#writing disability

A note obviously that psychosis is highly personal and your mileage may vary. This is not meant to be an all-encompassing post.

Conditions that can cause psychosis (not exhaustive):

Schizophrenia,

Schizoaffective Disorder,

Schizophreniform Disorder,

Delusional Disorder,

Brief Psychotic Disorder,

Major Depressive Disorder with Psychotic Features,

Bipolar Disorder,

Psychotic Disorder Due to Another Medical Condition (yes that's the real name and the Another Medical Condition usually refers to things like Alzheimer's, Parkinson's, brain tumors, etc.),

Substance/Medication-Induced Psychotic Disorder.

The first three are also known as the "schizo-spec" (schizophrenia spectrum) disorders, with delusional disorder and brief psychotic disorder sometimes also being included in that definition.

Hallucinations

[Plain text: Hallucinations]

There are many kinds of hallucinations, the most commonly discussed being auditory and visual. However, they are not the only ones! There are also tactile, olfactory, gustatory, and somatic ones (the latter are often categorized under tactile or vice-versa).

The most frequent kind of hallucination experienced changes depending on the exact disorder. Overall, the most common ones are either auditory or visual (e.g. auditory are the most common in schizophrenia, and visual in neurological disorders), then the other one of the aforementioned two, then tactile/somatic, then olfactory, and then gustatory.

A person can experience any number of those, and multimodality (involving multiple senses) is more common than unimodality (involving just one sense) in people who have a primarily-psychiatric condition. In other words, having hallucinations that involve multiple senses is common for those on the schizo-spec, but very rare for those with ocular conditions, for example.

Types of hallucinations:

[Plain text: Types of hallucinations:]

Auditory hallucinations: There are many things a person can hear, the most common and most discussed being voices. However, other common auditory hallucinations are whispering, hearing your name being called, music, and hearing people walking around.

Command hallucinations: a subset of auditory hallucinations. My absolute enemy. A hallucination, usually external voice but sometimes an "implanted voice" that commands the listener to do things, from something simple like standing up to hurting themselves or others. The listener can resist, but I personally find the longer I have command hallucinations the harder they become to resist or ignore. Often the thing that gets me sent to inpatient. The most important distinction for command hallucinations are that they are not intrusive thoughts - the person is insistent they are external from them.

Visual hallucinations: Less common than auditory hallucinations but still incredibly common. Not always shadow people or recognizable people - I see strangers and have never had the same visual hallucination twice, although some people do see returning "characters". I do see shadow people occasionally, but they aren't the only thing people see and can be a somewhat exaggerated depiction. I know a lot of people who see cats, for some reason. If you can think it, someone can see it!

Obviously hallucinations can but don't have to be scary, it simply depends on the person and experience.

A person can see almost anything as a hallucination. Some people experience what are known as "simple" visual hallucinations (as opposed to "complex" ones)—basic patterns, spots, geometric shapes, lights, lines. They are not lifelike or clear, and are visibly out of place. Simple hallucinations are less common on the schizo-spec, but anyone can have them.

Tactile hallucinations: my absolute enemy (hey, different mod here). Tactile hallucinations are less common than visual or auditory ones, and often come with other kinds of hallucinations as a bonus—especially somatic ones, since there's no clear distinction between those two a lot of the time. They encompass touch, feeling, and spatial sense in the broadest sense you can possibly imagine. They can be annoying in their own manner as there is often no way to check their validity; you usually can't just record or take a picture of them to verify them.

Tactile hallucinations can be, as most hallucinations, basically anything. One of the most common types is the feeling of parasites, bugs, or other animals, like snakes, moving across or under the person's skin.

Parasitic/formication hallucination is the main example of tactile hallucinations to the point that there are sometimes used as synonyms. It's also very often associated with delusional parasitosis, where the person actually believes that they are in fact infested, which will be mentioned in the "delusions" section.

For many people tactile and somatic hallucinations will be one and the same, or otherwise inseparable, like the feeling of blood or urine dripping down their body, being burned, feeling their organs or bones "move around", or having their skin stretched.

In my personal experience—YMMV—tactile hallucinations are the most difficult to acknowledge as fake (for me, this is in comparison to visual and olfactory ones). Even if you are aware of the possibility of being in psychosis, since they can't be reliably verified for the most part, are often at least theoretically possible, and frequently co-appear with delusions of the same theme.

Olfactory hallucinations: smelling things that aren't there. Those can be pleasant, gross, or completely neutral, as most hallucinations in general. Smell hallucinations can be (unofficially; this is just a distinction I've used myself) categorized into external (smells "outside" the person having the hallucination, like a fire) and internal ("in/on" the person having the hallucination, i.e. a smell that's coming from their own body). In my anecdotal experience, people tend to have more of only one of these types rather than both.

One of the most common ones is the perception of having extremely offensive body odor or bad breath, but it can also do with urine, blood, even decomposition, etc. The hallucinations generally revolve around mundane things (there's nothing "OMG I must be in psychosis!" about thinking you smell bad), which might make them difficult to spot as fake, even if someone is aware that they are overall psychotic.

Many kinds of olfactory hallucinations might make the person feel insecure (body related smells), paranoid (chemical related smells; e.g. I had a recurrent hallucination of smelling spilled gasoline), or cause problems with things like eating (smelling non-edible things in food; rot, mold...).

Gustatory hallucinations [disclaimer: none of the mods have first-hand experience with this one; this is entirely based on external sources]: tasting things that aren't there. The rarest kind of hallucinations statistically, though it shows up in some non-shizo-spec conditions more often (e.g. epilepsy).

Gustatory hallucinations are mostly realistically plausible (for example, feeling a bitter or sour taste) or realistic but unusual (e.g. metallic taste). They often coexist with other kinds of hallucinations and delusions, often exacerbating the problem (e.g. a person with delusions of being poisoned might experience a hallucination of dangerous chemicals in their food, solidifying the delusion).

Hallucinations FAQ

[Plain text: Hallucinations FAQ]

Q: How to describe hallucinations in a sensitive manner?

A: Sensitivity and hallucinations is less about being sensitive about the hallucinations and more about the person having them. Hallucinations can be anything, and I mean it. For every "stereotypical" hallucination, there's a thousand real people who will have it. Unless you're considering doing something extremely out there, I wouldn't worry about the content of hallucinations being sensitive or not; anything that's common enough to be listed as an example of a hallucination is more than safe. Some hallucinations are scary, a lot are deeply unpleasant. That's okay to show.

So, how do you describe the person having the hallucinations?

First of all, don't make them violent towards others. This is a very harmful stereotype that writers love to use. Psychotic people can be violent since they are people, but they're much more likely to be victims of violence as well as committing violence towards themselves (both in the self-harm context, as well as in attempts of dealing with psychosis that ultimately result in unintentional self-injuries). Don't make someone into a murderer because they are hearing voices or smelling blood in their food.

Second, show them as a full person and that psychosis is part of them as that person. Why* are they psychotic? How do they experience it? When did it start, and how often do they have episodes? Do they go to therapy? Do they take medication? How do they feel about it? Make them seem human while integrating psychosis into their character, not just a "normal" person with a "scary gimmick" slapped on top without considering what it actually means for them.

*—not as in "there needs to be a reason for a character to be disabled", but as in "what condition is causing them to hallucinate".

Third, don't push people with low insight under the bus. Someone who can't tell their hallucinations apart from reality isn't stupid or "worse" than someone who has higher awareness. It also doesn't translate to morals; someone who fully can't tell what's real isn't more likely to be evil. It also doesn't make them blissfully unaware angels that should be treated like children. Don't moralize a mental illness in either direction.

