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Coming Back from Combat: A Writer’s Guide to Combat Related Psychological Illness in Fiction

The aim of this guide is simple: plenty of people want to write about war, to explore it, to understand it and understand soldiers they know who are in it or have come from it. But, often times putting the aftermath, the pain, and the psychological impact war has on the mind into words is difficult to do well.

This guide exists to help fiction writers accurately portray psychological disorders in their work, because the people who suffer from these disorders and their loved ones deserve honesty and do not deserve to be misrepresented. The guide is here to help writers understand how these disorders come about, how they are treated, and how to think critically about how they might impact the person who has them.

I. Introduction
1. A disclaimer, and polemics.
2. Why are you writing a psychological illness into your story?
3. Terms you should be familiar with for this guide.

II. Types of Psychological Illnesses Often Found in Combat Veterans
1. Repression (including depression, anxiety, and nightmares)
2. Dissociative Amnesia (including fugues and flashbacks)
3. Emergence Delirium
4. Post Traumatic Stress Disorder

III. Incidences of Violence in Veterans Suffering Psychological Illness
IV. Common Fiction Pitfalls in Writing Psychological Trauma
V. Resource and Research Guide



I. Introduction

First, let me start with a disclaimer: I am not a psychologist, I am a military historian, and while this guide strives to be as comprehensive as possible, it will not cover everything. This has been done to the best of my ability and interpretation. I can say with certainty that the research is solid, and all pertinent citations are in the document itself, all cross-referenced. I have distilled and re-written most of the information to make it easier to read, and I removed as many period biases as I could, to make the data clean and as prejudice free as possible. Any differences between historical ideas and treatments and modern ones will be noted in the respective sections.

The second point is that, while I will be focusing chiefly on combat veterans, most of these disorders also affect civilians who have experienced a trauma. This guide will be equally helpful to anyone who is writing this kind of illness in any kind of traumatized character, not just a soldier.

Now, here is my most important question to all writers who want to put a psychologically traumatized character into their story:

Why?

I ask this because it is the single most important question. While there is an arguable moral imperative to always write what is true, with topics such as a psychological stress disorder, there is an absolute obligation to be true. This is a reality for a lot of people, a very painful, debilitating, awful reality. There are people around you, people on the internet, people at your work, your church, your grocery store, who might be suffering, really suffering daily from one or another of these disorders. Misrepresenting a disorder or a victim thereof in literature you plan to make public can seriously emotionally harm someone who reads it. And, there may well be others who read your story, believe you have done the proper research, and believe what you have written is true, thus spreading misinformation that will further harm anyone who actually has one of these psychological disorders.

So if you are going to write a story with a mentally traumatized character, have a solid reason why. Do you have something to say on this matter that you feel others need to know? Is it catharsis? Is it a warning, a story meant to enlighten others? If it is just that you think that it would be a more interesting story this way, or the character would be more pitiable or cool, please consider what I’ve said above. The internet is public, and I know that no one who writes here has the aim to harm others. But it can easily happen. So please, consider this point.

Terms You Need to Know For This Guide:

Traumatic Event:  Specifically, in psychological terms, an event which has the capacity to provoke fear, helplessness, or horror in response to the threat of injury or death. (Yehuda 2002)
Psychoform Symptom: A symptom that manifests in a mental way, e.g. paranoia, unwanted mental images, flashbacks. (Janet 1906)
Somatoform Symptom: A symptom dealing with motor or sensory function, e.g. muteness, nervous ticks, muscle spasms, phantom pain. (Van der Hart 2003)
Amnesia: Loss of memory to any degree
• Hypernesia: Ultra-sensitized, hyper memory (the memory is experienced as if the event is happening now).
Fugues: Prolonged amnesic states when the patient can live an entirely different life with no recollection of his prior one.
Flashbacks: Hypernesic state where a patient relives a traumatic event in vivid detail, often accompanied by hallucinations.
PTSD: Post Traumatic Stress Disorder (see Section II4).
Dissociation: When a group of memories or mental functions are split from the core personality/memory of a patient, particularly with amnesia and types of hysteria.
Pathological: Involving or relating to a disease or disorder (Rivers 1921)


I’ve selected four broad mental disorders that are common among combat veterans, and that cause other more specific problems. These problems have always existed, though the research is primarily modern.

Before the First World War, there was little to no real study of what was then termed ‘war neuroses’, and ‘talk therapy’ emerged as a fledgling field only around that time period (Van der Hart 2003, Rivers 1921, McDougall 1920, et al). Thus, psychology as we know it is only about a century old, though the disorders brought about by war are as old as we are.

II. Types of Psychological Illnesses Often Found in Combat Veterans


I will make a historical note here that, in older articles from, say, during the Inter-War period, the terms repression/suppression/dissociation are all mixed together and used interchangeably. In modern psychology, they are all delineated differently.

