The Psych Writer on Narcissistic Personality Disorder

Gilderoy Lockhart. Zaphod Beeblebrox. Scarlett O’Hara. What do these three characters have in common?

Well, if you read the title, then you could guess they’re all different portrayals of Narcissistic Personality Disorder (NPD). Even though I enjoyed reading those books, and find many parts of their characterizations to be spot-on accurate, your job as a writer is not to copy those characters. You need to make your own. Make them human. Because a person has a PD does not make them any less human, but they are extremes of the human condition.

The Psych Writer is here to help you with this. Remember, this is not a substitute for therapeutic advice. If you somehow manage to see yourself in these symptoms and it also somehow bothers you (or, you know, if your loved ones are ready to throw you out of the house because you have these signs and symptoms), then seek the advice of a professional health care provider.

Without further ado, here is the lowdown on NPD.

NPD is part of the Cluster B personality disorders. They used to be in the Axis II, but the DSM no longer uses that multiaxial diagnosis (much to their detriment, if I’m to be blunt). Cluster B is the cluster of dramatic, emotional, and erratic personality disorders. That means it’s in the same group as Borderline, Histrionic, and Antisocial personality disorders. (There are ten total, in three clusters.)

People who fit into Cluster B have difficulties with impulse control and regulating their emotions. Ever seen someone in line at the store who is just outrageously angry because the cashier won’t honor a coupon, and they start threatening to sue the store and the cashier personally, calling the employee every name in the book and demanding to speak to the president of the company? Yeah, like that. That’s a problem with regulating one’s emotions.

In order to receive a diagnosis of NPD, the person must have an enduring and persistent pattern of grandiose behavior and feelings, a continuous desire for admiration, and a lack of empathy for others.

NPD begins in early adulthood and is often lifelong (especially if untreated), and can be observed in a variety of contexts (home, work, school, social gatherings, public areas).

The disorder is only diagnosed if the person exhibits five or more of the following signs/symptoms (again, some have all nine, but this isn’t seen often):

  1. Has an exaggerated sense of self-importance that’s grandiose. In other words, they expect you to recognize them as your superior without proportionate credentials or achievements.
  2. They are preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. (In some cases, they are so preoccupied with the fantasy that they don’t do the work to make those dreams a reality, such as putting in work for promotions or completing their coursework.
  3. They believe they are special and unique to the point where they can only be understood and appreciated by high-status people or institutions, or they may also believe that they should only associate with the above-mentioned.
  4. They require excessive admiration. (If they aren’t constantly complimented and admired, they often become depressed or use manipulative tactics to gather attention.)
  5. They have an enormous sense of entitlement, unreasonably expecting favorable treatment, or having their expectations met without resistance or delay. Think about the coupon explanation above as an example.
  6. They are interpersonally exploitative. That means they’ll take advantage of others to achieve their own ends.
  7. They lack empathy. They refuse to identify or recognize other people’s feelings or needs.
  8. Envy issues: they think people are envious of them, and/or are often envious of others.
  9. They display  and possess attitudes of arrogance and haughtiness.

Behavioral characteristics include what’s known as “narcissistic rages,” which are hellish for the people who have to endure them. Some threaten suicide, some threaten homicide. Some come close to going through with it, and some complete it. Mostly, though, these rages are part of the loss of emotional regulation and sometimes impulse control. Occasionally, they are done to manipulate the other person into the behavior that the person with NPD wants from them.

Are they like this all the time? Yes. The majority of the time they are like this. That’s what pervasive and consistent mean. Don’t forget that when you’re writing the character!

When you do write a character with NPD, remember, you don’t have to hit all of these points. Not everyone is a textbook case and not everyone has every single symptom (in fact, they rarely do have all of them). Infuse your characters with what makes them uniquely human.

Happy writing.


Anne Hogue-Boucher won’t go into a narcissistic rage if you don’t follow her on Twitter or Facebook, but why risk it? You can also buy her books, and that will enable her to eat a sandwich.