To go back to the actual hallucinations—treat them as what they are: hallucinations. They aren't future-telling, prophecies, visions from an alternate dimension, sources of magic, whatever else, they aren't those things. A delusional person (or character) might believe that what they're experiencing is something "greater", but that'd be a part of a delusion; it's not something you should put as part of your objective worldbuilding. Even just implying that psychosis has some "deeper meaning" can mess some people up.

This is my least favorite form of psychosis representation in media. Honestly, personally, I'd rather be portrayed as violent than like I have some secret gift, but don't do either.

Q: How to integrate hallucinations into a story without the story becoming about them?

A: Depends greatly on whose POV you're writing from, how much insight the character has, and what emotions do they experience while hallucinating.

If it's a non-POV character who is aware they are in psychosis and are relatively unbothered by it, you can just describe them glancing around, or otherwise checking where the hallucination is. In most cases someone with high insight won't be interacting with a hallucination (an exception could be a pleasurable hallucination that the person enjoys).

They might ask another character if they also see/hear/feel the hallucination—even if someone is fully aware they are currently in psychosis, it might be difficult to verify which things are fake and which aren't. Maybe the character is sure that the person they're "seeing" is fake, but aren't sure about the dog that's with them.

You can describe the character being clearly distracted by something; looking into a specific place, moving weirdly, or not being able to stay on topic.

If you're trying to write about the character experiencing hallucinations and having low insight, it might be much more difficult to not make the story (or the scene) about it—if you don't go out of your way to acknowledge them as hallucinations then it will look like there is no hallucinations present, since the character will just consider them to be real. It'd just be another part of the setting—you can obviously throw in something that would be clearly out of place for the reader, but it will raise questions that you should probably address, thus making the scene about the hallucinations.

A similar thing can happen if your character is experiencing an unpleasant hallucination: you kinda have to make the scene about it. if the character is scared, it'd be weird to ignore that. You can of course go "they saw a peculiar creature in the yard, one so weird that they knew right away it wasn't really there, so they decided to ignore it," since you can be aware of a hallucination being fake while still being disturbed. In that situation you can have the character purposefully trying to distract themself, show them being under stress, or having another kind of reaction (e.g., using some sort of grounding technique, having a panic attack, etc).

Q: What are some common ways to tell what is and isn't a hallucination?

A: Visual: taking pictures/videos, taking off your glasses (hallucinations will sometimes stay in-focus when the real world blurs accordingly), asking another person if they also see it.

Auditory: recording the sound, asking another person.

Blind people having visual hallucinations and deaf people having auditory ones usually just assume that the hallucination is fake, especially if it's the only thing they are able to see/hear.

Olfactory: asking another person.

Tactile/somatic: no consistent way as far as I'm aware. In some circumstances you can tell by just looking (e.g. you feel like you're having a nosebleed, you can just look in the mirror to check) or asking another person (e.g. you feel like you're levitating), but for most hallucinations there is no way of telling (e.g. how would you check if there's something happening to your internal organs? Get a body scan of some sort maybe?).

Gustatory: if it's about a real food you can ask another person if they also feel the same taste, otherwise no way of telling as far as I'm aware.

Q: Does being able to logically differentiate between reality/hallucinations stop emotional responses?

A: It can, but it's not a guarantee by any means. Imagine you're on a rollercoaster or watching a horror movie: logically speaking, you know that you are safe—but still, you get scared, it's a natural response. If the insight helps someone emotionally, it's usually partial.

That said, being able to recognize something as a hallucination might (key word here) help someone stop having a psychotic episode, which could end the emotional response. But just because you know that something is fake doesn't mean you'll stop believing it. In fact knowing that you're believing something that is fake can be even more distressing than not knowing it's fake.

For some people, a hallucination could be traumatic or plain upsetting and continue to disturb them even after it's gone and they are no longer having an episode.

Not everyone will be particularly emotional though. Some people hallucinate 24/7 and just treat their hallucinations as another part of their day, even if they're fully conscious of them being fake.

Q: Can blind people have visual hallucinations/deaf people have auditory hallucinations?

A: Yes. For those where the two are connected, the former is called Charles Bonnet syndrome, the latter Musical Ear syndrome. The major distinction is that in both of those, the person experiencing the hallucinations usually has high insight (i.e., is aware that they are hallucinations) and they don't generally co-occur with delusions.

Blind and deaf people with residual vision/hearing can also experience "regular" visual/auditory hallucinations as well (and obviously other kinds too—nothing is stopping a deaf person from having olfactory hallucinations).

The one important caveat is that people with congenital (!) cortical (!) blindness do not, for unknown reasons, ever develop schizophrenia.

Delusions

[Plain text: Delusions]

Delusion is a fixed belief in something that is considered false, even after seeing evidence for the thing being untrue. The delusional belief isn't a part of the person's culture or religion, and isn't accepted as true among other members of their community. The belief is generally disturbing to the person and causes them distress.

The delusions that one can have are basically endless in terms of options, but they can be broadly put into two categories:

Bizarre: delusions that are impossible to occur in real life.

Examples:

being abducted by aliens,

having your thoughts broadcast over the radio,

being a supernatural entity.

Non-bizarre: delusions that are possible to occur, even if highly unlikely.

Examples:

being poisoned,

having a partner cheat on you,

being watched by the government.

Of course, in terms of fiction, what's considered "possible to occur in real life" might differ from these examples.

Delusions can also be categorized in "themes", such as:

Persecutory: the theme surrounds believing that one is being harassed, attacked, stalked, or conspired against, often by powerful entities. Frequently reported as the most common type of delusion, especially in schizo-spec disorders.

Grandiose: surrounds believing that one has special powers, status, knowledge, skills, has relationships with famous, powerful, and otherwise important people, or is such a person themself.

Jealousy: surrounds believing that one's partner is unfaithful.

Erotomanic: surrounds believing that another person—often of higher status, such as a celebrity—is in love with them.

Somatic: surrounds believing that there is something wrong with one's physical body, such as being infested with parasites, having blood replaced with a different liquid, or missing internal organs.

Religious: surrounds believing that one is a god or another religious figure, like a prophet or a saint, and/or is receiving directions/commands from those. A person doesn't have to actually be religious to experience religious delusions, nor has to be of the same religion that the delusion is about.

Thought manipulation: surrounds believing that one's thoughts are being manipulated in some way. Common examples include believing that one's thoughts are being broadcast, or that foreign thoughts are being purposefully inserted into their brain.

Mixed: delusions that match multiple of the aforementioned types. E.g. a character who thinks the government wants to kidnap them for their magical powers (persecutory+grandiose); a character who thinks that they are married to a famous pop star and that she's cheating on them (erotomanic+jealousy), etc.

Unspecified: literally everything else.

There are also specific delusions which are often referred to as their own syndromes/disorders. They are generally considered very rare but they are frequently referenced in media. Some of them are:

Clinical lycanthropy: a delusion that one is turning into a werewolf. Often clinical lycanthropy is a catch all term now for clinical zooanthropy, which is the belief you are transforming into any sort of animal. It's very rare and can be part of a disorder such as schizophrenia or exist as a delusion on its own. Often people with it will start to behave alongside the disorder, such as eating raw meat or feeling somatic transformation, or hiding so as not to hurt others in their beastly state.

Delusional parasitosis/Ekbom's syndrome: a somatic delusion where you believe there are bugs/bacteria/parasites inside your body, generally under the skin. Commonly co-occurs with tactile/somatic hallucinations, adding realism to the delusion.

