Mental Illness in Fiction

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Mental illness is often portrayed in fiction in a way that is highly innacurate. There are so many common misconceptions reinforced by depictions in books and movies, it can be difficult to separate fact from fiction. If you’re planning on writing a character (especially a main character) with mental health problems, it’s important to know where to get your information from. With an estimated 10% of the world’s population having at least one diagnosed mental disorder, it makes sense that the characters peopling your story might also have a few personal demons and maladjusted behaviors of their own. In some cases, a character’s mental illness can be the main plot. At the very least, representing mental health problems in fiction can create more complex (and realistic) characters and relationships. If you haven’t personally dealt with the problems your characters have, the first step is always…

Research—and try to use primary sources.

Talk to people with whatever mental illness you’re writing about, and if you can’t, at least read accounts of what it’s like to struggle with mental illness. If you’re close enough to somebody with a particular mental health problem, talk to them about their symptoms (if you’re both comfortable doing so). There are a lot of little moments and nuances to mental illnesses that aren’t captured in the scientific literature. That said, psychology journals and reputable medical information are the second best thing if you don’t know / feel comfortable asking somebody who actully has a certain condition. I’ll break down some of the most common misconceptions, particulalry as seen in the media. But educate yourselves, because if you’re going to write characters who are mentally ill, it’s really important that you do it in a way that feels authentic and not insensitive. That’s obviously basic advice, when writing any topic you’re not familiar with. As for the nuances of particular conditions…

Being depressed doesn’t mean you’re never happy, and it isn’t always as simple as feeling sad. There are a lot of less well-known symptoms associated with depression.

Depression is a highly complex mental illness that can vary hugely from person to person, situation to situation, and across cultures. While its primary symptom is usually prolonged sadness without cause, there are various reasons and ways in which depression can present as something else. This is especially true because of the stigma against talking about depression present in many cultures. Depression can look like apathy and exhaustion. People who are depressed often lose interest in things they usually love, and may be so emotionally and physically tired (depression can cause major sleep disturbances) that they withdraw from everything and everyone in their lives. In most cases, people who are severely depressed will either avoid making plans or cancel them frequently. At times, depression exhaustion can be so intense it can be difficult to get out of bed.

Depression, contrary to romanticized depictions in the media, has no aesthetic to it. It’s likely somebody who is severely depressed will neglect their hygiene and health to some extent because they simply do not have the motivation for it. Depression can also come through as anger. When I’m in a particularly bad place, I turn into a massive bitch. Straight up. I take out my frustration with life on the people I know won’t leave me. Being miserable when you know you have no reason to be and not being able to change it, or make people understand it, is maddening.

There’s a huge amount of potential here as far as storytelling. In the first person, a depressed narrator may have intense inner turmoil and guilt over their depression, particularly if their life is outwardly good. Most people suffering from depression will lie about it at least in some situations. For example, unless the depressed character is in crisis, when an acquaintance asks how they are, they’ll usually say they’re fine. In a longer story in particular, a main character’s depression could be a major plot point in their overall character arc; although it should be noted that unless depression is purely situational / not true clinical depression, it’s unlikely it will ever completely go away.

One final note on depression in fiction—make sure it doesn’t make a character who’s meant to be likable come off as annoying. Too much whining and complaining will turn readers off. You don’t want your protagonist to read like Edward Cullen. Crying also becomes grating and less impactful if it’s described, especially in detail, too frequently in a story. Show don’t tell is especially important in writing depressed characters—writing about how your protagonist looks after having stayed in bed for a week without showering, and getting into the effects their depression has on their relationships will almost certainly be more impactful than yet another lump in said character’s throat. It’s totally fine to have your character talk about their struggle with mental illness—just make it short and sweet, and make sure it isn’t redundant or excessively self-pitying. Also note that Bipolar Disorder is in many ways VERY different than Major Depressive Disorder (regular depression).

Suicidal characters may not “act” suicidal.