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The Psych Writer: Exploring Borderline Personality Disorder

I had an idea for introducing the personality disorders after I went through some of the others, but I also take requests, as I said in one of my previous posts. Via Facebook, a request came in for me to write about Borderline Personality Disorder. So I’ll be moving into the Personality Disorders a little earlier than I expected.

That having been said, personality disorders are what we consider “bigger” in therapy. Personality disorders are deeply ingrained into the personality of the client. They are invasive, pervasive, and ever-present.

I live in Georgia. Here in Georgia we have an invasive plant called kudzu. It’s everywhere. It grows all over the place and it can’t just be cut down or even burned (burning is illegal anyway because duh, we’re in a drought most of the time and the place would go up in flames faster than Michael Jackson’s hair in that Pepsi commercial). It has to be uprooted from the ground by its root crown.

That’s exactly what personality disorders are–they’re the kudzu of our personalities. They strangle the existing plant and take over completely. They become the plant itself.

So when we’re dealing with a personality disorder, it takes a long time to get to that root crown and eliminate it so that the person can be less miserable and learn to function better so that the people around them can have improved relationships with them. With several of the personality disorders, close relatives and friends grow weary of the “antics.” It makes it difficult to sustain and maintain relationships.

Personality disorders can also interfere with work relationships and productivity, as well as the general day-to-day functioning of the patient. While the same can be said for any disorder in the DSM-5, with a personality disorder, it is much  more treatment resistant, prone to severe relapse, and is lifelong.

A patient has a personality disorder for life. They are never cured. But they can manage it, find relief, improve their relationships, and even help themselves hold down steady employment. They can work towards stability if they work hard enough. It takes a demanding amount of work.

Borderline Personality Disorder (BPD) falls into “cluster B” of the personality disorders. If you don’t count Personality Change due to Another Medical Condition or Other Specified Personalty Disorder and Unspecified Personality Disorder (which we don’t), you have ten personality disorders in three clusters:

  • Cluster A: This is know as the odd or eccentric cluster. It includes Paranoid Personality Disorder, Schizoid Personalty Disorder, and Schizotypal Personality Disorder.
  • Cluster B: This is the dramatic, emotional, erratic cluster. It includes Antisocial Personality Disorder, Borderline Personality Disorder, Histrionic Personality Disorder, and Narcissistic Personality Disorder.
  • Cluster C: This is the anxious and fearful cluster. It includes Avoidant Personality Disorder, Dependent Personality Disorder, and Obsessive-Compulsive Personality Disorder (which is not the same as OCD).

Borderline is considered to be in the dramatic, emotional, erratic cluster. It is characterized by a lifelong pattern of of instability in interpersonal relationships, self-image and affects, and marked impulse control issues (DSM-5, p. 645).

So what the hell does that mean? That means the patient has little to no stability in their relationships with others (professional and personal), erratic behavior and lack of self-control to the point where self or others are harmed.

According to the DSM-5, the signs and symptoms of BPD are a pervasive pattern (as stated above)–but what makes up these patterns? The DSM-5 reports that for a person to be diagnosed with BPD, they must have five (or more) of the following (which I will give in plain English):