1. Repression

What is Repression?


Repression, as defined in the modern sense, is the conscious or semi conscious blocking of memories or emotions related to a traumatic event. It is not the term for amnesia, or dissociation, where memories are inaccessible to the conscious mind, though repression often goes hand in hand with dissociation, and really most of these disorders are all linked, and manifest in groups as opposed to individually.

Repression is a natural process, and is not all together bad. The mind represses things that are harmful, to keep a person from dwelling on awful things, or painful things (Rivers 1921). For instance, if someone teased you horribly in middle-school and you have strong emotions attached to it, but then come to understand that person has no effect on you, over time you will likely repress it, because there is no need for you to revisit something bad that no longer influences your life (this is, of course, assuming this teasing was not categorized as a trauma, but normal conflict in the course of human relationships). It also comes into play when socially adapting to situations, when you are in conflict with someone and you repress the urge to yell at them, because you know rationally you should not let your anger rule the conversation.

When repression becomes pathological is when it keeps the subject from being able to adapt and integrate new experiences into his/her mental framework (ibid). What does this mean? Basically, if you don't want to confront or talk about something badly enough, you will avoid it, and by avoiding it, cultivate fear surrounding it, so that eventually any time anything reminds you of the trauma you're avoiding, it will cause anxiety. Repression can make things seem far worse than they are, and cause far worse anxiety and discomfort than actually confronting the issue itself.

Why does Repression happen?


The main observed reason for repression in combat veterans (and by extrapolation, civilians who have experienced a trauma), is the debilitating fear of confronting the event in question. The fear of remembering, of possibly having to experience the emotions, sorrow, and horror of the event again is so great that people shut down and either cannot or will not talk about it.  Because a traumatic event can be so huge, it can be overwhelming or paralyzing, that a person who has experienced one avoids talking about details, and avoids any kind of situation that would remind him/her of the event (Rivers 1921, Yehuda 2002). Remember that the kinds of things a combat veteran normally goes through are truly horrific and not easy to put into words. Remembering the trauma in detail can be terrifying or threaten to break down the soldier's emotional defenses, leaving them feeling like they are not in control, which is absolutely not an encouraged state while on active duty.

And then, unfortunately, often times repression is encouraged by a society or a community.  Sometimes family or friends, or even doctors urge the combat veteran to ‘forget bad things’ or ‘put thoughts of the war from his mind’ in order to heal. Sometimes veterans are encouraged to think positively in order to banish negative thoughts from their mind. Sometimes military units will encourage each other to forget or not talk about traumas because it will threaten the mental health of the rest of the unit. But, this does not work (Rivers 1921, Myers 1940). What happens normally is that the repressed emotions or memories will flood back in the form of restless thoughts just before sleep, nightmares (that the subject can and does remember in varying levels of detail), and very severe bouts of anxiety and depression or anger during the day.

Soldiers might also repress their emotions or their memories in order to function so that they are not separated from their unit. They may also fear stigma or, in some historical time periods, they may fear the treatment they would receive if their condition were known.

Key facts about Repression:
• Repression doesn’t stop when the stress stops (Rivers 1921). It stops when treatment stops it.
• Both memories and emotions can be repressed. There are ample studies of soldiers suffering from acute symptoms because they are repressing guilt, shame, fear, or grief just as much as when they repress a traumatic memory or loss. (ibid.)
• Repression often happens more with people who have been under prolonged periods of stress prior to the traumatic event, which is why it is so much more frequent among traumatized military personnel than among civilians (Van der Hart 2000)
• Repression is conscious, and the subject often knows that they are losing the battle of forgetting something horrible. Sometimes it is semi-conscious, in that a person doesn’t realize the extent to which they are avoiding something, or do so on instinct, but it is not something out of control of the subject in so far as they have the ability to remember the event. (Rivers 1921)
• It can become habit so that it is almost unconscious if it is never treated.
• It does not have to be related to a head injury, and more often than not, no head injury is present.

Repression can cause…
• Nightmares/Night Terrors
• Notable Loss of Appetite
• Anxiety/Extreme Nervousness/Tics
• Depression/Suicidal Tendencies/Fatalism (depending on severity of the trauma)
• Sensory Related Memories (where a person cannot stop tasting/smelling/hearing something related to the memory)
• Sleep Deprivation
• Irritability/Hopelessness/Helplessness
• Flashbacks
(ibid)

How is it treated?