To add onto my point about depression, there is no consistent set of criteria for suicidality other than considering ending one’s life. Although suicide is usually tied to mental illness, there are many, many reasons for suicide aside from simply being depressed or escaping poor life circumstnces. Someone may want to escape memories of trauma, or guilt, or feel as though they’re a burden to their family. Crises of identity, especially related to sexuality or faith, can often lead to suicidal feelings. And when somebody is considering suicide, there are a wide variety of ways in which these thoughts can translate to behavior. Does the character truly want to die, or is their suicide attempt more of a cry for help? If the suicidal character truly wants to die, it’s unlikely they’ll tell anybody about their plans, and they may be cautious about giving off signs of what they’re about to do; although they will likely be acting differently in some way prior to a suicide attempt.

Your character may become more reckless (drug use and impulsive behavior are common) or withdraw from friends and family. They may visit with, or in some way say goodbye to, the people they love, although it may not be an obvious goodbye. Some people feel some small amount of relief and actually appear to be happier right before they end their lives because in their minds the pain is almost over. These are things that generally are specific to suicides which are truly intended to be “successful” attempts. These attempts are usually more well-planned and involve more lethal methods as opposed to “cry for help” suicide attempts.

In general, suicidal ideation varies greatly from person to person, based on the reasons and intentions behind the suicidal behavior. It’s also important to note that a character can certainly have suicidal ideation without behaving in a suicidal way or ever actually attempting suicide—this is actually quite common. Either way, make sure you carefully plan out how your character’s suicidal behavior will play out so it makes sense with regard to the character’s personal arc and the plot. Don’t include suicide in a story for shock value.

On a similar note, when writing anything that may be widely read, it’s important to be careful about how you depict suicide (especially successful attempts) in fiction. It’s usually better to not describe the actual suicide in graphic detail, not only because it can be triggering to some, but because it can encourage suicidal ideation in readers. I won’t say it should never be done, but unless the story will somehow suffer massively if we don’t see the character’s death, you might as well skip over it.

OCD is not generally limited to an obsessive need to clean and organize. The colloquial use of OCD as a descriptor is very misleading.

OCD has somehow essentially become a casual descriptor for somebody having Type A tendencies, but in reality Obsessive Compulsive Disorder is a disorder of thought that often dominates a sufferer’s inner and outer life. Intrusive thoughts are the core of OCD—unwanted and often disturbing thoughts that recur, sometimes on a constant basis. They are frequently of a violent, sexual, or sacriligeous nature, although they aren’t always, and they in no way reflect on the personality or intentions of the person having them. Everybody has intrusive thoughts at some point, but for people with OCD they are likely constant.

Behaviors associated with Obsessive Compulsive Disorder are called compulsions. Sometimes they’re tied to obsessive thoughts, but sometimes they’re just odd things the person with OCD feels an intense, unignorable need to do. For example, checking behaviors are common––most people have, at some point, gone back to check one more time if they’ve shut the stove off, even if they’re fairly certain they have. But in somebody with OCD, this may happen constantly, multiple times. They may be going back to check the stove five times each time they leave the house. This is one small, very specific example. In general, OCD compulsions are heavily tied to routine.

Repetition may be the key word to describe symptoms of OCD. Somebody may feel a need to touch a certain object a particular number of times, perform a series of seemingly meaningless “tasks”, or say a certain word or phrase out loud. Really, a compulsion can be just about anything. The key is that it’s unwanted and recurrent, and that it feels necessary. Frequently, compulsions can be tied to obsessions. For example, someone suffering from OCD may have an obsession with cleanliness, have constant thoughts of germs and dirt, and as a result have a hand washing compulsion that causes them to wash their hands so often they bleed.

The experience of having OCD can be hellish. Intrusive thoughts may come so constantly the individual having them can barely function, and compulsions left undone feel like the mental equivalent of a popcorn kernal stuck in your throat––you just have to get it out. OCD is a particularly varied disorder, because while it produces two primary types of symptoms, specific obsessions and compulsions vary completely person to person. Most importantly, OCD has nothing to do with being organized. These are all basic things to know when writing a character with OCD. There’s a lot of room for depth of character development with OCD, because obsessions and compulsions may arise from past experiences, and can be tied in with other character information or even themes of the story.

As someone with ADHD, there are a ton of lesser-known symptoms that have nothing to do with hyperactivity or inattentiveness, at least not directly.