  • Frantic efforts to keep from being abandoned, whether that threat of abandonment is real or imaginary. This does not include suicidal behavior or self-mutilation as that is a separate criterion.
  • Repeated unstable and intense relationships that alternate between extremes of idealization and devaluation. Going from “you’re perfect” to “you’re the scum of the earth.”
  • Unstable sense of self. This instability is marked and persistent and goes to extremes. Not only does the love-hate relationship apply to other people, it applies to themselves and their self-image.
  • Recklessness/lack of impulse control in at least two areas of life that will cause them harm, such as unprotected sex with strangers that could result in STIs, overspending, substance abuse, reckless driving, binge eating, etc.). This still doesn’t include suicidal behavior or self-harm.
  • Recurrent suicide attempts, threats, gestures and behavior, or self-mutilation.
  • ‘Affective instability due to a marked reactivity of mood.’ This one’s a bit hard to explain. Imagine the worst overreacting you’ve ever seen. Now imagine it could happen at any time for any reason. You run out of cotton balls and the person has a massive anxiety attack and the anxiety affect lasts for a few hours. It’s a bit like that.
  • Chronic feelings of emptiness. (Exact words from the DSM. Self-explanatory.)
  • Difficulty controlling anger. Intense anger fits. Inappropriate anger to the stimulus. Imagine telling the person you’re out of donuts and they smash a table in response, demand to see your manager, threaten to sue, and threaten to kill you. While that might be funny and unbelievable, yes, it is that extreme.
  • Stress-related paranoia or severe dissociative symptoms that are transient. In other words, it doesn’t last, but the person will abruptly become paranoid, or they’ll dissociate (the world isn’t real, people are inhuman or automatons, etc.).

Now, writing a character with BPD is actually a challenge. Sure, you can go through all nine of the criteria, but I could almost guarantee you that you’ll create a caricature instead of a character. Even with black-and-white perceptions that many people with BPD have, they are still human beings. Avoid making a cookie cutter. You’ll want to add lines of sympathy to that character. He or she didn’t get there on their own. In many cases of BPD, there is not just a genetic component–there is often a history of abuse–sexual, physical, etc.

The person with BPD does not mean to do these things. They cannot help it. That’s why Dialectical Behavior Therapy helps so much. Patients learn from a system of mindfulness and awareness. DBT was developed by Marsha M. Linehan, who has successfully managed the disorder herself. Bear in mind that if you are writing someone with BPD, remember, they cannot help themselves when they do these things. Yes, some of the behaviors are purposefully manipulative, but they are not malingering. Until they get professional help, they are often unaware that these things are not acceptable, because even though people tell them so, they are often focused on assigning blame to others for their reactions.

Always remember, you are still writing a human being, though these are the extremes of the human condition.

If you came here looking for help with BPD, know that it’s out there. Start with this article here and then search for a therapist in your area who specializes in DBT.


Anne is a former supervised therapist and current author. You can read her books, stare at her Twitter, or stalk her on Facebook if you want.

The Psych Writer comments on 11 Things People Do Because of Anxiety

When writing about depression, I came across an article a friend shared on Facebook. It’s a good article, written by a layperson who obviously did his research. He got everything on the nose–except for #11.

But I’ll get to that in a minute. First, I’d like to tell you when you’re writing an anxious character and you need to use show instead of tell, use this article as a guide. Don’t tell your audience the person has anxiety disorder, show them. Like with any disorder, you’re not going to tell them all about it, you’re going to show them all about it. Make the reader lean in and wonder what the hell is wrong with this character. Make them wonder why the character is obsessing over something trivial to the point of being ludicrous, for example.

The only reason I object to #11 in this article is because while anxiety does burn up a person’s energy, this type of burnout can be indicative of much, much more than Generalized Anxiety Disorder. Yes, anxiety wears a person out, but if it is to the point where a person cannot get out of bed, this is much more serious. It can be indicative of a physical problem, a nutritional deficiency, or Major Depressive Disorder. Any person who has anxiety should never, ever ignore this symptom and let their therapist or physician know immediately.

There are many different types of anxiety disorders, which I will go into later on for The Psych Writer (after an exploration of Munchausen Syndrome and Munchausen-By-Proxy).

In the meantime, enjoy this article from Simon Segal, and let me know what you think in the comments.

Source: 11 Things People Don’t Realize You Are Doing Because Of Your Anxiety

Wendy Howard tackles Beverley Allitt: Women in Horror

I really enjoy Wendy Howard’s writing. As a part of February’s Women In Horror Month, I had the privilege of meeting her in virtual space and writing an article about torture.

Maybe I’m biased towards Wendy because she shares a name with one of my favorite characters of mine (Wendy Willow). Nah. She’s just a compelling writer.