• Historically (WWI-WWII), it was treated with convalescence in a quiet place, light exercise, and a good diet, and encouraging the patients to repress more than they already were. (Rivers, 1921Myers 1940)
• Hypnotism was sometimes used for patients so anxious that they could not recount their problems on their own. (Van der Hart 2000, 2003)
• Catharsis through talk therapy was and is the most effective treatment. It is painful and hard but does relieve most of the dire symptoms so that the depression and underlying grief can be addressed.
• Encouraging the patient to find a silver lining if possible was always valued, so they could hold onto some shred of positive (for instance, a soldier sees his friend killed by a shell, at least the friend died instantly and without pain, which is something in a war setting).(Rivers 1921)

There is something to be said for ‘too much of a good thing’. Treatments for repression do normally involve confronting the problem, because otherwise it becomes so big and takes on such overwhelming significance in the patient’s mind that it rules their life. However, dwelling on the trauma often produces the same results as the repression itself.

Ultimately, repression plays a very large role in almost all of the other conditions listed here.

How to write repression:


If you are writing a character who is repressing something, you need to know what the event or emotion is that they are repressing. So first, outline what happened. Decide if they are trying to forget the event itself, or the emotions attached to it. (For instance, are they trying to forget that shell falling five feet from them, or the shame and guilt they feel over running from it and not staying with their unit?) If this is a historical piece, decide how the people around him/her are going to react, and how doctors are going to treat him/her. Remember that they will display symptoms and those symptoms are ever present, they do not come and go. Remember that memories of the event may intrude on this person, and this will affect their temperament and their personal relationships.

Also remember that after treatment, they are not healed. They still have all the grief, depression, guilt, and fear (in short the things they were repressing) to deal with. There is just no repression getting in their way anymore.


2. Dissociative Amnesia


By dissociative, I mean that this is not amnesia caused by a head injury. Though concussions in war are not uncommon, statistics show that a massive emotional shock is a far more frequent cause of memory loss than head injury (Manning, Ingrahm 1986, Van der Hart 2000).

Dissociative amnesia is tricky, because often times the symptoms do not present themselves until much later. As the traumatic memory itself has been lost, it does not constantly weigh on a person the way a repressed memory or emotion does. Often times the patient knows they have a memory gap, but then, they were in a very fast, loud environment and they mistake the blur in their mind for the normal memory loss that comes with a lot of adrenaline and emotion.

Mainly, there are two types of dissociative amnesia. (Van der Hart 2000)
1. Localized Dissociative Amnesia, which usually means that the moments before the trauma, the trauma itself, and the time until the subject reaches a ‘safe’ space (such as a hospital), are forgotten completely.
2. Generalized Dissociative Amnesia, which often accompanies LDA, and is the loss of general, often personal information about the patient, such as regiment, name, hometown, but not necessarily loss of all personal history.

Key facts about Dissociative Amnesia:

• Complete memory loss is very rare.
• Amnesia is very hard to fake, as there are a myriad of physical symptoms that go along with it (see below).
• Most combat related amnesia is preceded by at least six months of combat (and all the related stress)
• A patient’s memories are never truly gone and can, the majority of the time, be retrieved with treatment.
• Repression is not the same as dissociative amnesia, but often plays a key role in helping the patient continue to forget or avoid confronting the problem by maintaining dissociative barriers.
• People with dissociative amnesia often function just fine otherwise, and can continue on with the problem for years without anyone even knowing it.
• Attempting to remember what happened to them can cause acute pain, most often a headache.

But what is it?

In a nutshell, this type of issue happens when something so truly terrifying happens that the mind stops access to the memory in order to protect itself. Pierre Janet noted as far back as the turn of the century that when this happens, it is almost as if a piece of the person has been cut off. He says that there is an Emotional Personality, or the part in pain, which remembers the event, and the Apparently Normal Personality which functions day to day, but is significantly different, diffused, or more dull than the person was before the war (Janet 1906). But, this is not the same thing as multiple personality disorder (now known as Dissociative Identity Disorder). While there are similar processes at work with DID and DA, dissociative amnesia does not produce two or more fully functioning personalities. It simply means that a person suffering from dissociative amnesia doesn’t remember the full extent of themselves and has lost access to key emotions and ideas because they are associated with an extremely painful (and now forgotten) trauma (Van der Hart 2003).

What normally happens with someone suffering dissociative amnesia is that, when they are in vulnerable mental states, such as right before sleep, when dreaming, or under hypnosis, the Emotional Personality (EP) breaks through and can relive the experience in a hypernesic way, re-experiencing the sounds, smells, and feelings of the event vividly. In a hypernesic state, sometimes a patient will feel physical pain, sometimes pain associated with a wound sustained during the trauma, or general (but acute) pain such as headaches or throat aches. They do not remember these experiences upon ‘waking’.

During a dream state, a patient might re-enact the event in small ways by exhibiting fighting movements (not to say they are standing and fighting, but with arm or leg jerks, finger twitching, etc), shouting and reiterating things they said during the trauma, or sleep walking.

