Writing Borderline Personality Disorder

Borderline Personality Disorder (BPD) is a condition characterised by extreme emotional instability and sensitivity to criticism. This means that characters with the condition are naturally well suited to dramatic fiction. This article looks at how to write interesting and believable characters with Borderline Personality Disorder.

Originally named because it was the label given to those on the border between diagnoses (in particular psychosis and neurosis), BPD has taken on a somewhat different meaning in recent editions of the DSM. Indeed, some believe the name is no longer accurate, and the condition ought to be renamed as something like “Emotional Disregulation Disorder”.

People with BPD tend to have extremely strong reactions to criticism. This is believed to stem ultimately from a weak sense of self, which makes them prone to being heavily impacted by what other people say about them. It’s as if they don’t have the same defences that most people have when it comes to accepting criticism and resisting bullying.

They also tend to have problems when it comes to interpersonal empathy. A character with BPD might seem a bit narcissistic or psychopathic to other characters because of their apparent refusal to take other people’s feelings into account when making decisions. Alternatively, they might perceive someone to be angry at them when they really are not.

If the protagonist of your story has BPD, it might be that they experience even mild criticism as brutal, sharp and denigrating. This could make them seem extremely sensitive, or even narcissistic, to other characters. The difference between BPD and narcissism in this sense is that a person with BPD can be reassured that the criticism was not intended to be wounding, whereas a narcissist would likely bear a grudge.

People with BPD also tend to have a very strong fear of abandonment. It is uncommon for them to feel secure in romantic relationships. A protagonist with this condition will probably experience a lot of thoughts of jealousy and suspicion going through their minds. They will frequently perceive their partner as flirting with others when they really aren’t.

A protagonist that gets involved in a romantic relationship with another character who has BPD is probably in for a rocky time. People with BPD tend to treat their lovers like a demigod one minute and dogshit the next. This is often very difficult for those lovers, who then don’t really know where they stand. The line between this kind of behaviour and narcissistic abuse is not obvious.

On the other hand, a character with BPD might be more than memorable in bed. The combination of emotional intensity, need for reassurance, and lack of inhibition can make for an incredible sexual experience – perhaps even enough to make up for all the insanity otherwise endured. A psychologist can tell you that this kind of treatment is liable to become addictive, which makes for a tumultuous time.

Realistically, an experience with BPD is more likely to be deeply unpleasant than it is to result in legendary erotic achievements. Self harm is common among people with the condition, and could be considered characteristic of it. If the protagonist of your story encounters someone with scars on their forearms, this could foreshadow some intensely emotional scenes.

If your protagonist encounters a character with BPD, they might realise something is amiss on account of that that character has dysfunctional life goals. The borderline character might seem to drift from one meaningless activity to another, with little awareness paid to the fact that they’re getting older and that time is passing them by. This might manifest as a nihilistic streak.

A character with BPD might be disliked by other characters, sometimes intensely, if they don’t have sympathy for the condition. Because people with it tend to be deeply wounded by criticism, they can develop a tendency to lash out hard at minor insults. This can make them antagonistic and grudge-keeping. Other characters might get the perception that they have to walk on eggshells around the borderline or else run the risk of being attacked.

BPD is around three times more common in women than it is in men (this is likely one of the main reasons why women are often seen as less emotionally stable than men). This can add to the difficulty of having the condition. If you’re writing a female character with BPD, that character might discover that other people don’t take their condition seriously, because their prejudice leads them to put it down to being a woman etc.

In the eyes of a protagonist who is encountering a character with BPD, the borderline character might just seem like a loose cannon, akin to certain other conditions like Schizophrenia and Histrionic Personality Disorder. Much as with those conditions, the risk of self-harm and suicide is often present with BPD. This is partially a result of the disinhibition that comes with the disorder but it is also the result of the fact that people with BPD tend to have difficult lives.

All in all, a character with Borderline Personality Disorder is a good choice if your dramatic fiction needs some more drama. Things are unlikely to remain stable for long with such a character around. However, care will have to be taken to portray such a character with compassion, and not make them seem like an arsehole.

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This article is an excerpt from Writing With The DSM-V (Writing With Psychology Book 5), edited by Vince McLeod and due for release by VJM Publishing in the summer of 2018/19.

Writing Post Traumatic Stress Disorder

Post Traumatic Stress Disorder (PTSD) is an unusual condition in that almost everyone has it to a greater or lesser degree, but few realise the impact that it has had on their lives. As the name implies, the condition describes when a person’s stress levels or reactions don’t go back to normal after a major traumatic experience. This article looks at how to write believable characters and situations involving PTSD.

PTSD is caused by exposure to a traumatic event, usually one in which a person thinks they are going to die. The classic examples are exposure to warfare, traffic accidents, sexual assault or physical assault. Experiences like these cause the brain to flood with fear, which can form long-term associations with the other stimuli present. This means that future exposure to those stimuli can trigger that deep fear again.

The classic symptom of PTSD is becoming full of adrenaline and going into combat mode when exposed to a loud noise or a touch to the head. In the former case, the loud noise might remind a character of the explosions of grenades and shellfire in combat; in the latter case, the touch to the head might remind of early childhood abuse at the hands of a parent. In either case, powerful memories of immense fear can quickly come flooding back.