It very frequently results in self-harming behaviors in an attempt to "get them [parasites] out". That can be anything from skin scratching to auto-amputation or disembowelment. The less extreme ways can result in infections and painful skin conditions, sometimes solidifying the person in the delusion that their body is in fact infested. The more extreme ways can and probably will result in death for obvious reasons.

A common phenomenon associated with it is the "matchbox sign" where the person finds "evidence" of the "parasites" (usually dead skin, fabric, small pieces of food, etc.) and shows it to someone, often a doctor, as proof of the infestation (matchbox coming from it being the go-to container for the "specimen", but honestly it can be anything. Who even has matchboxes anymore). A person with this disorder can also obsess over parasites/other animals that can in fact infest humans, potentially forcing them to avoid certain activities as much as possible (not eating meat, not going into forests, obsessively washing themself, etc).

To my knowledge this is the most common syndromic delusion, though it could be related to the fact that people with delusional parasitosis are also the most likely to see a doctor about it (though the doctor of choice would practically always be a dermatologist, not a psychiatrist) and thus get counted in statistics.

[Disclaimer: the next three are entirely based on external sources since no mods have first-hand experience with them.]

Capgras syndrome: a delusional misidentification syndrome where the person believes that someone else has been replaced by a clone/double/impostor. Most commonly the person who was "replaced" is a close family member or a spouse. Rarely, a person can also think that multiple people or a group were "replaced". Very rarely, the person with the delusion might think that they themself have been "replaced".

The delusion might be persecutory in nature, where the person believes the "clone" is there to spy on them or hurt them. This can sometimes lead to attempts of "unmasking" or confronting the "impostor" in an attempt to get their loved one "back".

Fregoli syndrome: a delusional misidentification syndrome where the person believes that strangers or acquaintances are someone they know in disguise. While generally it centers around people, it can also happen with animals or objects. It usually has a persecutory aspect to it, where the person thinks the "disguised" person is trying to follow or harm them in some way.

Cotard syndrome: also sometimes known as "walking corpse syndrome". It's a wide-spectrum delusion where the person believes that they already are dead, are currently dying, are immortal (and thus unable to die), have died but were reborn in some way, or just don't exist. People who have it might also believe that their organs are gone, rotting, or dying. Some can also abandon their basic human needs (such as eating) since they think it's no longer necessary.

Cotard syndrome is very rare in real life, especially in young people.

This is not an exhaustive list, just some examples.

Delusions FAQ

[Plain text: Delusions FAQ]

Q: What do delusions feel like?

A: So, it primarily depends on "insight"—whether the person has no, low, or high insight into their own delusion. The vast majority of people who experience delusions will have very little to no insight during their psychotic episodes.

Delusions feel like every other thing that's real, except they aren't, well, real. During a psychotic episode, delusions are facts as much as everything else around you. You don't question them since they feel obvious.

In delusions, there's lack of proof—which can be filled in by hallucinations (person believes they have a lethal disease, and starts hallucinating symptoms), explained by the delusion itself (person believes that someone else is in love with them, and interprets regular behaviors as "signs"), or simply ignored (the average person also doesn't know how [random everyday technology] actually works, but knows that it's a real thing that exists—people don't tend to question things they simply consider to be true, even if they don't really understand them).

Q: How to describe delusions in a sensitive manner?

A: To quote myself from earlier: sensitivity and delusions is less about being sensitive about the delusions, and more about the person having them. Delusions can be of anything, about anything, they can sound stupid and seem absurd to outsiders. I'm not saying "write the most ridiculous delusion you can think of for fun", more so "yes, some people do have unusual beliefs due to having the Unusual Belief Disorder".

Delusions are frustrating for everyone involved almost by definition. They aren't true and they directly affect what you believe, so they make you believe nonsense. And you can't "just explain lol" to the person that what they're saying/thinking is untrue because, well, it's a delusion. By definition, the belief being verifiably false really doesn't matter.

What's important to remember is that the delusional person isn't doing it on purpose. It's not a case of someone Purposefully Spreading Misinformation or rejecting factual data to further their agenda, it's a mental illness. Portraying it as a choice or some moral failure is simply incorrect. You can't just "opt-out" and magically stop being delusional.

So, what to actually do?

Recognize that delusions generally aren't fun. Obviously, everyone's experience is different, but delusions tend to be distressing. Persecutory ones will almost always be very negative, while a religious or grandiose one could even feel positive for someone if they think they are an angel or have some amazing talent.

Try to show the character's feelings in a sympathetic way, not a mocking one. What they believe isn't true, but their feelings are as real as anyone else's.

It's also important to remember that a delusion is something you genuinely believe. Try to put yourself in that position: you simply know some things. What your name is, how your pet looks like, where you live, whatever. If someone tried to convince you that you are wrong about these things, you'd think they're crazy. Imagine your coworker talking to you like they know your home life better than you do. Depending on the exact circumstances, you would probably have some sort of reaction—whether that be anger, being baffled, or just kinda weirded out.

It's the same when someone is delusional, and the "things you simply know" just happen to not actually be true.

This kinda leads to considering the ways in which a delusional character interacts with others. Some delusions are ignorable—the other character can kinda just nod and change the topic and move on. Others are a bit more in your face (e.g. the character thinks they are some higher being, or they think the character they're directly talking to wants to hurt them). Again, just telling someone "that's not true lol" doesn't really do much, if anything it can make the delusion worse (again: imagine you confront someone who you think is poisoning you, and they just say "um but I'm not?? what are you talking about lol you sound crazyy"). Try to consider what the relationship between the characters is, and what their personalities are—are they considerate, are they impatient, do they understand how the delusions affect the other character? Does the other character realize/know that the psychotic character is in psychosis at all?

Q: How do I incorporate delusions into a character's voice realistically?

A: TLDR: It's can be hard to make dialogue that sounds realistic for a character who has the disconnect-with-reality disorder.

First, try to consider how your character experiences their delusions in general. Are they extremely disturbed and can't stop thinking about their delusion when they're having an episode, or is it more of a background noise?

If it's disturbing them, then it probably won't sound realistic. When the delusion is all-consuming, the person having it might talk about it in circles and relate everything to it. Depending on how the psychotic character actually behaves, other characters might feel like they're being pranked because it just seems like "too much". It might be "like in the movies". The character can be going in circles trying to figure out how to stop NASA from broadcasting their thoughts around the globe; this happens.

At the same time, sometimes the delusion is much more covert. Sometimes on purpose (e.g. character with persecutory delusions believes that they are being observed, and doesn't want the observer to realize that they are aware of the observing, so they actively choose not mention anything about it), sometimes as a by-product of the way the delusion affects them (e.g. character with an erotomanic delusion isn't distressed by it, and they just vaguely mention their 'partner' in a way that doesn't really even tip anyone off).

If it's the first, you might be dealing with a character who is simply nervous/hiding something (because, well, they are). They might avoid certain topics or visibly get more stressed if the conversation goes into uncomfortable territory.

If it's the second, it will probably be more subtle. Perhaps you-wouldn't-be-able-to-tell-it's-a-delusion subtle. It depends on the character's exact delusion. Some would just be considered non-events (they say they have a partner who's famous, or that they are accomplished in some way), relatively normal/common events (partner is cheating on them, they have some serious illness), and some would be clearly bizarre (they say that their parents have been replaced by robotic clones, or that they are some mythical creature). If it's the first or the second, there might be no "tell", or maybe there will be some logical errors that other characters can catch on to, maybe there will be some inconsistencies when the character asks about it further, or maybe there will be nonsensical changes that happen between different retellings of the story that let others know something is off.