If they can be helped via hypnosis to remember the event, their personality often alters dramatically, as though they are ‘restored to themselves, and made whole again’ (Brown 1916, Myers 1940).

Think of it this way: imagine the mind like a computer, and you had to restart it, but you've forgotten the password to your router. So the computer functions and all the data is there, in fact, nothing has changed about it except that part of the functionality is blocked. It's significantly diffused and the programs cannot update until the password is recovered.

Flashbacks

Flashbacks are basically waking nightmares, where something in a situation mirrors the original trauma, be it a smell, a sound, a taste, or a stress level (if there is some level of hostility or anger around the patient). The patient is also probably sleep deprived or otherwise somewhat vulnerable, and the dissociative state begins.

Now, if the flashback is sound related, or smell related, often there is a certain amount of what’s called ‘reality testing’ that the patient can do, and they will realize they’re experiencing something that is not actually happening. While they will be very afraid and disoriented, they are to some degree aware they are partially reliving an event. The more visual a flashback is, the less likely a patient is going to be able to accurately reality test (Silva 2000).

Sometimes a patient can remember what they experienced during a flashback, sometimes they cannot. It depends on the situation, the person, and the degree of their mental injury.

Fugues

Dissociative amnesia can also cause what are called ‘fugues’, or, extreme periods of total memory loss where a subject literally goes and starts a new life as a new person. Fugues can last between days and weeks, and rarer cases have gone on longer. Often a person wanders away from home or their unit and is brought back later, but cannot remember who they really are until they are treated by hypnosis and therapy. Also, once a person comes out of a fugue, they often cannot remember what happened during it, or what they did. This is not multiple personality disorder. The person might act in a slightly altered or 'less' of themselves way, but they are not drastically different from their general selves.

Fugues are extremely complicated, and I suggest if you want to put one in your story, you use the reading list provided at the end of this guide as a starting point for research. This is just a basic overview.

Symptomology

Normally, symptoms of dissociative amnesia are divided into two categories, psychoform (mental), and somatoform (physical/sensory). However, they are in no way mutually exclusive. All somatoform symptoms of mental disorders are inexorably linked to psycho-shock (Myers 1916, Van der Hart 2003). These symptoms mirror each other and  cannot be separated; one is the outgrowth of the other.

Some Symptoms of Dissociative Amnesia are… (but are not limited to)
Psychoform (Myers 1940)
• Fugues
• Flashbacks
• Night terrors
• Memory loss
• Fear/Anxiety/Depression
Somatoform (Nijenhuis 1999)
• Sleep walking
• Blindness/deafness/mutism/etc
• Loss of urge to eat/drink/urinate/loss of sexual function
• Change in level of consciousness, stupor
• Obsessive movements/tics
• Hysterical attacks
• Unexplained physical pain
• Eating disorders

If you are interested in a full list of these issues, either contact me, or look at the list of sources at the end of this guide.

How is it treated?

Nowadays, dissociative amnesia is treated with lots and lots of therapy, hypnotism, and the encouragement of hypernesic states in the hopes that the memories will reintegrate. Patients are also treated for repression via other methods of talk therapy.

It is worth mentioning a few things historically here as well. First, that prior to WWII, things like dissociative amnesia and fugues were almost not even recognized as disorders at all, and though cases were often documented, most doctors mistook the symptoms for general shell shock, repression, or malingering (the fancy term for faking it). There was a strong sentiment, particularly in the German, Austrian, and French armies, that dissociative amnesia was a poor excuse to get off the line, and ‘treatment’ was often punishment that could extend all the way to execution for desertion (Eissler 1986).

Also, dissociative somatoform disorders such as dissociative amnesia are much more frequent in situations where a subject is static, meaning they do not move much and feel physically trapped. For this reason, you can see why there was a much higher percentage of these types of cases in WWI than in WWII and other ‘free moving’ wars (Van der Hart 2003). This also applies to civilian settings where a person is trapped somewhere.

How to write dissociative amnesia:

If you want to write a character with dissociative amnesia, remember that just because they have forgotten the event does not mean the memory is gone and they are free from problems. They will have problems. You can decide the degree to which they have them. Just as with repression, decide the time period, the culture and community in which this person lives, and decide how the community and doctors will react to them and treat them.

It is not realistic or psychologically valid to use fugues or amnesia as an excuse or justification for the character doing something they ought not to have. There is still a base personality at work, and the fugue will not alter a person and give them a split personality.

Remember also that during a hypernesic state a patient is still more or less half asleep or fully asleep**. They will not be committing violent acts and then not remembering it. They are not fully awake and do not have full motor control. Dissociative amnesia is not a good plot device to have a character do something violent.