It’s fascinating to me how many seemingly unrelated personality traits can, in reality, all be connected to one diagnosis or type. To an extent, I think diagnoses aren’t useful because they box people in and don’t account for immense complexities of the human mind. But ADHD, like many other mental illnesses, is far more than its most well known symptoms.

Having ADHD is like having a ton of tabs open in your brain at all times. There are, in my experience, a surprising number of traits ADHD and Autism Spectrum Disorders share. While ADHD is characterized clinically by hyperactivity and / or inattentiveness (it can be more one than the other), there are also a lot of differences related to thought process and organization. Some random things that might be helpful in writing ADHD—we tend to have trouble switching from activity to activity, think of things as more black and white than they are, struggle to gather thoughts into a format that makes sense even when we know what we want to say, be more emotional / moody, have poor impulse control, daydream a lot and have very rich inner lives, and be weirdly sensitive to sounds, smells, and textures.

Hyperfixation is also a big ADHD mood—people with ADHD often have intense interests, particularly for short periods of time. While trouble focusing is definitely a symptom of ADHD, when we get into a certain thing / idea / task, we will literally do nothing else until we finish or get sick of it.

Split personality disorder is very rare, and often portrayed incorrectly in fiction.

Not too much to elabaorate on here, but it’s kind of staggering how many times split personalities have been featured in fiction when Dissociative Identity Disorder is quite rare, particularly as it is often shown in books and movies, where an individual is regularly and very suddenly shifting into another persona with no awareness that there are other personalities. Especially rare that one of those personalities is evil. DID is very real, but its prevalance is thought to be as low as 1 in 10,000. To give you an idea of how rare that is, schizophrenia affects somewhere around 1 in 200 people. On that note, schizophrenia is not the same as, or even related to, Dissociative Identity Disorder. Schizophrenia is characterized by delusions and hallucinations, among other symptoms, but it does not involve fragmentation of the personalities. Lastly, if you are going to portray a character with DID, know that the disorder is caused by severe trauma. It isn’t random or genetic.

Many, many adults with mental illnesses are fully aware their behavior is unreasonable or problematic, which often makes life even more difficult.

As someone who has multiple diagnosed mental health problems, I know I’m crazy. My self-deprecating tendencies are in some sense a defense against the immense frustration of being self-aware and mentally ill. While some mental illnesses by nature cause the person suffering from them to think their own thoughts and behaviors are normal, many people know when and how their disease is causing them to act irrationally. As a writer, you should know how a mentally ill character relates to their own mental illness, especially if you’re writing in the first person. Is your character delusional (psychosis), or aware of their symptoms (neurosis)? How aware? There could be a lot of internal dialogue over this.

People without clinical anxiety, in my experience, do not have a good sense of exactly how it feels, even if they’re familiar with outward symptoms of anxiety.

Anxiety is a WIDELY varied set of feelings and thoughts that may occur in response to almost anything. Everyone has their triggers, and this is something that could provide good character development—what sets your character off? Anxiety can be focused on social situations or a certain intense fear (phobias), or it may be generalized. As somebody with generalized anxiety, I have a much lower threshold for becoming stressed than “normal” people, and I require more reassurance.

Anxiety triggers may be things mentally healthy people wouldn’t think twice about. I once met someone who said they had trouble ordering in restaurants and would never think of telling the waiter if there was a problem with the food. People with generalized and social anxiety tend to overanalyze, especially when it comes to interactions with other people. If you’re writing an anxious character in the first person, there could be a LOT of internal dialogue over what other characters are thinking of them (ie. “Why did I say that? God, he must think I’m a freak!”). Depending on how comfortable the character is with talking about their anxiety, you might have them seek reassurance from a friend over something that’s bothering them. People with anxiety often get stuck on little things and have trouble letting go of stressful events, and also tend to apologize a lot. They’re often highly observant as an effect of constantly being on high alert, and they tend to imagine the worst. Anxious people usually tend towards negativity. As a result, they may find it difficult to make decisions. They may also fixate on uncomfortable situations or mistakes they made in the past, even the distant past.