This was one post that Wendy wrote for WiHM. She discusses a very real serial killer who had Munchausen Syndrome AND Munchausen-By-Proxy Syndrome. These are both rare conditions, and to have them together was, as I said in the comments, “like finding a unicorn. A horrible, flesh-eating unicorn, but still.”

In my series The Psych Writer, I will be tackling both Munchausen and MBP. I think it would make for some interesting characters if handled correctly, and I like to pick things apart. As I said, Munchausen Syndrome and MBP are rare, but they’re fun to explore (as long as you’re not the one suffering from it).

Enjoy Wendy’s article and sleep tight.

Read here: Beverley Allitt: Serial Murderer and Evil Woman In Pop Culture | Women in horror

The Psych Writer on Major Depressive Disorder, Part Three – MDD with Psychotic Features

This is the final installment of The Psych Writer series on Major Depressive Disorder. This week, we turn our focus on MDD with Psychotic Features.

Of course, when writing any disorder, focus on showing rather than telling, and remember, your character is human. Give them more dimensions than their disorder.

What’s tricky about writing MDD with psychotic features is not making it look like schizophrenia or bipolar with psychotic features. You will need to make sure that the depressive features are most prominent, otherwise the reader isn’t going to get it.

Naturally our writings are always open to interpretation by the reader–that’s what makes it such an enriching experience. It’s not the focus on the symptoms that makes the writing interesting, anyway. It’s the expression of the character and their life that makes the reading compelling.

So, we’ve already reviewed what MDD is all about, but what about psychotic features? Psychotic is a word that’s used in lay terms that tends to get confused with other terms (hell, even I’ve confused the terms when I was exhausted at one point). Psychotic is a term for losing touch with external reality.

The patient who is psychotic can experience any of the following, with some examples for illustrative purposes:

  • delusions – believing someone has bugged their home, is being gang stalked, they have a terrible disease, or that they’re the Archduke Ferdinand.
  • hallucinations – seeing, hearing, tasting, or smelling things that aren’t there, such as seeing a person that no one else can see.
  • anxiety – the person may seem anxious and restless.
  • withdrawal from family and friends – sometimes due to the delusions and hallucinations, the patient withdraws from social interactions. This is not just an “oh, I don’t want to go to the mall.” This is more like they don’t answer any of their phone calls and they stop talking to people entirely. Think the most extreme form of withdrawal possible.
  • suicidal ideation and actions – they may attempt to kill themselves or think about it all the time.
  • disorganized speech – this isn’t your average non-sequitur. Disorganized speech is often completely incoherent. There are several types of DS:
    • word salad – seemingly random words put together in a sentence. “My pants raisin toggle the burp slurped in a cat.”
    • derailment – completely unrelated or tenuously related ideas put together as if they were related. “I have to pick up my dry cleaning. There’s a bar in the street that keeps me from walking to the park.”
    • neologisms – words that are made up. “I took my wife to the helgistahooven for a new haircut.”
    • perseveration – a response repeated uncontrollably (this can be verbal or gestural). “Did you pack a pair of socks?” “Socks, socks, socks, socks, socks, socks, socks…”
    • thought blocking – when a person stops talking abruptly in the middle of a sentence without any explanation. “I went to the store and-” *silence*
    • pressured speech – rapid speech that sometimes is incoherent.
  • difficulty concentrating – this is pretty self-explanatory.
  • hypersomnia or insomnia – sleeping too much or not enough.
  • suspicion of others and situations – this is usually due to delusions.

Keep in mind that the person with psychosis is typically unaware of these symptoms and signs. They are often so out of touch with external reality that they have no idea that their delusions or hallucinations aren’t real, and that their behavior has changed to be out of the ordinary.

Here you see there are some things that crossover with depression, such as suicidal thoughts or actions, anxiety, and withdrawal. Knowing this, it’s easy to understand how difficult differential diagnosis can be.

The standard treatment for MDD with psychotic features is antidepressants and antipsychotics. If that doesn’t bring relief, ECT (electroconvulsive therapy) is another common method.