If it's the third clearly-bizarre option, then the "delusion reveal" might feel like it's coming out of nowhere, or create a sudden tone shift. It will be explained further in the post more, but psychosis isn't always obvious. Sometimes you learn that someone is psychotic because they say one thing that makes absolutely no sense. Again: it might feel abrupt, unexpected, other characters might think that they are being pranked at first. Just don't make the narrative make fun or mock the delusional character.

As to what you shouldn't do: no matter how delusional someone is, people still have other traits. Delusions aren't a replacement for backstory, relationships, preferences, or personality. They can and do affect them (and vice-versa), but if all the character talks about is their delusions, it will come off as either boring and flat, or a parody.

Psychosis FAQ

[Plain text: Psychosis FAQ]

Q: Can psychosis go undetected by the people around the person experiencing it, or is it very obvious?

A: Depends (sorry). But yes, sometimes it can absolutely go undetected, especially in case of a person experiencing mundane non-bizarre delusions and/or hallucinations.

It can also depend on the actual cause of the psychosis—for example, schizophrenia often comes with disorganized speech (among other things) which is definitely noticeable.

On the other hand, delusional disorder is often referred to as a "high functioning" disorder where it can be very hard for others to notice anything is wrong. It's generally characterized by non-bizarre delusions, unremarkable behavior ("not odd"), relatively non-impaired functioning, and any hallucinations that come with it are relatively minor and most importantly, fit the theme of the (probable) delusion.

My own absolutely worst psychotic episode went undetected by everyone I was living with at the time (in a tiny apartment at that). For someone else, a stranger could notice that they are experiencing psychosis from the other side of the road. It's a very wide spectrum, and a person can be on different ends of it at different times of their life.

It's basically: could you tell that your coworker who is ranting about their wife cheating on them is having a psychotic episode? Because they could be, and you probably wouldn't even consider it as an option since it's a very mundane delusion. On the other hand, if the coworker told you that their wife has been replaced by an identical evil clone overnight, you will know there's something going on because that's not a thing that happens.

Q: What impacts what hallucinations and delusions come up? Are they random?

A: As far as I'm aware, there's no actual research on this. We know that certain types of hallucinations and delusions are more common in specific disorders (e.g. in schizophrenia, auditory hallucinations and persecutory delusions are more common than other types), but that's about it. We don't know why certain people hallucinate cats meowing, and other ones hear demonic screaming.

Anecdotally speaking, people tend to stick to their delusions rather than have a completely new kind every time they have a new psychotic episode. It could be literally the same delusion following them ("the government is watching me"), it could branch out over time ("the government is spying on me and stealing my thoughts"), or incorporate other delusions that still somewhat connect, either in theme (in this case persecutory) or in subject (in this case government-related). In my experience, it would be very unusual for a person to have a psychotic episode where their delusions center around one thing with a specific theme, go into remission, and then have their next episode center something completely different with a fully unrelated theme (excluding "major event happening between the two episodes" type stuff).

Having unrelated hallucinations is more frequent since multimodality is very common.

The content of delusions or hallucinations is essentially "anything". It can be related to trauma, but doesn't have to. It can be related to the person's daily life, but doesn't have to. It can make sense from the outside, but doesn't have to.

Q: What do antipsychotics do from a more first-person perspective? How do they affect the symptoms of psychosis?

A: Make you sleepy... no, the biggest thing my antipsychotics have done when dosed correctly and on the right mix is they have helped give me a tool to more easily establish what is real or true and not. Even "in remission", a person with psychosis may experience hallucinations or mild delusions. It's less the symptoms that stop and more that they stop being as disturbing and disruptive, in my (mod bert again!) experience. They do not affect speech or negative symptoms for me, however.

Other mod here! When on the wrong antipsychotic, my delusions and hallucinations got meaner. They were more persecutory and I also experienced "old" hallucinations that I had not seen in a while returning. However, on my best dosage, my antipsychotics made my hallucinations nicer and quieter. Not as in like literally less loud, but they became easier to ignore. Like above, I have never seen an improvement in my speech or cognitive symptoms from medication.

Q: What kind of things can trigger a psychotic episode?

A: Technically speaking, anything can. It depends a lot on the actual disorder causing the psychosis (no points for guessing what triggers an episode in someone who has Medication-Induced Psychotic Disorder), but the most common triggers would be:

high stress,

recent traumatic event,

substance use,

sleep deprivation,

and social isolation.

My symptoms can be triggered by talking about them or seeing content similar to my hallucinations and delusions. For example, hearing a bible story triggered a religious hallucination, etc.

Sometimes the trigger is also "nothing" as far as the person experiencing the episode knows.

Things to Avoid

[Plain text: Things to Avoid]

Violent psychotic characters, especially ones that kill others because of "the voices"/"the visions". Psychotic people are much more likely to be violent towards themselves than anyone else.

Magical psychotic characters where the psychiatric disorder is some sort of magic system mechanic. A mentally ill character can have powers or whatever, but don't make symptoms into something they aren't.

Delusions/hallucinations that predict the future or have some other kind of omniscient quality to them. Again, this is a real medical condition, not a writing prompt.

Rule of thumb: would you still make the character psychotic even if their symptoms served no purpose in terms of worldbuilding and/or establishing something supernatural? Because if the answer is no, you have to rethink some things.

Psychotic characters who always have to be one of the like, four possible character archetypes (evil cannibalistic serial killer/mad scientist/Victorian era child in a horror movie/side character whose delusions are played for a joke and/or to show how 'dumb' they are).

Things We Want to See

[Plain text: Things We Want to See]

Regular people who just happen to be psychotic because of a mental health condition.

Psychotic characters who also experience other symptoms of their condition. Schizophrenia, the most commonly portrayed psychotic disorder, has many more symptoms than just that.

Psychotic characters who aren't young. Elderly people are actually the most likely to develop psychosis, childhood onset is extremely rare in comparison.

Psychotic characters who aren't white, physically abled men. Your character can be of literally any background, anyone can develop psychosis. In media it's almost exclusively either white men with poorly "researched" schizophrenia to portray them as crazy and dangerous, or sometimes women with delusions (usually erotomanic/jealousy type for obvious reasons) to portray them as crazy and unbearable to be around.

Characters who experience other kinds of hallucinations than just auditory and visual ones.

Characters who experience cognitive and speech symptoms.

Characters with other disabilities.

Characters who need a lot of support as a direct result from their psychosis. This should be portrayed as a neutral thing.

Psychotic characters who still have a social life! And hobbies!

Characters with MDD [major depressive disorder] that experience hallucinations/psychosis as a result. This was something I experienced during one of my worse periods and I have quite literally never seen anyone talk about MDD with psychosis outside of a medical context.

Happy writing!

