and impact their future employment, legal issues, and personal interactions regardless of if they need the meds or not.

    In my experience, having a good 80% of my relatives treated for real (and perceived) mental illness, there’s a rush to diagnose and sedate without much time spent on discovery. Psychiatrists/psychologists make people miserable and ruin lives, and when their mistakes are discovered, it still doesn’t matter because the diagnosis is still on the record.

    You’ve got an entire field trained by people who can’t make a differential diagnosis because there IS no way to make one definitively, and those people run around claiming to know the cause of disorders they can’t even prove exist.

    It’s a sick joke and it’s played on the people they call patients.

    • lbdiamond says:

      I understand it’s a scary and frustrating experience in some cases. It’s true that the meds can be sedating and if someone is so ill that they are a danger to themselves and/or others, then it’s necessary to keep them calm. It’s not our intention to be cruel. We want to keep the person and those around them safe.

      Diagnosis can be tricky because there is a huge overlap of symptoms and many diagnoses are syndromes. And there is a time component–someone can look depressed at one point and manic at another based on their symptoms and presentation.

      One doesn’t necessarily *have* to have a hard and fast diagnosis. If the person’s symptoms are enough to cause them distress, then it’s beneficial to offer medications and therapy.

      I hope this helps. Best of luck to you and your family.

  6. Vicki Tremper says:

    Wow, intense, Stina. Thanks, Laura, this brings up all kinds of plot possibilities.

  7. Where I live the police are trained to handle calls where a person has a Mental Illness which makes the lives of social workers and case workers a lot easier.

  8. Well done post. Very interesting. A couple of my teenage family members have been admitted into mental facilities under emergency situations, so it’s an issue close to my heart.

    In my experience, how the kids are treated can vary depending on the facility. Mental illness, depression, and cutting are important issues to young people. I’m glad to see it dealt with in YA fiction.

  9. Very interesting! But since the character’s symptoms have an external source, the medication could cause a lot of confusion to both the doctors and the paranormals. πŸ™‚

  10. Karen Lange says:

    Interesting stuff. There are just so many things to use in our writing, you know? Thanks for sharing.

  11. Lydia K says:

    This inside info is so invaluable! Thanks Laura and Stina. πŸ™‚

  12. Linda Gray says:

    This is all really interesting. This statement: “Antipsychotics (if symptoms are resolved and thought to be part of a depressive episode) can be discontinued within a few weeks or months.” was particularly so. Do you need to test results somehow after you’ve discontinued the antipsychotic in order to determine the accuracy of your assessment, or is it usually very clear whether the symptoms were part of a depressive episode?

    • lbdiamond says:

      There aren’t any tests per se. It’s based on clinical presentation. If someone has a known history of depression with psychosis and their psychosis resolves and they stay on anti-depressant medication, they don’t have to stay on the anti-psychotic.

      Discontinuing any medication should be done slowly and under the guidance of a doctor. The dose can be increased again if a relapse of symptoms occur. πŸ™‚

  13. roguemutt says:

    Have you ever had a post on hoarding? That’s what I need for my sisters.

  14. lenny says:

    hi dr laura! wow you said lots. im thinking that first generation stuff gets used cause its a shot and it gets inside real quick and helps get you calmed down fast. that second stuff is tablets for when the guy is doing better. i learned all that from my brothers work and he said sometimes you could get those voices and other stuff from using drugs so you gotta know if hes using drugs. i love learning about mental stuff. for sure its a big help in doing characters.
    …hugs from lenny

  15. This was awesome stuff, Laura. There’s definitely a lot of plot possibilities this can lead to. Now to make sure I don’t undermine the seriousness of mental illness because I’m taking a paranormal route to the story. πŸ™‚

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