The effects of PTSD are what could be expected from a close brush with gruesome physical death: adrenaline and cortisol prime the character for either combat or running. A character with the condition might easily become stirred into fight-or-flight mode as a response to the trauma. Here it can be seen that PTSD has considerable overlap with other psychiatric disorders, in particular Panic Disorder, Avoidant Personality Disorder and Generalised Anxiety Disorder.

Other effects are an increased propensity for self-harm. After all, one of the natural consequences of having a massively traumatic experience is that a person comes to realise that the world is much nastier or more dangerous than they thought it was. Some people with PTSD might decide that this world is actually pretty shit and not worth living in, given the horrors it contains.

In the case of violent crime or rape, a person might also come to lose all trust in a major societal demographic, which entails everyday difficulties. If a woman comes to distrust all men or a robbery victim comes to distrust all blacks, their life might become a lot harder and quickly, for no real fault of their own. Like children who have had bad experiences with dogs, a person with PTSD might come to dislike anything associated with their initial trauma.

Because PTSD is frequently portrayed in dramatic fiction, care must be taken not to write in cliches. The example of a nightmare leading to someone waking up in the middle of the night screaming, only to realise that the object of their terror is no longer present, is a striking one but also very heavily used. So too is the man staring into the distance, reliving a traumatic experience, not hearing someone calling to them.

A protagonist who suffers from PTSD might be aware of their condition or unaware.

If they are aware that they have PTSD, they might be a deep and sensitive character. They could be directly aware that a particular early life event has damaged them irreparably. This might be the reason for their unusual levels of compassion – the character knows what it feels like to be scared to death and commiserates with others who also do.

A story featuring such a character might be one about how they overcame their psychic damage and managed to find a way to engage joyfully with life. Often this involves healing oneself, the shamanic path. An extremely wise character may have attained their insight through having overcome an equally extreme trauma earlier in their life. Perhaps this experience caused them to understand what another character is going through.

It’s common to have PTSD and to be unaware of it. This is especially plausible on account of that people who incur severe psychological trauma might not show signs of it until many years later. A person might grow into early adulthood with a particularly surly or nasty character because of some heavy trauma incurred while a child. They might also show other signs of being strongly emotional, reckless or impulsive.

Just because a character with PTSD is not aware that they have PTSD, doesn’t mean that other characters will not be aware. In some cases it will be very obvious, because they will observe the first character go into kill mode for what seems like an insufficiently grave provocation. The character with PTSD might soon find that their condition is part of their reputation – they seem “damaged” in the eyes of others.

A combination of the two can also tell a story, such as the case of a protagonist who gradually becomes aware that they have PTSD or something like it. Perhaps they are perceptive enough to realise that a prior event has damaged their psyche – for example, they observe that they feel intense anxiety when presented with a stimulus that reminds them of a particular traumatic event.

If your protagonist encounters a character with PTSD, how that protagonist behaves might depend on their naivety and openness. A naive character might think that simply by being nice to someone with PTSD they can get them to behave normally. Although this is sometimes true up to a point, the reality is that PTSD often carries with it sinister undertones of bitterness and resentment.

It’s common for people who have PTSD for similar reasons to bond strongly over the fact. This is especially true in the case of soldiers, emergency personnel and survivors of abusive relationships. For one thing, misery loves company, but for another, severe trauma is often the kind of experience that deeply shapes a person and their conception of life and reality, so people who share the trauma often share an entire worldview that’s based on it.

C-PTSD (Complex Post Traumatic Stress Disorder) isn’t actually in the DSM-V, but it’s worth covering here for the sake of completeness. Essentially it’s a similar condition, only brought about by repeated exposure to a traumatic person or stimulus, as opposed to one single, horrifying event as is usually the case with regular PTSD.

The major difference with C-PTSD is the loss of a sense of self. One’s boundaries are violated with such consistency that it becomes hard to say where one ends and the outside world begins. This can be related to Depersonalisation Disorder and frequently coincides with a deep sense of distrust about other people.

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This article is an excerpt from Writing With The DSM-V (Writing With Psychology Book 5), edited by Vince McLeod and due for release by VJM Publishing in the summer of 2018/19.

Writing Narcolepsy

Best known as the condition that causes Grandpa Simpson to fall asleep at a moment’s notice, narcolepsy is an uncommon disorder linked to sleep patterns. This article looks at how to write believable characters with narcolepsy.

Narcolepsy is a decreased ability to regulate sleep-wake cycles. The overwhelming problem with narcolepsy, and its most characteristic feature, is that people with it can feel extremely tired during the day. The most notable symptom is recurring bouts of extreme daytime sleepiness, which can result in falling asleep in unexpected and inappropriate places.

Because being properly awake during the day is virtually a necessity for normal life function, narcolepsy can be a crippling condition for those afflicted. If it’s bad enough, driving a car will be impossible because of the risk of crashing (similar to epileptics). Taking public transport might not be possible either, which means that the life of the a narcoleptic character in your story might have to be a restricted one.

The author should pay close heed to what’s known as the “tetrad of narcolepsy”: cataplexy, sleep paralysis, hypnagogic hallucinations and being extremely tired during the day.

Cataplexy is a strange condition that involves the sudden weakening of large muscle groups. A bout of cataplexy can involve a weakening at the knees, or in the neck and head (similar to nodding off to sleep). This is one symptom that can truly wreck the life of a narcoleptic. It isn’t just that the physical debilitation is a problem, it’s that the narcolepsy sufferer learns to fear the social occasions that pose a risk of provoking one.

