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. 😉

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!

Mental Health Monday–Loner Style

Amanda (writer and blogger–A Fortnight of Mustard) asks:

My character is a loner. He’s afraid to get close to people. He wasn’t neglected as a kid, but he’s lost most people close to him in [an epic tragedy]. Is this attachment disorder?

GREAT question, Amanda!

Attachment Disorder means there is a failure to form normal attachments to others. It is often associated with early experiences of neglect and abuse by primary care givers (ex. parents), or abrupt separation from caregivers between the ages of 6 months and 3 years, or frequent change in caregivers, or lack of a caregivers response to the child’s efforts to communicate.

An example of an attachment disorder is Reactive Attachment Disorder. This is evidenced by a toddler who fails to stay near familiar adults in a new environment or failure to be comforted by a familiar person OR by a six year old who displays excessive friendliness and inappropriate approaches to strangers.

Attachment theory posits that infants will attach to a caregiver as a means to protect itself from danger or as a means of survival. (This is an evolutionary theory.) This is not the same as love and affection, although those behaviors are needed to create a strong bond. 😉

Each person has his or her own Attachment style (or pattern of relating to others) based on early childhood caregiving experiences. The styles include: secure, anxious-ambivalent, anxious-avoidant, and disorganized. These styles are not in and of themselves disorders, but can lead to problems with relating to others, based on how prevalent the style is and which type.

I’m sure my dear friend Sarah Fine, who is a child psychologist, writer, and blogger (The Strangest Situation), can give a much better explanation of all the jargon I just threw at you.

I included the above discussion to state that it doesn’t appear your character has an Attachment Disorder because he wasn’t abused and he was normal before this traumatic incident.

However, there are several other things that could be going on, which I’ll touch on now.

Someone who goes through a severe trauma is susceptible to developing Post-Traumatic Stress Disorder. To be diagnosed with PTSD, the person has to be exposed to something that is PERCEIVED as life-threatening. They can develop flashbacks, nightmares, hypervigilance (ex. looking for any potential foe wherever they are, sitting in a corner to watch the exits, planning an exit strategy wherever they are, checking over their shoulder every few seconds), hyperarousal (ex. startle response–jumping when the phone rings), numbing of emotions, and avoidance (of talking about the situation, avoidance of others, avoidance of any stimulating situations).

Amanda, your character displays avoidance and perhaps numbing of emotions. He lost several people close to him and so it would seem that he’s at risk of having PTSD. I don’t know if he has intrusive, recurrent memories (flashbacks) or nightmares of the incident or if he has hyperarousal, so it’s difficult to do a formal diagnosis.

Additionally, you mentioned he is (or can be) reckless and go headlong into dangerous situations. So, it could be that though he is traumatized by what happened, he is also desensitized to horrific experiences. Interestingly, soldiers who are exposed to combat become more effective in that environment than in a civilian environment. They have in a way become adapted to staying in the hyperaroused state (for survival) and then can’t handle things when the danger is gone.

Finally, loss is one of the most difficult things a person can experience. I wouldn’t be surprised if your character also experiences significant bereavement, grief, or even depression secondary to loss. This can last years. AND it would be advantageous, in a way, to avoid getting close to others because then he wouldn’t have to face the agony or terror of losing someone else.

I hope this was helpful!

Keep your questions coming, folks! And check out Lydia Kang’s Medical Monday while you’re at it. Remember these posts are for writing purposes ONLY and are NOT intended to be medical diagnosis, treatment, or advice.

 

Mental Health Monday–Teen Guilt

This week, Kimmy (a writer of YA paranormal and QueryTracker forum bud) asks:

My seventeen-year-old protagonist lives with the guilt of her father’s death and mother’s car accident (she feels she caused both and she doesn’t really know how to handle her feelings). What type of behaviors can we expect from a teen carrying this type of grief inside?

Great question, Kimmy! Striving for authenticity and accuracy is BIG in the Young Adult genre. If a character’s reaction seems forced, contrived, or flat, a teen will pick it up in seconds.

That being said, each person reacts to situations in their own individual way. Because of this, the best advice I can give is to really “research” your character. Know her inside and out. To do this, some writers use “interviews.” Others use character sketches. I write a whole novel, then start over when I finally figure my characters out. (Um, yeah, that was sort of a joke, but totally true, LOL!)

But seriously, knowing—like really KNOWING—your character will show you what response she’d have.

Now (if you allow me some artistic license to bring this to the mental health arena), someone carrying around guilt could experience it to the extent where it significantly interferes with their functioning.

A teen grieving the death of her father—especially if she thinks she caused it—could be experiencing a range of diagnoses from bereavement (a sorta fancy term for grieving), complicated bereavement, or even major depression, sometimes with psychotic features and suicidal ideations if severe enough.

In bereavement, one could see any range of emotional, physical, social, cognitive, even philosophic responses. Crying, expressions of anger, nightmares, appetite problems, and even hallucinations (generally in the form of hearing the deceased call the person’s name) can be normal.

In complicated bereavement, there is an added time component. For example, if the death occurred a year or two ago and the person starts to worsen.

Major depression is a constellation of symptoms, usually including depressed mood (for a majority of the day) for at least two weeks, change in appetite and sleep, feelings of GUILT, worthlessness, hopelessness, helplessness, decreased (or increased) energy, anhedonia (loss of pleasure or ordinarily enjoyable activities), and suicidal ideations.

Teenagers have a much higher risk of attempting suicide as a reaction to grief. They also may display sudden changes of behavior such as becoming a delinquent or an over-achiever. Some will engage in repetitive behaviors or mind-numbing type things like playing video games (my apologies to those of you who enjoy gaming) as a means to drown out the emotions.

Thanks, Kimmy, for such a thought-provoking topic!

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Let me know if you have a question for Mental Health Monday! And, as always, the information contained in this blog series is for writing purposes only. It is NOT to be construed as medical treatment or advice.

Be sure to check out Lydia’s post on Medical Monday.

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