I meant it when I said this is a really, really a common trope, so much so that the majority of the media I've seen with amputees and characters with limb differences that released in the last decade or end up using it. Even stories where becoming an amputee is treated like a fate worse than death, ironically, aren't excluded from this. I have a few theories as to why this has happened: The pessimistic answer is that it's easy. You get to have a disabled character and claim you have disability representation, without really having to do much extra work or research because most of your audience won't notice if you aren't accurate - in fact they kind of expect it. You also, for the most part, dodge the backlash other kinds of disability representation (or really any minority representation) usually get. The more optimistic reason is that, for a long time, amputees and people with limb differences (as well as a lot of other disabled people) were predominantly shown in media as sad, depressed and unable to do anything, very much falling into the "sad disabled person" trope. As a kid, this was really the only way I saw people like me on screen or in books. And so, the limb difference community pushed back against that portrayal and were pretty successful in changing the narrative in the public's eye. A little too successful. A lot of creatives were genuinely trying to do right by our community, listen and do better, but many simply overcorrected and instead ended up creating stories where prosthetics were essentially cures instead of the mobility aids they are. I also think the public's general lack of understanding about disability plays a roll in all this. There are a lot of people who, in my experience, believe that the more visible a disability is, the worse it is. Limb differences and amputations are very visible, but prosthetics, even those that aren't trying to be discreet, make them less so. While using a prosthetic is very, very different to a biological limb, you won't necessarily see how in a casual interaction with, say a co-worker or neighbor, especially because there is a very real stigma applied to people with limb differences to keep those things hidden from the public. There are other reasons too, such as the fact that a lot of creatives don't even consider the connection to real amputees when creating characters with robotic limbs in genres like sci-fi and some fantasy, so they never stop to consider that these tropes could be impacting real people. Amputees are also very frequently used in "inspiration porn" content that uses the angle that disabilities can be "overcome" with a good attitude, downplaying the way those disabilities actually impact us. The prosthetics industry - specifically the component manufacturers, often also push the idea of prosthetics being the only way to return to a "normal" life, both to the wider public and to people with limb differences and amputations (which can add to that sense of shame I mentioned when it doesn't play out that way for them). On top of that, I also think the recent increase in popularity of concepts like trans-humanism contributes to it as well. these movements often talk about robotic or bionic body parts being enhancements and "the way of the future", and I think people get a bit too caught up on what may be potentially possible in the future with the real, current experiences of people with "robotic limbs" aka prosthetics, now. There are also inherently disabling things that come with removing and replacing parts of your body, things that will not just go away with some fancier tech.

So How do you actually avoid the trope?

So, we have some ideas about why it happens, but how do you actually avoid the "perfect prosthetic" trope from appearing in your work? The most important thing is to remember that this is still a disability. The loss of a limb, even with the best prosthetic technology or magical item in the world, will always have some inherently disabling aspects to it - and this is not a bad thing. The key is to not over-do it, lest you risk falling into the old "sad disabled person" trope. So let's go over some of the ways you can show how your character's disability impacts them. You don't have to use all of these recommendations, just choose the ones that would best fit your character, their circumstances and your setting.

The prosthetic itself is just different

Probably the most important thing to address and acknowledge for prosthetic-using characters, is the actual ways in which the prosthetic itself is different from a biological limb, and the drawbacks and changes that come with that. For the sake of simplicity, I'm mainly going to focus on modern prosthetics here, but it's worth considering how to apply this your own, more advanced/fantastical prosthetics too. One major thing that most people writing amputees fail to acknowledge is that prosthetic limbs are not fleshy-limbs with a different coat of paint. They do the same basic thing their meat-counterparts do, but how they do it is often drastically different, which changes how they are used. A really good example of this is in prosthetic feet. There are dozens of joints in a biological foot, but most prosthetic feet have no joints or moving parts at all. Instead of having dozens of artificial joints to mimic the real bone structure of a foot, which are more prone to failure, require power and make the prosthetic much, much heavier for very little gain, prosthetic feet are often constructed from flexible carbon fiber sheets inside a flexible rubber foot-shaped shell. This allows the bend and flex those bones provide, without all the drawbacks that come from trying to directly mimic it. Making the sheets into different shapes makes them more ideal for different activities. E.g. feet made for general use, like walking around the city, are simple and light, shaped to encourage the most energy-efficient steps, while still allowing their users to do things like wear normal shoes. Feet made for rough terrain often have a split down the middle of the foot to allow the carbon fiber sheets to bend better over rocks when there is no ankle, and some newer designs also include a kind of suspension using pressurized air pulled from the prosthetic socket to allow some additional padding. Running feet have large "blades" made of these carbon fiber sheets to absorb more pressure when the foot hits the ground, and redirect the force that creates to propel their user forward as quickly as possible.

[ID: A photo of 4 prosthetic feet. On the left, the foot is covered with a black shoe, the one to it's right consists of a small, carbon fiber blade, split down the middle, in roughly the same shape and size as the previous foot. Next to the right is an even simpler and smaller carbon fiber foot with no split, and finally is a very short foot that is vaguely rectangular in shape. /End ID]

These are some of my own prosthetic feet I've had over the years. The two on the right are designed to be used by someone who is less mobile, and the ones on the left are made for someone who is more active. As my needs changed over the years, I've used different designs and styles, and keep the old ones since my needs do tend to fluctuate.

There are also robotic feet available that are designed as a kind of "all-purpose" foot that use an electronic ankle which more closely mimics a biological foot, but they are not very popular as the mechanism adds a lot of extra weight and it requires a battery and power to work, with many amputees feeling the jointless carbon fiber feet do a better job at meeting their needs. The same goes for arms and hands. "Robotic" hands that mimic a meat hand exist, but they aren't really that popular, even in places like Australia where the prohibitively expensive price tag isn't as much of an issue due to government programs that pay for the device for you. Instead, most arm amputees who use prosthetics that I know prefer simpler devices that do specific tasks, and just swap between them as needed, rather than something that tries to do it all. A big part of this is because the all-purpose hands can be clunky. they often require manual adjustment using the other hand to do simple things like going from holding a deck of cards to putting them down and picking up a glass of water, for example. The few that don't require that, I've been told, are often temperamental and don't actually work for every person with a limb difference.

Altered Proprioception

Loosing a limb is a big deal and this is always going to have an impact on the body in some way that won't be solved with a fancy piece of tech. One such example is how limb loss effects your sense of proprioception. This is your sense of where your body parts are in space. It's how you (mostly) know where your foot is going to land when you're walking, or how you're able to do things like lift up a glass of water without needing to actually watch your hand do it. Your brain does this by creating a mental map of your body, but this map doesn't get adjusted if you loose a limb. If that map doesn't accurately reflect your real body, you're not going to have an accurate sense of proprioception. This might look like a leg amputee being a bit less stable on their feet, or like an arm amputee needing to look at their arm or hand to be able to grab something with it. Those born without their limbs who take to using prosthetics often have a lot of trouble adapting, as their brains aren't used to having that limb in the first place, whereas an amputee's brain can sometimes be tricked into using their outdated body map to help them adjust to the prosthetic (though its impossible to line it up perfectly). Prosthetics that directly integrate with the nervous system, while rare, do exist, and even this direct connection doesn't completely erase this issue for reasons doctors aren't quite sure about. This is something that does become less of a problem with time. Eventually, someone proficient with their prosthetic will learn to compensate, but their sense of proprioception will never be 100% perfect. At the end of the day, no matter how it attaches, a prosthetic is still not a natural part of the body, and that will always cause some issues. It also means if they aren't practicing it all the time, they may have to relearn how to compensate for it.

Extra weight

You also have to remember that a prosthetic is not a natural part of the body, like we already talked about, and so no matter how good it is, your brain will most likely always interpret the weight of the prosthetic as something attached to you, not part of you. This means that, even though prosthetics are actually a lot lighter than biological limbs, they feel so much heavier. This is because, while a meat limb is heavier, a lot of that weight is from muscles which are actively contributing to the limb working, so it doesn't really feel like its that heavy. When you have less of your meat-limb though, you have even less muscle to work with to move this big thing strapped to it, so it feels heavier. The more of the limb you've lost, or just didn't have, the heavier the prosthetic has to be, and the less muscle you have left to move it. It's for this reason that a lot of amputees and people with limb differences get tired faster when using prosthetics. Some of us are fit enough where you almost wouldn't notice the extra effort they need to put in, but once again, just because you can't see it from the outside, doesn't mean it's not an issue.