Sleep paralysis is the experience, often terrifying, of not being able to move one’s body when awakening or falling asleep. The experience of a character undergoing sleep paralysis might be similar to one undergoing night terrors. They may feel as if they have died.

Hypnagogic hallucinations are felt by narcoleptics when falling asleep. These are intense, vivid and dreamlike experiences that usually manifest as sights and sounds. These experiences can feel much like salvia divinorum experiences in that they are surreal and cause one to feel like one is present in another world. These hypnagogic experiences are sometimes disturbing enough to cause a person to get out of bed again.

The excessive daytime sleepiness is probably the most striking and obvious symptom. This manifests as powerful “sleepiness attacks” that overcome the narcoleptic, no matter how much sleep they have had the previous night. These attacks may be irresistible, so much so that the narcoleptic can literally fall on the ground asleep.

Narcolepsy might be more useful as a plot device than as something to afflict a character with. It could be that someone’s narcolepsy in the past led to a car accident, which then had far-reaching consequences for the protagonist of your story. Or it could be that, as a small minority of narcoleptics are “supertasters” with heightened olfactory awareness, your protagonist has a special use in forensic science or perfumery.

It might even be that a character’s narcolepsy has led to them waking up and rearranging their environment during the night. This could be combined with more interesting sleep disorders, like somnambulism.

Another curious point about narcolepsy is that it’s easy to confuse with an addiction to heroin or some other drugs. After all, it need not be immediately obvious to a close observer if a given person nodding off is doing so because of narcolepsy or heroin, drunkenness or something else. A character with narcolepsy might then feel that they are hard done by on account of being treated like something they’re not.

Unlike most of the other psychiatric conditions in this book, narcolepsy is not caused by early childhood abuse or neglect. So a character with it is unlikely to demonstrate signs of being damaged. Possibly they are an entirely normal person by most apparent measures apart from the narcolepsy.

Many stories about mental illnesses are tragedies because of the exposure to violence, neglect or abuse that caused the trauma underlying the illness. In this sense, a story about narcolepsy is probably different. The trauma might be ongoing, on account of that the coming of narcolepsy can ruin the life of an otherwise entirely normal person who had previously given no indication that they might be mentally unusual.

Alternatively, the narcoleptic could be a good choice of character to place at the centre of a comedy. A problem with suddenly falling asleep all the time could make it very hard to get things done. If a band of characters had to achieve some set goal, and one of their number was a narcoleptic, that character might constantly be letting the others down by falling asleep at inopportune times.

Likewise, a narcoleptic guard, surgeon or helicopter pilot might be considered inherently funny, on account of that their condition makes them exceptionally unsuited for that particular job, in a fish out of water sense. The author will have to take care to find the right balance between comic and ridiculous here.

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This article is an excerpt from Writing With The DSM (Writing With Psychology Book 5), edited by Vince McLeod and due for release by VJM Publishing in the summer of 2018/19.

Writing Conduct Disorder

Unlike most of the conditions in this book, Conduct Disorder (CD) is only diagnosed in children and adolescents. As the name implies, people who get diagnosed with it conduct themselves in ways that the clinician considers disorderly, in particular when it comes to respecting the rights of other people. This article looks at how to write believable and interesting characters with the condition.

The most important thing is to distinguish CD from Antisocial Personality Disorder. CD is the developmental precursor to Antisocial Personality Disorder – it can only be diagnosed in those too young to have a diagnosis of Antisocial Personality Disorder (i.e. 18 years of age). It is therefore a developmental condition.

One of the key symptoms of CD is a lower level of fear. This will express itself in a wide variety of ways.

The most notable way that a lower level of fear expresses itself in young people is when it comes to transgressions. A young person has not yet had time to internalise knowledge about the effects that their actions have on other people. They therefore have to learn to be afraid of punishment. This corresponds to Level 1 of Kohlberg’s Scale of Moral Reasoning.

A young person with CD will have a hard time internalising rules about those transgressions, in part because they don’t feel much fear, and so don’t have as much inhibition when primitive impulses towards violence and destruction start playing up on them. Because of this, they regularly violate boundaries relating to other people’s personal space and property.

Another way low levels of fear find expression is in transgressions against one’s own health. Young people already play fast and loose with their health when it comes to having a good time; young people with Conduct Disorder are nihilistically reckless. If the protagonist of your story has Conduct Disorder, chances are that they will be into the booze, weed and pills from their early teenage years.

A character with CD will likely be something of a daredevil. If they are male, they might find themselves drawn to racing motor vehicles or street fighting; if female, to shoplifting and starting trouble between men.

A story with a protagonist who has Conduct Disorder might read like J. D. Salinger’s Catcher in the Rye. Care must be taken here, therefore, not to sound cliched. Anti-hero stories mostly appeal to the same young audience, because they will most readily identify with the spirit of rebellion expressed by such a character. People with Conduct Disorder push the boundaries, for good or ill.

Punk stories, in particular cyberpunk, often feature protagonists who would appear (at least from the authorities’ perspective) to have Conduct Disorder. Young men like John Case of Neuromancer or Jonty Gillespie of The Verity Key are unrepentant criminals, usually because they have to be in order to make a living in the cracks of the edifice of respectable society.