**The exception of visual flashbacks with delirious misidentification is discussed in part III.

3. Emergence Delirium

Emergence delirium is one of the easier and tougher ideas to explain. It’s completely linked to all of the other issues noted in this guide, and yet it only occurs when coming out of general anesthesia.

Basically, it is a phenomenon that occurs immediately after emergence from a general anesthesia that can include agitation, confusion, and violent behavior, due to being hyper trained, and also not entirely in control/aware of surroundings (McGuire 2012).  There is a direct correlation between having previous combat experience and previous mental disorders, and the rate of ED. It appears to be becoming more and more frequent in modern war veterans (ibid).

At this point, little is known about ED and it has been hypothesized but not proven that it relates to the type of anesthesia used, as well as the experiences already undergone by the patient. It is much more frequent in veterans than civilian populations, but there is also a higher frequency in children than in adults in civilian populations (Lepouse 2006).

The primary risk factors for combat veterans suffering ED are anxiety, PTSD, and depression (McGuire 2012).

Symptoms of emergence delirium are…

• Severe anxiety
• Confusion
• Anxiety or strange unconscious motor functions while under the anesthesia
• Violent lashing out or defensive actions
• Lack of awareness of surroundings
• Fear

How is it treated?
At this point, again, little is known about ED, and so the treatments are few, however:
• Pre-screening before entrance into the military, and communication of that information to the surgeons
• Regular counseling for the underlying problem
• Identification of risk factors and strange in-surgery behaviors so patient can be restrained during detox.

How to write emergence delirium:


The key word is delirium. This person is drugged. They are not fully in control and they don’t know precisely where they are, and, if this is a soldier, they are in surgery because they have recently been fighting for their life and were injured in the process.

That being said, you also must know the underlying cause of the emergence delirium. What did they suffer? What is their medical history? What was the trauma that led them to the surgery? Also, do a little research on what drug they’re being given for general anesthesia, because they all act differently.

Remember some historical surgeries didn’t have general anesthesia. Or, they had ether, which made people vomit upon waking, so they had less time to react violently, but probably were just as anxious.

4. Post Traumatic Stress Disorder


PTSD is probably the most ‘popularized’ and sadly, the most glamorized problem suffered by trauma victims.

Let me say from the beginning, there is nothing glamorous about it. It is not a general anxiety disorder. It is not generalized depression. PTSD is what happens when someone has faced a significant horror or threat to their lives, and it is not easily lived with or treated. I often see PTSD misrepresented, or used to justify actions in stories that it does not generally cause. So I will try to be as clear and thorough as possible with it, as I believe it really must be treated with great care.

What is PTSD?

Post Traumatic Stress Disorder is a mental issue that occurs after a massive traumatic event. In order for someone to be classified as having PTSD, they must be evaluated and meet the following requirements:
1. The person must have been exposed to a traumatic event “in which he or she responded with fear, helplessness, or horror.” (Yehuda 2002, pg 108) (see definitions list)
2. He or she must have three distinct types of symptoms consisting of re-experiencing the event (flashbacks, night terrors), avoiding reminders of the event, and he or she must have hyperarousal/hyperawareness for at least one month. (ibid)

It is important to note that a person does not have to be the direct target of the traumatic event. PTSD can develop after watching a traumatic event happen to another person. The key is how the patient reacts to the trauma.

The symptoms of PTSD are numerous and can appear to be other problems if proper questioning into the trauma is not conducted. There are several factors that go into the development of PTSD, such as the degree of control the patient had at the time of the trauma, the strength of the perceived threat, the predictability of the threat (a random explosion in the street would have a low predictability, whereas an explosion in a known minefield would have a high predictability), and the success the person had in minimizing the pain or injury at the time of the event.

Key Facts about PTSD:
• There is no evidence that proves men or women are more vulnerable to PTSD overall, though statistically they appear to have higher or lower incidences in certain categories of traumas (ibid)
• 55% of people who underwent an incidence of interpersonal violence, or witnessed one, develop PTSD, while only 7.5% of people who experienced a natural disaster or accident do.
• Not everyone exposed to a trauma gets PTSD.
PTSD is not limited to soldiers.
PTSD is not something that happens to ‘weak’ people. It is always dependent on the situation, the person, and other factors. Anyone can get it.

Why does PTSD happen?

Fear is a biological response to a massive emotional shock. It is what we call fight or flight, when our adrenaline is up and our body rhythms shoot through the roof. After a shock, that feeling gradually ebbs away, in most cases. Normally, when a person’s safety is challenged, it leads to a sense of vulnerability and helplessness. Confronting that feeling of vulnerability and converting it to a sense of resilience and relief is what allows people to adjust. But, if the biological fear response is prolonged, it can interfere with the reconciliation, particularly if the traumatic event just leads to more totally terrifying traumatic events (like during a war or a period of abuse). (Yehuda 2002)

Living in a constant state of fear or stress leads to avoidance, because the fear and the ongoing trauma make a person feel so helpless and powerless that they avoid thinking or taking about the event(s), and so there are less opportunities for them to actually recover.