Avoiding Water

Most prosthetics also aren't waterproof, and so prosthetic users have to be very careful about when and how they come into contact with it. For amputees with electric components, contact with water at all will likely damage the device. This can even include especially heavy rain, something I was told to avoid when I got my electronic knee prosthetic and something I assume would also apply to arm amputees with complex, electronic hands. For those with non-electronic prosthetics, water can be hazardous for different reasons. If the prosthetic has metal components, water may cause them to rust, especially if it's salty water. Other prosthetics have foam covers to give the illusion of a limb with the general shape of muscles and fat, but these covers do not come off, and if they get wet enough that water seeps all the way through, it is very hard to dry it and they may become moldy. Finally, cheaper modern prosthetics may also float. Many are made of very light-weight materials and some have pockets of air trapped inside them. For leg prosthetics in particular, this means a user might, at best, struggle to swim with them on, but at worst, may get flipped upside down and become trapped underwater - something that happened to me as a very young child. On the flip-side, older prosthetics were usually made of heavy materials like wood or steel, and so had the opposite problem, acting like a weight and pulling a person down if they were to wear them in the water. Water-safe prosthetics do exist, I had a pair of prosthetic legs as a teenager that were hollow, and designed especially for me to swim with fins on when swimming in the ocean, and Nadya Vessey, a double leg amputee in New Zealand even got a mermaid-tail prosthetic made especially for use in the water. Most amputees though just swim without any prosthetics at all, and in 99% of cases, this is the easiest and safest way to go.

Prosthetic-Related Pressure Sores and Pain

Many people with limb differences also experience pressure sores from their prosthetics. Modern prosthetics typically attach to the body using a socket made of carbon fiber or fiberglass, held on either by pressure, using a vacuum seal or through a mechanical locking system built into the socket. No matter the specifics though, the socket has to be very tight in order to stay on, and this means that extended periods of use can lead to rub-spots, blisters and pressure sores. Many socket prosthetics also use silicone liners to add extra padding, but this means wounds caused by the pressure can't breathe, and bacteria in sweat has nowhere to go, meaning if the person doesn't rest when one of these wounds occur, it can very easily and quickly turn into a serious infection. In a properly fitting prosthetic, used by someone who has fully adjusted to them, this doesn't happen often, but it is something most amputees and people with limb differences have to at least be mindful of. Some new prosthetics use a different method of attachment, called Osteointegration - where the prosthetic attaches to a clip, surgically implanted into the person's bones. While Osteointegration avoids many of the issues like pressure sores that come from a socket, they have their own issues: mainly that they are incredibly expensive, and as of right now, have a pretty high failure rate due to the implant getting infected. Because the implants are directly connected to the bone, these infections become very serious very quickly. Many people with Osteointegration limbs have to be on very strong medication to keep these infections at bay, and they are generally considered unsuitable for anyone who is going to regularly come into contact with "unclean" environments.

Maintenance

[ID: A screenshot of Winrey, from Full Metal alchemist Brotherhood, a white woman with blond hair hanging out the sides of a green hat. She is measuring a piece of metal from a prosthetic she is making while Ed, the prosthetic's owner, gives her a thumbs up in the background. /End ID]

Finally, prosthetics also require maintenance from a specialist called a prosthetist, and they don't last forever. Some parts, like a foot or hand, can be reused over an over, but the sockets of a prosthetic need to be completely remade any time your body changes shape, including if you gain/loose weight, you start experiencing swelling, or you're just a child who is growing. Children in particular need new prosthetics every few months because they grow so fast, and as such, their prosthetics have to be made with this growth in mind. If they go too long without adjustment or an entirely new prosthetic, it can seriously impact the child and their growth but even small adjustments can be costly, depending on where you live. While prosthetics are built to be sturdy and reliable, they need a lot of work to stay that way. The more complex the prosthetic, the more work is needed. Complicated electronic components may need to have regular maintenance done by your prosthetist or even the specific component's manufacturer, and depending on where you live, this might mean having to send your prosthetic limb away for this to be done. While my prosthetist technically has the skills and knowledge to do the maintenance on my electronic knee, for example, the manufacturer forbids anyone not from their company to provide this service, meaning my leg needs to be shipped off to Germany once every few years if I want to keep the warranty. This has the unfortunate side effect of sometimes your limbs getting lost in postage (shout-out to Australia Post, who lost mine twice), meaning it can be months before you get it back or get a replacement. Usually, you'll be given a replacement in the meantime if you need it, but walking on a leg that isn't yours, even when its correctly fitted, always feels a bit weird (maybe that's just me though).

Not every difference is Inherently Negative

We've talked about some of the negatives that come from having a prosthetic, but not every difference is negative or even really that big of a deal. In fact, often times, it's these little moments in the depiction of a disability that go the furthest and make it feel the most genuine. My amputations effect me from the moment I wake up, to the moment I go to bed, but that doesn't mean every single way it impacts me is always inherently bad or negative. For example, back when I was working a normal job and going to university, I would often come home, throw my legs off at the door with the shoes still attached and get into my wheelchair, the same way you might throw your shoes off after work and replace them with comfy socks and other comfy clothing. This is something I've only ever seen on screen once, with Eda from the Owl House (and she wasn't even an amputee yet, her limbs were just detachable)

[ID: an screenshot of Eda from the owl house, a very pale woman, laying on the couch in a bathrobe, her hair in a towel. She has taken her actual legs off, throwing them to the other side of the seat. /End ID]

After that, my day mostly looked the same as most other people working a 9 to 5, I'd make myself dinner, watch some TV or play some games, maybe do some extra work at my desk or chat with friends. The only difference is that it would all be from a wheelchair, mainly because my prosthetics were heavy and it was just easier to use the chair around the house. The fact my afternoon and evening routine was done from a wheelchair wasn't a bad thing, it was just different. Likewise, I also don't sleep or shower with my prosthetics on, for the same reasons most other people wouldn't take a shower or sleep in thigh-high, steel-capped boots. In your own stories, this might look like giving your characters similar alterations to how they go about their day. Let them take their arm or leg off when they're resting or relaxing, show them taking a few minutes longer to get ready because they have to put it back on, show them doing some things without it. Arm amputees in particular tend to get very good at going about their days without their arm prosthetics, and leg amputees often either learn to get around more relaxed spaces like their homes using a different mobility aids like wheelchairs or crutches, or just through hopping if that's something they're physically able to do. Even when everything is going well and working as intended, your limb-different character won't wear their prosthetic 24/7, no matter how much they love it. There doesn't have to be something wrong with it or painful about it to not want it glued to them at all times, just like you can love a pair of big heavy boots but not want them on when you're trying to sleep. For more action-focused stories, being an amputee, also changes things like how you fight. The specifics will vary from person to person, but for example, when I did Hap Ki Do, a Korean Martial art, my instructor heavily modified when I learned what techniques. Beginner-level kicks and most leg attacks were impractical for me, as the force from the kicking motion would usually cause one of my legs to fly off. I also couldn't jump very well, due to some complications with my original amputation that made my stumps too sensitive to withstand the force of landing again. So I ended up learning a lot more upper-body attacks much earlier than it is typically taught. By the time I got my green belt, I was practicing upper-body techniques usually saved for black belts - including weapons training that I could use my secondary mobility aids for, like crutches and my cane in a bad situation. Many holds that rely on creating tension in your target are also less effective on amputees, because either the anatomy that causes those holds to be painful just simply isn't there, or the body part in question can just be removed to escape. Whether we're talking about the negative things, or just neutral differences that come with using prosthetics, you don't want to go too far with any one example. The key is to strike a balance. Of course, the old writing advice of "show don't tell" also applies here. It's one thing to tell us all of this stuff, but unless we actually see it play out, it won't mean much.

How NOT to avoid the trope

Before we move on, let's focus for a moment on some common things I've seen that you SHOULDN'T do as a way to get away from the trope.