After all, one man’s Conduct Disorder is another man’s righteous rebellion against a tyrannical oppressor. So a character with the condition might be the perfect choice of protagonist if your story involves going up against a large, faceless, totalitarian entity. After all, most of us have a point which, if pushed beyond, we will no longer behave in a co-operative manner.

If a character with CD is pitted against a malicious, evil entity (corporation or government), much of the difficulty in writing your story will come from making that entity unsympathetic enough that the reader readily comes to identify with that character. The more credibly this can be done, the less that character will look like a CD sufferer and more like a righteous hardarse.

Unsurprisingly, Conduct Disorder is highly correlated with all forms of early childhood abuse. A character with the condition might have learned by way of mimicry of their parents that violence and cruelty are perfectly acceptable ways to advance one’s interests, and that fear is for the weak and an invitation to be destroyed.

So if you are writing a character with CD they might not necessarily be a cool, daring and adventurous antihero. Realistically they are more likely to be somewhat brutal. If your protagonist encounters such a character, they might find them intimidating – the class bully, or local street thug.

If your protagonist encounters a character with CD, they could respond in a wide variety of ways, depending on how they themselves are (and their decision will be very revealing to the reader). They might consider that character a cool rebel to be befriended, they might consider them a danger to be avoided, or they might consider them a little brat to be corrected.

Conduct Disorder often occurs at the same time as Attention Deficit Disorder. It’s likely, therefore, that any character with it will have extreme difficulty at school, at work, or with either friends of family. Their life will probably be very chaotic, and will considerable Police or social worker involvement.

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This article is an excerpt from Writing With The DSM (Writing With Psychology Book 5), edited by Vince McLeod and due for release by VJM Publishing in the summer of 2018/19.

Writing Avoidant Personality Disorder

Avoidant Personality Disorder (AVPD) is characterised by extreme action taken to avoid certain feared stimuli, usually social. Social anxiety, feelings of unworthiness, timidity and sensitivity lead to a pattern of avoiding situations that involve interacting or socialising with others. This article looks at how to write engaging and realistic characters with the condition.

AVPD is a Cluster C personality disorder, which means that it’s primarily an anxious condition. The essential characteristic of it is an inability to form social bonds brought about by an extreme desire to avoid particular feared stimuli. For example, people with AVPD tend to be very sensitive to social rejection or humiliation.

It is believed to be caused by abusive or neglectful parenting patterns. In particular, rejection by one or both parents is thought to correlate highly with the condition. It can be observed in other mammals that rejection by one or both parents sharply reduces the ensuing life expectancy for that creature. No doubt the trauma from such treatment makes an impact on the behaviour of human survivors.

If your protagonist has AVDP, it might be that they experience loss and social rejection so strongly that they are simply devastated by it. They might have an internal monologue that heavily plays on fears of social encounters going wrong. A story featuring them might read very strangely as it involved a number of events that ended up not happening or not being attended by the protagonist, who felt too anxious to participate.

This can easily lead to a darker, resentful pattern of behaviour, especially if a protagonist with AVDP comes to feel a malicious desire for revenge as a consequence of their rejection. Social rejection need not lead to learned helplessness and submission in every case – it can lead to violent reprisals, especially if the rejected person feels that they have been treated unjustly.

Someone with AVDP might make a convincing villain if the author can convincingly portray a character who has become nasty as a result of their pride. It might be that the villain received some mild slight or insult and their massive ego was punctured, leading to narcissistic rage. They could be the sort of person who never forgives an insult, leading to complicated revenge schemes.

To many outside observers, AVPD looks very similar to just having low self-esteem. People with the condition tend to believe that their social presence is unwanted, and that they are unworthy of the time and attention that they are given in their social relationships. In cases of parental rejection it’s obvious how such thinking might come about, but it can be caused by other things, such as a generalised perception of social rejection.

In the mind of a character with AVPD, the everyday experience might be one plagued by self-doubt and feelings of unworthiness, in much the same way that it can be for a depressed person. Indeed, one particular strain of AVPD has a number of depressive features, in particular the casting away of, and refusing to deal with, certain traumatic memories.

A protagonist with the condition is likely to consider themselves socially inept. There might be a lot of blame directed at the self in their internal monologue. It’s possible that there is a personal quality of their own that they fixate on as an explanation for their lack of social success. As mentioned above, this can easily become projected outwards onto society.

People with AVPD can be difficult socially because they can be very needy and very resentful. There is a particular strain of the condition that is hypersensitive in a way that is not dissimilar to those with Narcissistic Personality Disorder. This type can become easily wounded by jokes or banter, to the extent that others might call them “precious”.

Feedback loops are an unfortunate common effect of this condition. Anxiety about being socially rejected often leads to a range of behaviours that themselves increase the likelihood of social rejection. Anxious eye contact often appears shifty to other people, who then come to distrust the person with AVPD. Because these people trust the person with AVPD less, they speak to them in a less friendly manner, which validates the initial feelings of anxiety and strengthens the avoidant behaviours.

A protagonist with AVPD might find their everyday experience tormenting, because people with the condition have a normal need for social interaction and intimacy – they just fear it. Because of this fear, and sometimes because of resentments, a protagonist with the condition might find their everyday experience tormenting. It might be a relentless march of anxiety, blame, missed opportunities, guilt and rejection.