Some symptoms of PTSD are…
• Flashbacks/night terrors, reliving the experience
• Fear/Helplessness
• Intense stress reactions when exposed to any reminder of the event
• Avoidance of any people, places, or pursuits that remind the person of the event
• Avoidance of talking about the event
• Difficulty concentrating
• Sudden outburst of anger
• Trouble falling asleep or staying asleep (sometimes for fear of having nightmares)
• Exaggerated response to sounds or movements
• Physiological reactions to reminders of the event (sweating, palpitations, difficulty breathing)
(American Medical Association 1994)

How is it treated?

“Patients should be made to understand that their symptoms represent a psychobiologic reaction to overwhelming stress, rather than a character flaw or sign of weakness.” (Yehuda 2002, pg 112)

PTSD is now treated by educating patients about what is happening to them, combined with several different types of therapy, including talk therapy, exposing them to things about the event so they can cope gradually, anxiety management, group therapy to lessen the sense of stigma, and having a support network that creates a safe environment to live in.

Coming back from PTSD is a hard road, but it is treatable.

How to write PTSD:

It’s just so complicated. It means having a good grasp on both repression and dissociative amnesia, and also depression and anxiety. As writers, our job is to empathize, and mental problems are some of the hardest things to do that with. How can we imagine a mind that has undergone trauma if we haven’t ourselves? The basic thing to remember with PTSD is that it is normally accompanied by anxiety, bouts of depression, and while it does get better with treatment, you should not be writing a character with PTSD whose symptoms only manifest just to move the plot. This person is living with PTSD, not occasionally having tea with it.

So to do this properly, I really suggest using what I’ve written here as a stepping stone. Read first hand accounts, read case studies, find articles or read the ones I’ve listed.

First hand accounts are easy to find on the internet. Plenty of people who have PTSD are writing blogs and journals, and the educational resources and awareness are growing every day.

III. Incidence of Violence in PTSD and Dissociative Amnesia


It is not uncommon in returning combat veterans to develop some violent tendencies along with a psychological disorder (often more than one disorder). But, the incidences of these violent actions are very specific and often limited to very specific symptoms and situations.

Something about a situation, stress level, aggression from another person, smell, sound, or taste, has brought about a state of high anxiety because it is related to the original traumatic event.

The first factor is that their PTSD or Dissociative Disorder went unchecked and they are not receiving treatment.

Alcohol and drug use often exacerbate the situation, but have not been proven to be the direct cause.

Cause 1: Flashbacks with Delusional Misidentification

Let’s break that down into more understandable terms: We are talking about flashbacks which are visual (See Part II.2, Dissociative Amnesia), and in them, the patient sees another person and misidentifies them as someone else (like, say, an enemy soldier). Furthermore, the patient is delusional, and he also understands that the misidentified person is a threat to him. Both of these factors need to be present to set up a violent incident during a flashback (Silva 2000).

Next, something about the situation needs to have triggered a flashback or dissociative state. Something is a very strong reminder of the original trauma. This increases the patient’s anxiety and fight or flight response.

The flashback is strong enough that instead of just seeing the faces of the enemy in place of the other person’s real face, the background has changed as well, and the whole visual spectrum has been altered. The patient cannot accurately reality test. (Silva 1989)

In this situation, the patient is likely to respond violently, because he or she perceives a threat. They often do not remember what happens between the start of the flashback and
‘waking up’ from it. (ibid)

Cause 2: Sleep Related Violence

Again, most times with dissociative amnesia, nightmares happen where the patient relives the traumatic event, and sometimes, they swing their arms or fight or flail. Generally, they do not get up. They will fight in bed and the victim is the person sleeping next to them.

This is also a problem related to insomnia and general anxiety. In this type of violence, though it can be strong violence and spouses or bedmates can walk away with broken bones, it is not intentional. Even in the dream, the blows are not deliberate, and the damage is done by aimless flailing (Oswald 1985).

Sleepwalking and violence during sleepwalking has been documented, but it is far less frequent, and still, the violence is not deliberate (ibid).

Cause 3: Anger Effect

Sometimes when a soldier returns from combat they are in a state of being constantly angry and irritated. When someone acts under the anger effect, they are more or less aware that they are starting physical fights, but, they are unable to control their rage and anxiety. They react poorly to people challenging them and perceive this as a threat to themselves.

When this happens, the person is constantly angry, from the time they leave the traumatic event onward. There are often several other mood and psychological disorders cooperating with the anger effect, most prominently insomnia, depressive disorders, and substance abuse (Silva 1989, Silva 2000, Beckham 1997).