The Enhanced Prosthetic

A lot of sci-fi in particular will take prosthetic limbs, make them function exactly the same as a biological limb, but add something extra to it. This does change the way the prosthetic functions and is used, but it usually still ignores the actual disabling parts of having a prosthetic. A really good example of this can be seen in pretty much any futuristic setting, but personally, I think Fizzeroli, from Helluva Boss is the best one to demonstrate what I mean. Fizz is a quadrilateral, above knee/above elbow amputee with highly advanced prosthetics that function, more or less exactly like the limbs he lost, but with the added benefit of being super-stretchy. Fizz is an acrobat and a clown in service, at least initially, to Mammon, one of the Seven Deadly Sins. These prosthetics help him perform and we even do see how they change little things like how he walks and just goes about his day, but the show still treats them like natural arms and legs, but better. 

[ID: A screenshot of Fizzeroli from Helluva Boss, a white-skinned imp with 4 black, prosthetic limbs, dressed in teal a nightgown as he lays in bed, reading from a list /End ID]

We see that he never takes them off, even when sleeping, and when he needs to use them as regular arms and legs, they do everything he needs, perfectly fine - at least when they're working correctly. The only time he ever even takes them off or has any issues with them, is when they break in season 2. The word amputee is never used to describe him, as far as I remember, and the fact he is one never really comes up at all, except for when they break or when the story focuses on how he lost them. Which brings me to my next point.

The Glitchy/Broken Prosthetic

One way I see people try to avoid the perfect prosthetic trope, is to take the prosthetic and break it or otherwise make it unreliable by having it malfunction, but not really changing anything else. This approach is heading in the right direction but still kind of misses the point of the criticism a lot of limb different folks have with the depictions of prosthetics in the media. Yeah, prosthetics do break down and some do require extra maintenance, but if your character's prosthetic is still exactly the same as a biological limb (or even better, in the case of the "enhanced prosthetic") when it's not broken, and the only time their disability is treated like a disability, is when it breaks, you're not really addressing the issue. Real prosthetics, like we discussed, even when functioning at 100%, exactly as the manufacturer intended, don't function the same as a meat-limb. They are fundamentally different, and the glitchy/unreliable prosthetic completely ignores all of that. Once again, Fizz is a really good example of this - the only time his prosthetics are not perfect, is when they break or are malfunctioning (despite the criticism, I do genuinely love Fizz as a character, but he unfortunately does fall into a lot of disability tropes).

[ID: Another screenshot of Fizzeroli, this time in a torn up jester outfit, looking down, panicked, at his prosthetic arms which are fully extended and laying motionless on the ground, with his left arm visibly short-circuiting with electricity around it. /End ID]

Now this isn't to say you can't have your character's prosthetics break down or malfunction at all. just that this shouldn't be the only way you differentiate the prosthetic from a biological limb. You should also be mindful of how or why they're breaking. A typical prosthetic isn't going to break down randomly from normal use unless something is very, very wrong or your character just has a terrible prosthetist (which unfortunately, does happen). You might experience issues if you try to make the prosthetic do something it just wasn't designed to do, or expose it to something it wasn't designed to deal with though (e.g. submerging an electronic prosthetic in water and trying to use it to swim).

Just add Phantom Pain

Another common pitfall I see when people are trying to avoid the perfect prosthetic trope, is to just give the character in question phantom pain - which is a side-effect of amputation where your brain's mental map of the body doesn't acknowledged you lost a limb. Your brain tries to fill in the gaps, since there is no signals coming from that part of the body anymore, and assumes either something must be wrong and so you should be in pain, even when you actually aren't. Alternatively, it can also happen when your brain was so used to feeling pain from that area before, in the case of people who had chronic conditions before they lost their limb, that it just keeps remaking those old signals itself. Like the broken/glitchy prosthetic approach, this also doesn't really address the issue with the perfect prosthetic trope, because it has nothing to do with the prosthetic itself. Phantom pain doesn't come from the prosthetic, nor does it effect how they're used, and so including it doesn't really address the issue of the prosthetic being functionally the same as the original, biological limb. This isn't to say that you shouldn't include phantom limb sensation or pain as something your character experiences, but just keep in mind that, when used on it's own, it doesn't counter the trope. Also, just be sure to do your research, everyone's experience with phantom pain is different and it's not something everyone with a limb difference even experiences.

Why is this trope even a problem?

Alright, so we know what the trope is, we know why it became so prevalent, ways to avoid it and also how not to avoid it. All good information, but why is this trope even bad? Why should you try to avoid it? Outside of just wanting to portray a real disability that effects real people more accurately in your creations, the prevalence of this trope actually contributes to a lot of real-world issues, especially when it's as overused as it currently is. I've talked before about "the jaws effect" - where the depiction of something in the media, especially something that the public is widely uneducated on, influences how people see it in real life. The Jaws effect specifically referred to how the popularity of creature-feature movies featuring sharks, like Jaws, caused the belief that sharks were monstrous killing machines to become much more wide-spread, even going so far as to influence decisions about laws and policy surrounding real-life shark preservation and culling in some parts of the world. But sharks aren't the only thing this has happened to.

Disabled people are so thoroughly misunderstood by wider society, that when tropes like this one become popular, people can and often do start to believe the misinformation they spread - in this case, believing that our prosthetics are a perfect replacement for a biological limb, and that getting a prosthetic means you're not disabled any more. While this can be annoying and cause small scale issues for some of us, like people giving us a hard time for using disability accommodations we very much need, it can also impact us in systemic ways too. If the wrong people believe these tropes, it can and does have a very real impact on the lives of disabled people through things like changes to policies to make it harder for amputees and people with limb differences to access financial assistance for other things outside of our prosthetics we may need assistance with.

Conclusion

Dissociative Identity Disorder (DID)

– “Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession (...)” and “marked discontinuity in sense of self and sense of agency, accompanied by related alterations in affect, behavior, consciousness, memory, perception, cognition, and/or sensory-motor functioning.”

"Two or more": keep that in mind! There is a minimum number of two alters a system can have (host included, the host is also an alter), but no maximum. This is due to how individual each DID experience can be! Someone can have exactly two alters in their system, while others can have 100+. (These experiences are known as polyfragmented DID. This type of DID is developed under very specific circumstances, highly complex, and highly under-researched, to the point where I'm only not going over it longer because I feel as if it warrants its own post.)

The average reported system count is around 8-13. If you need a baseline, go off of that!

Marked discontinuity in "sense of self and agency" can be a lot of different things; affect and motor functioning refers to tone, cadence, the way you speak and move and hold yourself, cognition/perception/memory refers to amnesiac barriers, outlook, morals, likes and dislikes -- everything down to the way you think can and will differ.

People with DID often feel indecisive, or inconsistent, and don't understand quite why until it's revealed (if ever). You can have one opinion one day and the complete opposite the next because of conflicting interests in alters. You may have to explain why your feelings and views contradict so frequently without consciously remembering that conflict happening.

It's also noted that changes in behavior may be noticed by others, but not always. And if they do, it rarely is thought to be DID -- my sibling, for example, while I was still in high school, would notice blatant switches and assume I was just having a "weird day" or I was "stressed". They noticed the consistency in behavioral changes, but thought nothing of it because I'd always been like that. EXTREMELY subtle symptom presentation is the norm.

– “Recurrent gaps in the recall of everyday events, important personal information, and/or traumatic events that are inconsistent with ordinary forgetting.”

Day-to-day life, important events, personal details, years and years of childhood and later, will just be gone. It's not there. Inaccessible. You might not even notice it's missing, either.