AVPD sounds, and is, similar to Schizoid Personality Disorder, but there are crucial differences. For one, a character with AVPD will like be more anxious than a schizoid. For another thing, schizoids don’t generally care about other people, whereas people with AVPD will still desire positive social contact.

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This article is an excerpt from Writing With The DSM (Writing With Psychology Book 5), edited by Vince McLeod and due for release by VJM Publishing in the summer of 2018/19.

Writing Histrionic Personality Disorder

People with Histrionic Personality Disorder (HPD) are colloquially known as “drama queens” or “shit-stirrers”. Fundamental to the disorder is a desire for attention that borders on the narcissistic, as well as strong, shallow, rapidly-changing emotions. This article looks at how to write realistic and believable characters with HPD.

As is the case with many of the conditions in this book (and especially the personality disorders), people with HPD are often high-functioning in several ways. As with most of the conditions in this book, people with HPD can often be entirely competent and effective in their niche. For instance, they excel at screen and theatre acting.

A simple (if crude) way of conceptualising HPD is that, for people with it, drama is like a drug. They get hooked on it, they seek it out compulsively, they try to get bigger and bigger doses of it. The more attention they can draw to themselves the better. A cynic might call them a “psychic vampire” because dealing with them frequently leaves a person tired.

For these reasons, HPD is a fitting and excellent choice for some of the characters in your fiction. A character with HPD will naturally liven things up – even if they end up causing chaos. Because they seek drama out, it is never far from them. Not only do they like drama, but they tend to have just enough narcissism to bring some truly dark emotions out of others.

From the perspective of other characters who might encounter a character with HPD, one of the most difficult things about them is their apparent need to be overly emotional and dramatic all the time. Because emotional reactions are contagious to some extent, a person with HPD will tend to trigger those around them – a great quality in a bartender perhaps, but if there is a need for calmness and order this is usually unhelpful.

Other characters might also find the constant self-aggrandisement extremely tiresome. People with HPD like to use elaborate and flowery speech when unnecessary or even unhelpful, and love to tell stories that feature themselves looking good or being heroic. Such typically unsubtle attempts to draw praise are sometimes described as “needy”. Indeed, it is common for people with HPD to display symptoms typical of Dependent Personality Disorder.

Several common characteristics of HPD overlap with common characteristics of Narcissistic Personality Disorder. One of these in particular is the usual reaction to criticism. For the histrionic, any and all criticism is a brutal personal attack, an act of the utmost cruelty. It is so bad that any retaliatory measures are justified (although a character with HPD will tend toward passive-aggressive revenge tactics).

Related to this is the constant seeking of reassurance or approval. A protagonist with HPD might have compulsive thoughts about not being a good enough person and so seeks out ways of being told that they’re worthwhile. If a character has HPD, there might also be very clear ways that this can be shown through their clothing choice: “Loud and proud” would sum up their dress style.

Other characters might find it very stressful to be around a character with HPD, partially because of the narcissism but mostly because they don’t leave other people in peace. Because of their need to be the centre of attention, a character with HPD might continually butt into other people’s conversations, or make it all about them. They’re also generally happy to spread rumours around, especially if they think that doing so will make someone angry.

A character with HPD might strike other characters as superficial or false. After all, their emotions might strongly rise, but they also strongly fall and quickly transform into other ones. A second character might come to feel that they can’t really trust the histrionic one. It’s hard to know whether they’re acting or genuine.

One area in which the lives of people with HPD tend to be in particular disarray is romantically. They commonly perceive sexual interest where none exists. This makes their own lives difficult, as they often end up misreading the signals and making a move on someone who then rejects them. It can also make other people’s lives difficult, as people with HPD tend to perceive sexual infidelity where it doesn’t exist. This jealousy can fuel untold dramas.

On a darker note, people with HPD are well-known for hitting on people who are already in established relationships. This is partly because of the aforementioned tendency to perceive sexual interest where none exists, but this can also be influenced by a narcissistic refusal to respect other people’s boundaries and an inability to delay gratification.

Having said that, people with HPD are often very engaging to make love to. Excessive sensitivity and dependence on other people’s approval can make for a powerful contribution to the bedroom magic.

Adding a character with HPD to your story, or adding aspects of it to a character in your story, has the potential to liven things up but there is a risk that it can also make things more trivial. Because histrionic characters can get upset over small things, they can be hard for the reader to relate to, and therefore are often better as a foil to another character or as comic relief.

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This article is an excerpt from Writing With The DSM (Writing With Psychology Book 5), edited by Vince McLeod and due for release by VJM Publishing in the summer of 2018/19.

Writing Paranoid Personality Disorder

Paranoid Personality Disorder (PPD) is a condition characterised by extreme distrust and suspicion of other people and their motives. Characters with PPD are well-suited to serving fictional roles as fiendish adversaries or challenging social obstacles. This article gives some useful tips for writing a believable and engaging character with Paranoid Personality Disorder.

People with PPD are generally very low on the agreeableness scale. Characteristic of the condition is an extreme suspicion of other people’s motives. To be paranoid is to be distrusting, and without a significant element of mutual trust it’s impossible to have any kind of social organisation.

A diagnosis of PPD comes when paranoia has led to a level of disruption that has caused significant disruption in the life of that person or others. It’s not hard to see how this can easily happen in the case of extreme paranoia, for the aforementioned social reasons. A person with PPD is unlikely to trust their employer or supplier to not be ripping them off, and nor are they likely to trust a professor or a doctor.