Still, even in this case, the violence is not random. It must be triggered by a precipitating event that significantly raises stress levels or reminds the patient of the traumatic time period or event.


**There are a couple of other times that this kind of psychological disorder causes violence, but they are rare, and I'm still finding corroborating sources on them. If you are interested, note me, and I'd be happy to discuss my findings.

IV. Common Fiction Pitfalls in Writing Psychological Trauma

These are five tropes I often see in fiction with traumatized characters. Again, there is a bent towards combat veterans, but easily these can be applied to anyone who is living with a trauma related psychological problem. And I don't just mean on dA: I see this in books, in movies, and TV shows, sometimes more than one of them at a time. I very, very strongly suggest not practicing these as plot devices or character backgrounds.

1. Psychological Trauma Ends When the War is Over


This is patently not true, but was held as true even as late as the 1920s by some psychologists, including Freud. (Van der Hart 2000, Freud 1919). Trauma symptoms last long after the event, sometimes not even manifesting until months to a year later, and can last a lifetime. Though the trauma may become less influential, and the symptoms more sporadic depending on the person, the strength of the trauma, and the treatment received, unless treatment is dedicated and the subject is in a quiet environment, likely the reaction will persist years after the event.

2. Psychological Trauma Can Be Healed by Love

While I would never venture to say love harms someone who has undergone psychological trauma, it does not heal people. It helps. And sometimes it doesn’t. That’s the sad reality. Time, treatment, a safe and stable environment, and a good support network will heal a person, and sometimes even all of that will not completely erase the effects of a trauma.

My caution here is not showing that love can ease a trauma or help a person, but the ‘trope’ that a war torn veteran meets an innocent and caring partner, and his or her pain is magically erased, so that after forming a romantic relationship, the trauma no longer plays a role. The trauma and its after effects in this case are used as a plot hook or as a way to define a character, and it is then discarded when it is no longer necessary to help the author get the story to where the author wants it to be.

This point is very important, because people who were/are lovers or loved ones of people suffering from a trauma related disorder, may not have been able to stand by their loved one. They may have done their level best to provide a safe and happy home, been patient, and tried to bring peace to someone, and been unable to help them.

3. Psychological Problems Only Manifest at Convenient Times

I see this one a lot. A psychological problem, such as a flashback, nervous tic, or anger management will only come up at times where it is convenient to move the plot. I realize that not all actions/thoughts a character does/has need to be present in a story, but if they are suffering from a psychological disorder, it needs to be present and threaded through. It cannot simply disappear once it is not longer useful as a plot device.

4. Psychological Disorder Is Used as Excuse for Violence or Cruelty

I have seen this happen in real life as well, but honestly, even if someone does commit a violent act due to a combat related psychological disorder, it is not ok. It is not justifiable. It might be more understandable, pitiable, but hitting someone ‘because of the war’ is not ok. Especially when coupled with point three, and the violence is done, and then conveniently, it was because of the war, yet no other symptoms have presented themselves. That’s just being abusive, and it’s not related to anything discussed here.

5.  A Random Event Somehow Triggers a Psychological State of Hysteria


Just because another person in the story yells at a character, or they have a bad day, does not mean it is a large enough trigger to start a flashback or state of high anxiety. It’s good to remember that triggers usually need to be specific to the traumatic event, and that if a person is functional, they have some degree of coping skills. Yes, they will be more sensitive to stress in some cases, but not every stressful event is going to warrant a massive psychological reaction.


V. Resources and Research Guide

It did take me quite a while to compile and read all the articles to make this guide, but that was the hardest part. Finding good, verified sources online is easier and easier now, and for things like scientific journals, there are two free, good sites to use:

1. PubMed: www.ncbi.nlm.nih.gov/pubmed is a site put up by the National Library of Medicine and the National Institute of Health, and has over 22 million articles on line for free!

2. GoogleScholar.com: can find you just about any scholarly article you need. Sometimes it only gives you abstracts, but if you can find the article title, you might be able to find it on PubMed!

3. Also, if you or one of your friends has a university account, you can probably access JStor.org , which is a massive journal storage site you need to pay for. Fortunately, if you have a university email, your university probably buys subscriptions to most of the journals.

4. For older articles, dating back to the earlier half of the 20th century and before, you might be able to find them at archive.org.



The list of sources I used for this article:

American Medical Association, 1994, Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. American Medical Association Press, Washington DC.

Boscarino, J.A., 1996, Posttraumatic Stress Disorder, Exposure to Combat, and Lower Plasma Coritsol Among Vietnam Veterans. Consult of Clinical Psychology Iss. 64.