Overall, when writing a character with this disorder, there’s an opportunity to do a little reality bending. Just don’t make it too much of a trope.

Coming up for The Psych Writer, we’ll tackle some of the following subjects (not necessarily in this order):

  • Bipolar Disorder I and II
  • Munchausen Syndrome
  • Munchausen-By-Proxy Syndrome
  • Anxiety Disorders – Generalized Anxiety Disorders, Panic Disorder, PTSD
  • Schizophrenia
  • Autism Spectrum Disorder
  • Personality Disorders: Exploring the three clusters of the ten disorders.

I also take requests. Any disorder you’d like me to explore? Contact me via Facebook.


Anne is a former supervised therapist at the Master’s level who abandoned it all to become a writer. Visit her shiny Author Page to learn more about her and read some of her more macabre thoughts on paper (or eBook).

The Psych Writer on Major Depressive Disorder, Part Two – Treatment Resistant Depression

Welcome to part two of my series on Major Depressive Disorder (MDD). If you’re looking for the introduction to what MDD is all about, you can find that here.

Last week in part one, I wrote about writing a character with MDD, after detailing the symptoms for the disorder (link in the first paragraph). This week, I’m going to discuss Treatment Resistant Depression (TRD), which I still like to pronounce as ‘turd,” because it really is a turd. When you’re writing a character and would like them to have TRD, it’s important to understand what it is.

So rather than go on with a laundry list of how your character may be written, I’ll go through what TRD is and how it is treated. Then you can decide how your character will fit into it or not. Remember, you’re writing your character as a human being, so it’s okay if they deviate a bit. Humans are not their disorder, so neither are your characters.

TRD is defined as MDD that has not responded to a minimum of two antidepressants. Although some literature says only one, in most professional settings, two antidepressants are tried before determining whether  the depression is treatment resistant.

The difficulty lies in determining the threshold for TRD. There is complete remission and partial remission in symptoms, and there is also reduction in severity of depression. So determining what’s enough for the patient is what determines whether depression is treatment-resistant or not. Personally, I prefer elimination of symptoms, and if any are left, then that’s not good enough, so it’s time to try something else or add something to the treatment. But some people are okay with partial remission. It’s sometimes enough to have some relief over no relief, so best practice is to support the patient’s decision if they have good decision making skills.

When a person has TRD, there are things that they can try to get help. Usually treating TRD begins with an increase of dosage or switching medications. If that doesn’t help, then an add-on is usually used. For example, if the SSRI isn’t working, a combination of an SSRI and an NRI may be used.

Sometimes playing around with medications doesn’t help, though, and sometimes it does exactly what it’s supposed to do. But if it doesn’t work and the patient isn’t already in counseling, they can try a combination of medication and psychotherapy.

Other treatment avenues are Electroconvulsive therapy (ECT), Transcranial magnetic stimulation (TMS), and Vagus nerve stimulation (VNS). Most people cringe when they hear “ECT,” but that’s because they associate it with what they’ve seen in the movies and in old videos when the treatment was actually horrible. Now, the patient is given a sedative and most sleep through it. I’ve watched it done (on video rather than in vivo) and the experience was underwhelming. Of course, there are risks with ECT, including short-term memory loss, but for some patients it beats the hell out of MDD/TRD.

Now, finally, the numbers. This is something you may want to consider when creating a character. Around 10% to 30% of people have TRD, and that number varies on the spectrum of TRD (whether it’s full or partial remission, reduction in severity, etc.). So when you’re creating this character and you want to give them TRD, consider Special Snowflake Syndrome (SSS).While it’s recently been co-opted as a political inflammatory term, I refuse to use it in that manner. SSS means that your character has become a little too precious. If you give them TRD, make sure that they don’t come out corny and cliched, and actually make their suffering real rather than something they manage to brush off whenever it’s inconvenient to your plot.

If you came here looking for help with depression, please seek the help of a licensed professional in your area. Depression is a horrible, soul-sucking disorder that takes your life piece-by-piece. Don’t let it take control over you. Call for help. It’s out there.