A protagonist with PPD might live in a world of perceived malevolence. They might see schemes, tricks and traps around every corner. No-one ever approaches them with good news, or with a good offer: all human contact represents merely just another attempt to cheat them. In this regard, the life of a character with PPD might be socially impoverished in a similar fashion to someone suffering from Schizoid Personality Disorder, only with distrust replacing indifference.

If the protagonist of your story encounters another character with PPD, chances are high that they won’t like them very much. It isn’t a pleasant experience to be spoken to as if one is a liar, especially when one had never considered actually lying. It also becomes quickly apparent that investing time and emotional energy in a friendship with a paranoid person is unlikely to be reciprocated, because their constant suspicion will quickly lead to them discounting the value of any favours or friendship offered.

This could make for an interesting story if the protagonist was tasked with winning the trust of a character with PPD. Such a story might mean that the protagonist has to find a way to tease out the few remaining trusting elements in that person and making sure that they get rewarded.

It might also mean that your protagonist ends up learning exactly how someone can end up with PPD in the first place. Perhaps the character they are interacting with did genuinely get cheated, on multiple occasions, by liars who they once trusted: parents, teachers, lovers, bosses. There could be a further twist, if the character with PPD brought all this upon themselves owing to their own malignant personality.

It’s common for individuals with PPD to have what appears to be a “fragile” personality. Ambiguous comments are frequently interpreted as personal attacks, and jokes are often taken in bad humour. Even worse, these reactions are often permanent, because individuals with PPD do not readily forgive slights and insults. For obvious reasons, such behaviour tends to attract enemies, which only serves to fuel the paranoia and mistrust.

A commonly related phenomenon to PPD is that of projection. People who are paranoid are often narcissistic in the sense that they think everything is about them. For this reason, they tend to project their own selfishness and malevolence onto other people. Many cases of paranoia are based on the fact that the paranoid person is themselves not worth trusting.

Some theorists have delineated a variety of subtypes of PPD. Some people with it are particularly stubborn, obsessed with order and regularity and consumed by a fear that someone is trying to cheat them out of something. Others are insular, and lead hermit-like lives far away from the crowds of crooks and criminals that make up society. A third type is malignant – their distrust of other people comes from from suspicion but from hatred.

It’s unlikely that a character in your story will see it as a good thing to encounter a person with PPD, but it is possible. After all, paranoia is an extremely useful aptitude in a variety of security and surveillance-related roles. So if you’re writing about a spy, for example, you might use touches of PPD to flesh out their personality. A character who was once an intelligence officer, but who was let go because they became too paranoid, would be a fitting example.

An interesting twist on a story featuring a character with PPD is if they were actually correct. What if the PPD character was correct in their suspicions of everyone else, and there was, in fact, a great conspiracy or scheme going on?

An important distinction to make is the one between PPD and paranoid schizophrenia (note that paranoid schizophrenia is not in the DSM-V). Paranoid people don’t hallucinate from paranoia alone, and the paranoia involved in PPD is not ludicrously delusional. In other words, a person with PPD may have a twisted conception of reality, but they will not have lost touch with it.

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This article is an excerpt from Writing With The DSM (Writing With Psychology Book 5), edited by Vince McLeod and due for release by VJM Publishing in the summer of 2018/19.

Writing Illness Anxiety Disorder (Hypochondria)

Lying awake at night worried that you have cancer, despite having no real sign of it, is symptomatic of Illness Anxiety Disorder

Illness Anxiety Disorder is more commonly known as hypochondria. Most people are familiar with the concept of someone who worries so much about imagined illnesses that they cause themselves actual ones, and everyone can relate to feeling fear when faced with uncertainty about a personal medical condition, but despite the familiarity it’s easy to get it wrong. This article looks at believable and realistic ways to portray a character with Illness Anxiety Disorder.

Hypochondria is one of the most common of psychiatric conditions, probably because humans have evolved to be concerned about their health. Getting alarmed about someone you know getting sick makes a lot of sense if you live in a small tribe of about 150 people, while contagious diseases can decimate society. Getting alarmed because you saw something about cancer on television doesn’t make sense, and if this gets bad enough it can become a real problem. .

The disorder is really a gross exaggeration of what would normally be a healthy level of anxiety over one’s physical condition. Instead of maintaining a moderate level of awareness about one’s body, ready to take appropriate measures when necessary, a person with Illness Anxiety Disorder will compulsively check and re-check spots and bumps and marks, and will intently track all rumblings and pains.

Hypochondriasis is believed to be ultimately caused by depression and anxiety, which manifests as an obsession with illness. As with many anxiety-based illnesses, dysregulated stress responsivity as a consequence of early childhood abuse is frequently a factor, although this also commonly arises from a single traumatic shock.

If the protagonist of your story has Illness Anxiety Disorder, this might manifest in ways that are similar to the other anxiety-based and obsessive conditions. They might go to considerable lengths to avoid triggering their condition, such as refusing to visit sick friends or family members. This can quickly cause conflict with the people closest to them, especially if those people think that the hypochondriac is shirking their duties.