Brown, W, 1919, The Revival of Emotions and Their Therapeutic Value, British Journal of Medical Psychology Vol. 1

Freud, S, 1919 Zur Psychoanalyse der Kreigsneurosen, Internationaler Psychoanalytischer Verlag, Vienna.

Ingrahm & Manning, 1986, Military Psychiatry: A Comparative Perspective. American Military Psychiatry, Greenwood Press, New York.

Janet, P, 1906 The Major Symptoms of Hysteria, MacMillian, New York.

Lepouse C, 2006,  Emergence delirium in adults in the post-anaesthesia care unit. Br.J.Anaesth Vol. 96

McDougall, W. 1920 The Revival of Emotional Memories and Its Therapeutic Value III, British Journal of Medical Psychology Vol. 1.

McGuire JM. 2012, The Incidence of and Risk Factors for Emergence Delirium in U.S. Military Combat Veterans, Am. Journal of Military Psychiatry, Vol 4.

Myers CS, 1940, Shell Shock in France 1914-1918, Cambridge University Press.

Nijenhuis, E.R.S., 1999, Somatoform dissociative Phenomena, In Images of the Body in Trauma Ed Goodwin, J. Basic Books, New York.

Oswald, I, 1985, On Serious Violence During Sleepwalking. British Journal of Psychaiatry Vol 147.

Rivers, W.H.R., 1921, On the Repression of War Experience, Royal Society of Medicine, Section Psychiatry, Vol. 11.

Silva, J.A., 1998, Dangerous Misidentification of People Due to Flashback Phenomenon, Journal of Foresnic Science. Iss. 26.

Silva, J.A., 2000, A Classification of Psychological Factors Leading to Violent Behavior in Posttraumatic Stress Disorder, Journal of Foresnic Science. Iss. 46.

Van der Hart, O, 2000, Trauma-induced Dissociative Amnesia in World War I Combat Soldiers, Austraian and New Zealand Journal of Psychiatry, Vol 33.

Van der Hart, O, 2003, Somatoform Dissociation in Traumatized World War I Combat Soldiers. Journal of Trauma and Dissociation Vol 1.

Yehuda, R, 2002, Posttraumatic Stress Disorder, New England Journal of Medicine. Vol 346.
I have very strong feelings about this. Clearly. 17 pages worth.

Great big thanks to ~oboe-wan and *PlayinTheDead for the mountain of help they gave me on this.

Big ups also to =TheSkaBoss for helping me out with some of the finer points of DID/DA.

EDIT: 20/7/13 I want to give a special thank you to ^NicSwaner, for the DD and for understanding how important this piece is to me/in general.
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Daily Deviation

Given 2013-07-20
A Guide to Writing Combat-Related Mental Illness is a must-read guide by =doughboycafe for any writer planning to explore psychological trauma. ( Featured by Nichrysalis )
:iconfulcrum45:
Fulcrum45 Aug 27, 2013  Hobbyist Traditional Artist
Excellent piece. I think this is the most thorough guide I've seen here on DA. I'll have to refer back to this when I start working on a relevant project of mine. Thanks for writing this!
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:icondoughboycafe:
doughboycafe Sep 18, 2013  Professional Writer
Thanks, I really appreciate the comment, and I hope it proves useful.
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:iconanapests-and-ink:
anapests-and-ink Aug 7, 2013  Hobbyist Writer
(finally posting a comment...:blush:)

I found this very helpful, not just for writing but for understanding people in general. I know a couple people who have illnesses covered in this guide. It's good to have something like this to refer to (for myself, not for them). Thank you so much for writing this! It's truly invaluable.
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:icondoughboycafe:
doughboycafe Aug 10, 2013  Professional Writer
:heart: I´m always happy to see you, whenever you show up.

I hope that it is helpful, not just for writing. The funny thing is Repression is totally something everyone does. Conflict resolution classes and therapy sessions are basically lessons in how not to repress and cultivate fear around an emotion, so I thought it was something that might be useful for everyone!
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:iconassureastheskyisblue:
I have to write a narrative for my English final assignment, and this will really come in handy! Thankyou for the fantastic information :)
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:icondoughboycafe:
doughboycafe Aug 10, 2013  Professional Writer
You are more than welcome :)
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:iconheronwolf:
heronwolf Aug 5, 2013  Hobbyist Writer
Heya! I've just featured you here: fav.me/d6gqhjc
Have a fantastic day ;-)
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:icondoughboycafe:
doughboycafe Aug 10, 2013  Professional Writer
Thank you very much!
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FreakieGeekie Jul 21, 2013  Hobbyist General Artist
Best guide I've ever read on dA because you've cited all your sources so the readers can do more research on their own :highfive:
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:icondoughboycafe:
doughboycafe Jul 21, 2013  Professional Writer
Thank you very much. I'm so glad so many people came out and responded to it. The kindness is overwhelming.
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