Severe anxiety colors every aspect of thought and emotion, directly or indirectly. It’s a highly physical mental health problem too. Clinical anxiety is like being constantly scared for no reason (as Holly Golightly says in Breakfast at Tiffany’s, “you’re afraid but you don’t know what you’re afraid of”). Your character may feel this fear in their body, in the form of nausea or headaches, among several other possible physical symptoms. The most common and acute embodiment of anxiety is a panic attack. Commonly misrepresented in fiction, a panic attack is more than just hyperventilation in response to a stressful event. Oftentimes, a panic attack isn’t brought on by any particular thing, but rather a generally high level of anxiety. And panic attacks can be INTENSE, causing an array of uncomfy physical symptoms. If your character has a full-blown panic attack, it will not be solved with a few seconds of them breathing into a bag. Panic attacks feel like the world is closing in—your heart races, it becomes genuinely hard to breathe, and depending on how severe the panic attack is, there may be other symptoms. There is usually (but not always) a feeling of intense, unreasonable terror. To give you some idea of how bad panic attacks can be, I once went to the ER because of one—I legitimately thought I was having a stroke. In addition to the usual racing heart and shortness of breath, half my body started tingling, I couldn’t uncross my eyes, got so dizzy I could barely walk, and began slurring my speech. I was almost certain it was a neurological issue, come to find out it was just one fucking hell of a panic attack.

I also want to briefly touch on medication for anxiety, because it’s quite talked about in the media and in fiction (I’m sure you’ve read or watched something in which a character pops a Xanax). Benzodiazepines are a class of medication that includes drugs like Xanax, Valium, and Klonapin. As somebody who has had all three, and had a pretty intense addiction to Xanax (Xanax withdrawal is brutal), they’re incredibly helpful but also dangerous. Mixing them with alcohol or other drugs is flirting with death, and in high doses they can very seriously impair judgment and coordination. If your character has severe anxiety which plays a role in the story, it may be realistic they would be medicated, so it’s helpful to know how people act when they’re taking Benzos.

Lastly, as far as depicting anxiety in a way that isn’t heavy-handed or awkward, focus on the character’s behavior—dialogue, and body language. If your character is feeling especially anxious, they may be having trouble with eye contact, fidgeting, or seem restless / be moving around in place a lot. If the anxiety-ridden character is the narrator, really milk that neurotic introspection.

Your character doesn’t have to be diagnosed, and their mental illness doesn’t have to be super obvious.

I just finished editing my first novel, in which mental illness plays an extremely central role, and have written many short stories involving characters with various mental health problems. But for the most part, the characters’ mental health problems are never explicitly diagnosed. In real life, it’s incredibly common for mental illness to go undiagnosed, and in my opinion diagnosis is overrated anyway. It tends to over-generalize and make assumptions. Human beings are far more complex then their illnesses and neuroses, and two people with the same disorder may experience very different symptoms. There’s nothing wrong with having a character’s diagnosis be known to the reader, but it certainly isn’t necessary.

Tie in your character’s mental illness with the story as a whole.

Overall, when writing a character with any mental health problem, their illness and how it presents should make sense with who they are, and compliment their role in the plot. Before you begin writing, you should be thinking about how this character’s mental illness affects them, their relationships, and the events of the story. You should also have some idea of how their mental health changes over the course of the story and in response to plot events. As is the case with every facet of a story, it shouldn’t be random or unplanned. Do the research, know your character, and decide how their mental health will impact the narrative before you begin it.

Given that psychology / mental health is something I have a lot of academic and personal experience in, there’s a lot more I kinda want to include here. There are so many types of mental health problems, and endless complexities to each disorder. These complexities can be put to good (great!) use in character development. But if I don’t stop myself at some point I’ll summarize the entire DSM (a great source for writing mental health problems, BTW). So I’ll leave this here—focus on the character, not the illness. Make sure there’s more to them than their disorder, and that their mental health problems are well-researched and portrayed realistically.

(I’ll be doing separate posts at some point about writing trauma / PTSD, addiction, and autism. I have too much to say to include those three here, as they’re special areas of interest for me and things I write about a lot.

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