A character with Illness Anxiety Disorder is likely to fixate on a particular set of symptoms that they have come to believe is indicative of a medical condition. In fact, they are likely to identify a condition and name it. As could be expected, the availability of Dr. Google to everyone’s home has been tempting for those inclined towards Illness Anxiety Disorder. Many hypochondriacs obsessively research their self-diagnosed condition online.

It’s easy for other characters to become frustrated with a protagonist who has Illness Anxiety Disorder, especially if the hypochondria starts to have an impact on their punctuality or ability to hold an ordinary conversation. It quickly becomes tiresome to listen to a litany of medical complaints every time you see a person, and once other characters start to dread such a thing then they are likely to leave the protagonist on their own.

A protagonist who encounters another character with Illness Anxiety Disorder might find it a great challenge to keep the conversation away from that character’s morbid pre-occupation with death and disease. They might have to make a great effort of will to keep their patience and not become angry. It might also be hard not to tell the hypochondriac to “harden up” or to “get over it”.

As with most of the other conditions in this book, Illness Anxiety Disorder has to cause significant disruption to the life of the character with it before it can qualify as a clinical condition. However, there is a wide range of subclinical forms of hypochondria, such as a preoccupation with various symptoms like everyday pains in the chest, stomach, head or gut. These might be symptomatic of a deeper problem.

Most of the disruption caused by this condition is a consequence of the heavy anxiety it is linked with. This anxiety makes hypochondriacs difficult to get along with, because they are always checking their body functions or fidgeting. The constant need for reassurance that hypochondriacs have is apt to drive their doctor up the wall, let along their partner or caregiver.

Usually, a character with hypochondria will not realise it, at least not initially. Most people are not aware of the extent of physical symptoms that can be produced by simple anxiety and depression, and it’s common to attribute these symptoms to a severe disease instead of psychological origins. It’s possible, then, to use physical symptoms – even if psychosomatic – to foreshadow a general decline in health .

At the end of the day, most of your readers will already know about hypochondria and will have met someone with the condition, even if it was at a subclinical level. It won’t take very many hints for them to realise that a particular character in your story is a hypochondriac. The real challenge, from the perspective of the writer, is to depict such a character realistically and not as a stereotype.

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This article is an excerpt from Writing With The DSM (Writing With Psychology Book 5), edited by Vince McLeod and due for release by VJM Publishing in the summer of 2018/19.

Writing Generalised Anxiety Disorder

Everyone knows what it feels like to be anxious. The clammy hands, the tightness in the gut, the dizziness, the sudden need to urinate. Where anxiety becomes a psychiatric problem is when this anxiety gets out of control, causing suffering and an inability to get through everyday life. This article looks at how to write engaging and believable characters who suffer from Generalised Anxiety Disorder (GAD).

One cluster of problems that people with GAD tend to have relates to restlessness and irritability. They think too much about what might go wrong. A number of small problems can then have the tendency to build up and to provoke an outburst over something small. Often a person with GAD will hit their limit and explode, to the astonishment of others around them who didn’t appreciate the underlying anxiety.

Other characters might see the usual signs of anxiety, only writ large. They might notice the signs of despair in the face – tight lips or a pallid look. The character with GAD might tap their feet a lot, fidget or stammer. Other characters might be able to detect and increase in the tension level of the room when someone with GAD is present.

The author might prefer to be more subtle, however. A character with GAD might to prone to explosive anger or hysteria, but the other characters might not be able to perceive the anxiety that underlies the fractiousness. They might also be prone to mind blanks from the anxiety. The other characters might only perceive the surface expression of the GAD, leaving the reader to draw their own conclusion.

For instance, people with GAD tend to smoke a lot of tobacco. If the protagonist of your story has GAD, it might be that they’re reaching for the cigarette packet every time the telephone rings. If the protagonist of your story encounters someone with GAD, it may be that the constant presence of tobacco smoke or smell causes them them to realise that that character has an anxiety disorder.

Insomnia is another common sign. If the protagonist of your story is an insomniac because of GAD, this might be something close to a living hell; a nightly torment that they are forced to endure. Other characters will be able to pick it in their face as well – they will look tired, with puffy eyes and a downcast look. They will look every bit like someone for who life is difficult.

People with GAD, like many people with mental disorders, have a tendency to suffer low self-esteem. As with many other conditions, it’s not easy to tell where the border between the mental disorder and personal weakness is. A character with GAD might frequently be asking themselves if they’re a coward, or if they’re really cut out for the challenges of life. Naturally such an attitude will eat away at their self-confidence.

Intertwined with this is the reality that people with GAD will often not be treated too well by other people. For one thing, anxiety tends to be contagious. If another person is anxious it’s hard to properly relax around them because of the chance that they might blow their top any moment. For another thing, anxiety tends to make people selfish, because the focus is on the desires of the self and not the needs of others. This selfishness tends to be reciprocated.

GAD can cause some of the same thought-loops and obsessional thinking as other psychiatric conditions. With generalised anxiety it’s easy to become anxious about being anxious, especially once one has become conditioned by unpleasant physical side-effects of worry. A character with the condition might feel highly anxious every time they feel a slight gut disturbance or chest pain, fearing that death has finally come.

Although there’s a shared component of extreme anxiety, GAD is distinct from phobias. Phobias (as discussed at length here) are fears of specific things that are hard to escape. GAD is also distinct from social anxiety. People with social anxiety tend to only feel anxious in anticipation of the risk of social judgment, whereas people with GAD tend to be anxious all the time.