There is little more horrific than what lies in our own imaginations. If you love reading about nightmare worlds and strange happenings, check out my author page. You can also follow me on Twitter or Facebook.

From My Quora Blog: The Existential Crisis First-Aid Kit™

This post first appeared on my Quora Blog, where I write about things unrelated to writing. I hope you will enjoy it. Of course, I also hope you’ll keep reading because I’ll be back soon with more installments of The Psych Writer.

Also, for those who asked–my dog is still alive. She is doing well and the terminal illness is still there, but we are enjoying all the time we have left with her. Thank you for asking.

Okay, so I get a lot of questions about the fear of death, so I’m making a corral where you can read all about it if you’re having an existential crisis. I think it’s important to know that you’re not alone.

These five links are proof you’re not alone:

Anne L. Hogue-Boucher’s answer to I am 21 years old and i started to get panic fear of death, what is the problem? Should i go to psychologist ?

Anne L. Hogue-Boucher’s answer to How can I help someone who’s afraid of dying and who’s obsessed by the idea of disappearing?

Anne L. Hogue-Boucher’s answer to I have this extreme fear of death. I have heard many answers, but none of them could convince me. What do I do?

Anne L. Hogue-Boucher’s answer to If I always have constant fear of death, should I seek a Psychologist?

Anne L. Hogue-Boucher’s answer to How do I get over fear, emptiness and other negative emotions?

I think if you go through each one and read them completely, you’ll see common threads such as a fear of isolation, the unknown, and feeling trapped. You’ll also see that it’s a fairly common fear to have.

Use these tools in each of the links to help you overcome your existential crisis. If that doesn’t work, seek the help of a licensed therapist in your area who is trained in this particular field.

All materials included in this post are intended for informational purposes only. This post/information is not intended to and should not be used to replace medical or psychiatric advice offered by physicians or other health care providers. The author will not be liable for any direct, indirect, consequential, special, exemplary or other damages arising therefrom.

If you’d like to read about two people with the ultimate existential crisis, pick up a copy of Exit 1042. Or, if you’d like to scare yourself into being glad you’re alive, grab a copy of Now Entering Silver Hollow.

The Psych Writer: What Next?

Since we took a break for a few weeks from The Psych Writer after a seven-part series on grief, I’ve noticed that TPW is actually pretty popular. So because I love the subject, and I love to write, and I love to have people read, I was thinking of reaching out to all of you by opening up comments.

What kinds of things would you like to read about next, in the context of writing/creating a convincing character with a mental health issue? There are so many I can write about, including the ones I find are most misunderstood and abused by laypeople who watch far too much television and think that Sherlock Holmes is actually a psychopath (WRONG!) because the writers are ableist twats.

I’ll open the comments up to you, or you can comment via Facebook or Twitter.

What would you like to see next for TPW? Below are a few choices, but you’re welcome to come up with your own.

  • PTSD
  • Major Depressive Disorder and Dysthymic Disorder
  • Bipolar I, II, and Cyclothymic Disorder
  • Schizophrenia
  • Dissociative Identity Disorder
  • Antisocial Personality Disorder
  • Autism Spectrum
  • Borderline Personality Disorder
  • OCD and OCPD

Now I’ll probably work on all of these and more, but I’m reaching out to you, my fine and beautiful reader, for what you’d like to see next.

In the meantime, happy writing, and try not to tear up my inbox too much. *wink*


While I was doing all of this, I was getting a book ready for publishing. If you’re up for a journey through Perdition and back, hop in your car and head for the sign that says Now Entering Silver Hollow. It’s available on several eBook platforms, and in print through CreateSpace and Amazon.

The Psych Writer: Grief – Phase Seven: Acceptance

This is the final installment of the grief section in The Psych Writer series. Last week, we took a look at The Depression Phase. But now we can take a nice, deep breath and look at how far we’ve come. All the way to acceptance.

These phases are organized for the benefit of the clinician. They are not set in stone and the patient will likely not feel these things in order, or one at a time. They might, but they might not. Grief is individualized. There is also fluidity in acceptance. It can fluctuate, just like the other phases.

Oh, acceptance, this phase is so lovely, right? Happy bluebirds sing all around you as you realize you fully accept that x loss has happened and sunbeams arch from your head in a golden halo of enlightenment.

NO.

Acceptance isn’t pretty. It’s not always peaceful. It’s not often a loving, gentle tutor that allows us to smile once again. No. It’s part of the process, and sometimes, perhaps most of the time, it’s ugly before it is fine. The experience varies from person to person.

What acceptance is can be anything from a bitter resignation to one’s fate, to a calm recognition of this is how the way things are, and everything in between. This is the moment where a person says, “my mother is dead. Nothing can change that,” or “I lost my job and there’s no going back.”

Acceptance is the first step to putting one foot in front of the other and rebuilding life without whatever was lost.

Acceptance from the Patient’s POV
The patient feels the loss, though often less acutely than in the other stages. The grief has been replaced with the ability to function without the target of their loss. There may be lingering feelings of sadness, anger, and those feelings may resurge from time to time, but there is a sense in the person that they need to move forward. Acceptance of a non-lethal event, such as job loss or divorce, a spark of interest in other activities may arise. The person may have found a new love interest, or a new job may have them ready to move on from the old one.

Acceptance from the Therapist’s POV
While this is often a good sign that the patient is ready to make significant leaps into moving forward, it is important to check in with them to see how they feel about their newly found acceptance. Is there resignation? Optimism? Pessimism? Fear of moving forward? It will be up to the therapist to help the patient work through those retentive feelings so that the patient can move toward healthy and more helpful feelings.

What this Means for You, The Writer
Getting to acceptance might be a good starting point for your character, and however they get there will be far more interesting than the feelings themselves. Does your character need revenge in order to accept something that was taken from them? Will it help? Will they regret what they’ve done, or will they accept it and move on to better things? Starting a character in the acceptance phase might be interesting if you can flip the acceptance on its ear. What comes next after they’ve accepted their fate? These are all questions you may wish to answer for your character.

If you came here looking for psychological assistance, please contact your local crisis line. Dial 2-1-1 in the US for the United Way, or contact the Samaritans in the UK. For a list of international crisis lines, click here.

Breathe easy, we’ve gotten through this together. Now go write.


Now that we’ve done this in-depth examination of grief, let’s move onto some other topics. I take requests (you can ask via Facebook or Twitter). Next week I’ll do some fluffy topics or post a picture of my cat. Maybe. Or I might drag you further into the abyss. Who knows with me? If you’re in need of some lighthearted diversions, check out my Facebook and Twitter. Or for some entertaining fiction that touches on grief and loss, grab a copy of Exit 1042.

The Psych Writer: Grief – Phase Six: Depression

This has been a dreary series for some, I’m sure, so thank you to all the readers who are stubborn enough to get through it with me. For others, you understand that death and grief are part of the human condition. It’s worth closer examination. Sometimes it even helps.

Last week as part of The Psych Writer series, we took a look at the fifth phase of grief: anger. This week, we examine depression.

Remember (and for regular readers, say it with me): these phases are organized for the benefit of the clinician. They are not set in stone and the patient will likely not feel these things in order, or one at a time. They might, but they might not. Grief is individualized.

As clinicians we have a bit of a conundrum on the use of the term “depression” here, because depression is a clinical diagnosis. It’s more than just feeling sad. Depression is an illness that is typically long-term, can be lifelong, and can be hazardous to the patient. Yet we use the term here because depression not only means feelings of sadness, but a patient can develop Major Depressive Disorder in this phase. Not only that, those who already have MDD can face a downturn in mood or behavior. In other words, grief can push them further down the spiral.

Basically, you’ve got a lot of shit to do in this phase, too.