GAD is also distinct from Obsessive-Compulsive Disorder, but several patterns of thinking overlap between the two. In particular, people with GAD are prone to worrying about things like whether or not they left the stove on when they left the house. Because anxiety is always present in such people, and because the risk of burning down one’s house is (reasonably) something that many people are cautious of, people with GAD are frequently triggered into panic by such common concerns.

The best thing about GAD from an author’s point of view is that virtually all of the readership will be able to identify with it. Almost everyone knows what it’s like to feel unpleasantly high levels of anxiety, so GAD will also be reasonably easy to identify with. Probably they also are aware of how unpleasant it is to be around highly anxious people, so they can identify with that also.

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This article is an excerpt from Writing With The DSM (Writing With Psychology Book 5), edited by Vince McLeod and due for release by VJM Publishing in the summer of 2018/19.

Writing Hallucinogen Persisting Perception Disorder

Hallucinogen Persisting Perception Disorder (HPPD) is an uncommon condition that arises as a consequence of permanent perceptual changes brought on by use of hallucinogens. There is almost no data on the prevalence of this condition, and some don’t even believe it exists. Nevertheless, this article will discuss how to believably portray characters with HPPD.

HPPD usually causes a problem because of visual disturbances that are akin to those that accompany a hallucinogenic experience. It’s common to see glowing halos around various objects, or visual trails that linger behind moving objects. It’s also possible to perceive objects as being much larger than they actually are, or much smaller. Some people even see a kind of “visual snow” between objects, like the static on a television set. Auditory hallucinations are also possible.

A character who has HPPD might appear kind of ‘spaced out’ to the other characters. Those other characters might suspect that the one with HPPD is, or has been, on a heavy drug of some kind. Because their perceptions are so vivid, a character with HPPD might be too distracted to pay proper attention to what’s going on around them. This could create a number of social difficulties for that character.

The author might decide that writing a character with HPPD is not very interesting if focus is placed solely on visual and perhaps auditory disturbances. It might be possible to tell a far richer and more engaging story by showing the reader some of the other lingering psychological effects of psychedelics, especially the deeper emotional and spiritual ones.

The problem with this approach is that one soon steps outside the bounds of the clinical – which is perfectly fine for the sake of literature, but it has to be kept in mind that the strictures of the DSM are distantly removed from what follows here.

Many psychedelic drugs have the capacity to break down a person’s existing perception of reality and replace it with something entirely different. This means that some of the persisting perceptions that arise from hallucinogenic drugs use are not so much sensual, but intuitive.

A common persisting perception from using hallucinogens is a belief that the material world isn’t real. Our culture is materialist; we take for granted that the material world is real and that the human brain generates consciousness. For the vast majority of us, it seems intuitively true that the material world genuinely exists and that the brain gives rise to consciousness, and this perception is so common that it’s taken for granted by most.

People who have HPPD might no longer believe in materialism. They may feel that, in the course of a hallucinogenic trip, they were granted a particular insight into the way the cosmos truly functions. Maybe they now believe that the world is a dream in the mind of God. A character who has had a change in perceptions relating to cosmic attitudes might find themselves coming into conflict with some of the other characters around them. Theirs could be a story of how easy it is to get ostracised from a community for having unique beliefs.

In practice, it doesn’t actually matter whether materialism is correct or not; a character who becomes a non-materialist as a result of a hallucinogenic experience will have extreme difficulty fitting into society in any case. They will frequently be rejected and mocking for being mentally ill. In particular, it will be impossible for them to convince a psychiatrist that their new belief is anything other than a mental illness. A character who thinks like this will therefore likely be an outsider to some degree.

Another common change in perception relates to the presence of a light at the end of the tunnel. Dovetailing with materialism is atheism – the two seem to follow each other closely. The vast majority of people who were raised atheist do not believe in the presence of a benevolent force that watches over their life with a desire to end their suffering. The cosmos is indifferent to human suffering and misery.

A person who has a strong experience with a hallucinogen can easily come to change their opinion on this subject. It might be that your protagonist has suddenly decided to believe in God – not the God of Abraham, but the benevolent, all-pervading force that gives rise and motion to the world. This might not be received well by the other characters in your story, especially if they are materialists, or if they believe in a dead God such as the Abrahamic one. They will probably think your protagonist is mad or evil.

This can make for an interesting story because of the contrast between the good feelings that arise naturally inside a person who has spiritual satisfaction, and the bad feelings that comes from the outside world as a consequence. Their social life might become much more difficult than before, on account of pressure to go back to the socially-approved way of thinking. This could push them into the arms of a new group of people, such as those who have also seen beyond.

These persisting changes in perception are much more subtle than the visual and auditory ones, but they might have just as large an impact on a person’s ability to live a normal life, primarily because of the social disruption just mentioned. In extreme cases, these changes in perception might make employment also impossible, leading to radical life changes that could lead anywhere.

Writing a character with HPPD is no easy task, because it is likely that most of the readers are not intimately familiar with the effects of hallucinogens and so will have difficulty relating to the often bizarre and surreal perceptual changes that accompany the condition. However, if executed skillfully, a tale with a character who has HPPD could be highly entertaining, insightful or even edifying.

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This article is an excerpt from Writing With The DSM (Writing With Psychology Book 5), edited by Vince McLeod and due for release by VJM Publishing in the summer of 2018/19.