Depression from the Patient’s POV
Life is empty and pointless without X, where X is the source of loss. This is the phase most commonly associated with grief, so chances are, you’re familiar with it. Life is colorless. Bland. Some of the things I’ve heard from people in this phase have been soul-sucking. The depths of despair when facing a loss can be, well, depressing.

“I cannot live without them.”

“Not even food tastes the same.”

“I’ll never be able to listen to jazz again. It reminds me too much of my [loved one].”

“We used to go for walks together every day. Now I can’t even get out of bed. Without X, it’s just not worth it.”

“If I’m dead, then I can join them.”

Anything you can imagine that reflects the loss that’s depressing as hell can be found in this phase. It is utter disaster for a patient. Some believe they will never recover.

Sadly, some won’t recover. Some will spiral into MDD, and some will get worse if they already have MDD.

Depression from the Therapist’s POV
It is up to you to help the patient move away from this phase. It is not done quickly, and there is no efficient magic trick to make them better. Sometimes, you have to call in a psychiatrist’s consultation, particularly if the patient is already on medication for MDD, or they really should be on something for MDD. No, you’re not giving them a magic pill that will take away their pain of loss; nothing will do that. When you suggest medication, it’s because you are using a tool that may help pull them back from the abyss and give grief clarity.

In other words, you are helping them to just grieve, rather than get sucked down into the horrific abyss of MDD.

Remember some of the things I mentioned that I’ve heard from people in the depression phase? Let’s look at them through the lens of an ethical therapist.

“I cannot live without them.” (Silent warning bells. Find out if the patient is suicidal. Find out if they have the plans, and means. You may have to hospitalize.)

“Not even food tastes the same.” (Anhedonia is possible. Discuss what this means for the patient. Find out if they’ve had any unexpected weight loss. Note it. If patient has history of an eating disorder, consult with treatment team. Work with them and the patient. Work with the patient to help them find a way to remember their loved one through food, but in a healthy way.)

“I’ll never be able to listen to jazz again. It reminds me too much of my [loved one].” (Anhedonia is possible. Discuss the reasons. Let the patient talk and tell you a story about their loved one’s favored music. Help them remember this is a process and that over time it may become a positive way to remember the loved one.)

“We used to go for walks together every day. Now I can’t even get out of bed. Without X, it’s just not worth it.” (Loss of a physical activity can make depression worse. Discuss and explore alternatives, or how to get back to walking, etc.)

“If I’m dead, then I can join them.” (MAJOR ALARM BELLS BETTER BE GOING OFF IN YOUR HEAD. Patient has suicidal ideation. Check for plans and means. Hospitalization may be necessary.)

What this Means for You, The Writer
Of course it depends on where you’re going with the story. Usually when a writer examines grief in fiction, this is the phase that they start at because it’s the most recognizable and seemingly the one that gets the point across. Your character may have stopped eating. They may overeat. They stopped showering and grooming.

But consider writing from one of the different phases or combining a few instead of starting at depression. If and when you do choose to write this part, don’t forget the impact of show over tell. Show me the uneaten dinner in the fridge. Show me the ashtray full of cigarettes and the character lying in bed with a red face puffy from crying. Show me the dirty hair and stench of two-week’s worth of unwashed laundry, piled up in the corner and threatening to grow legs and walk off. Show me the guitar in the other corner just gathering dust. The darkened room. The unmade bed. The broken mirror.

Remember, it’s not the grief itself that’s interesting, it’s how the character faces it, doesn’t face it, or makes matters worse that is interesting to the reader.

If you came here looking for psychological assistance, please contact your local crisis line. Dial 2-1-1 in the US for the United Way, or contact the Samaritans in the UK. For a list of international crisis lines, click here.

Now go write. Go for a walk, too. Get a little fresh air.


Wow, just one more topic and you can breathe easier. We’ll move onto other subjects too, and I do take requests (you can ask via Facebook or Twitter). If you’re in need of some lighthearted diversions, check out my Facebook and Twitter. Or for some entertaining fiction that touches on grief and loss, grab a copy of Exit 1042.