Due to the nature of dissociative disorders being dissociative, these gaps are very good at camouflaging themselves. You aren't paying attention to these things like your peers are, so you don't pick up on warning signs right away. And it takes even longer to notice patterns.

This can also look like having the same realization about the same thing multiple times. And it feeling new, and world changing, Every Time. It can feel like you're going in circles indefinitely with everything you do.

– “The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.”

It's A Disability If It Disables You Basically. Again, some level of dissociation is normal to experience, it is the severity that is the problem. Like how daydreaming itself is fine, but could become maladaptive and disrupting in daily life.

– “The disturbance is not a normal part of a broadly accepted cultural or religious practice. Note: In children, the symptoms are not better explained by imaginary playmates or other fantasy play.”

This is why tulpamancy is not and should not be lumped in with dissociative disorders. It is a religion-specific practice, and something only a Tibetan Buddhist can speak on, which I am not, so I can't. What I will say: the implications you might see from people that tulpamancy is in any way comparable to a trauma-centric dissociative disorder are both ableist (implying OSDDID is a "practice" or something somebody can decide to "do") and extremely culturally insensitive (there is nothing disordered about Buddhist practices).

On topic again:

(Additionally: the idea of "tulpas" the way most Westerners practice it when divorced from the religion is a skewed interpretation of something only lightly "inspired" by Tibetan Buddhism. It is a very similar situation to how white people will talk about the "seven chakras" when that is nothing at all close to what chakras are. Not only is it appropriation, people are also defining it incorrectly! I plan on compiling my own post about misinformation related to these things once I have enough applied knowledge to be able to do that.)

(Update (September 1, 2025): Tibetan Buddhism in itself is NOT a closed religion! It is open for people to practice! I wasn't aware of this and have corrected it! That said, practices are still related to that sect of Buddhism, and the appropriation I was referring to was when people say they're practicing tulpamancy separate from Buddhism and divorced from the context, which is literally when appropriation happens. And which I see people doing all the time, specifically IN system spaces, trying to equate things that cannot be equated. THIS is what I was referencing, people that are not Buddhist and say they are not Buddhist trying to redefine what Buddhism is.)

(The religion is open but that does not mean its practices shouldn't be handled with respect. That is what I meant by "taking inspiration," when people that otherwise have no interest in the faith are only ever involved for one thing they think Looks Cool. That Sucks. And, STILL, a cultural practice of religious significance is still not the same as a complex trauma response.)

If the experiences line up with cultural or religious practice and are not disabling to the person, it is not OSDDID because it did not form the same way. If a child is engaging in escapism via fantasy play and said play is controllable by the child, it is not OSDDID because the motions are voluntary.

These experiences are all still real! And deserve respect! But they cannot be categorized the same -- like how generalized epilepsy and psychogenic non-epileptic seizures present similarly in some ways but aren't the same thing, or how a fainting spell might look like a seizure but isn't a seizure. It'd do a disservice to both to lump them in with one another, if that makes sense!

– “The symptoms are not attributable to the physiological effects of a substance (e.g., blackouts or chaotic behavior during alcohol intoxication) or other medical condition (e.g., complex partial seizures) (American Psychiatric Association, 2022).”

Speaks for itself but I'm Including It Anyway.

— All criteria backed by the DSM-5. All quoted text brought from the linked organization (DID Research) and goes into further detail than I have, if that's something you're interested in. (And you should be! Don't take my word alone for it, look deeper!)

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All other types (OSDD, P-DID) are disorders that mostly fall under this criteria, but diverge in some significant way. This does NOT make anyone with these disorders "less real", it only means they have a different experience with structural dissociation -- and structural dissociation is highly individual, dependent on the person and their situation (so you'll be hard pressed to find two systems that experience their disorder the exact same way).

This is just something that happens. Very confusing disorder to have!

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Partial Dissociative Identity Disorder (P-DID)

– All criteria for DID diagnosis is met, EXCEPT:

– “(...) the person still experiences a disruption of their identity, like in DID, but there is a ‘dominant’ personality which is usually at the front. Intrusions from other parts are infrequent and irregular, perhaps only happening during a particularly distressing or emotional experience.” — “What are the Dissociative Disorders?”, International Society for the Study of Trauma and Dissociation

By "intrusions", people mean switching, or executive control. Different terms that mean the same thing.

In OSDDID cases outside of P-DID, alters will have the ability to take executive control of the body -- this is something that, most of the time, is not present in P-DID. I've seen it described by a P-DID system through the roommates allegory: that collective is there in the building, and they all share the space, but only one of them answers the door.

This is usually the case, but a P-DID system can break out of that -- switching, etc. can still happen in some P-DID systems, particularly when under severe distress.

P-DID, as said by the International Society for the Study of Trauma and Dissociation, is most commonly recognized and diagnosed outside of North America. P-DID is also the least discussed from what I've seen, which may or may not be correlated in some way. (Again, how these things are labeled and understood will vary from place to place and group to group! It's important to get multiple perspectives on a given subject for that reason.)

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“Other specified dissociative disorder (OSDD) is a dissociative disorder that serves as a catch-all category for symptom clusters that do not fit neatly within another dissociative disorder diagnosis.” — “DID Versus OSDD-1”, DID Research

Otherwise Specified Dissociative Disorder, Type 1A (OSDD-1A)

– All criteria for DID diagnosis is met, EXCEPT:

– Alters are not distinct enough for the circumstances to be treated the same as DID. For this reason, this particular type of system will especially go under the radar, often misdiagnosed as PTSD or BPD, or not read as a disorder at all.

Otherwise Specified Dissociative Disorder, Type 1B (OSDD-1B)

– All criteria for DID diagnosis is met, EXCEPT:

– Inter-identity amnesia is not present. Emotional amnesia is more common than complete blackouts; I hear the term "greyout" used quite often in reference to this kind of amnesia.

NOTABLY: I distinguish between the two here because they used to be more heavily utilized in the diagnostic process, but aren't anymore. It is NOW mostly refered to as OSDD-1 and that is IT, but I wanted to include this information anyway because of how often it circulates. The labels may be outdated in some places, but they will come up in research so it's handy to at least know what they mean.

AND ANOTHER THING TO ADD: because of this some systems with OSDD have been diagnosed under the old criteria and may self-identity as having 1A or 1B instead of OSDD-1 on its own. It is their right to self-label how they feel fits their circumstances. Please do not go around telling people not to call their disorder the name they've been using for forever. It's not like the case of autism versus "Asperger's" it is NOTHING like that the context is SO different PLEASE!!

Back on topic, and As Said Above. Both of these OSDD types above fall under type 1. Types 2, 3, and 4 are also considered OSDD, but are not system disorders.

Presentation of a dissociative disorder, overt and covert, is also nearly never this cut-and-dry. [For all intents and purposes you CAN be very straightforward as you build your character at first, but the disorder is complex and messy, so if somebody doesn't seem to fit cleanly into one type as you write at first, that's alright!]

What About UDD?

Unspecified dissociative disorder (UDD), from my understanding, is used in the way that DDNOS (dissociative disorder not otherwise specified) used to be. A medical note of UDD is there to clarify that a given patient has a dissociative disorder, but it is not yet clear which category they fall into.

UDD encompasses any disordered experiences outside of specific known conditions, and many (but not all) people with a UDD diagnosis are given more specific names for their condition later -- someone could have P-DID and have UDD in their medical record because they haven't got the chance to be fully evaluated yet, for example!

“This diagnosis, along with Other Specified Dissociative Disorder, act as a "residual category for dissociative symptoms which do not fit within a more specific category" and either the clinician decides not to specify the reason that the criteria for other Dissociative Disorders aren't met, or not information information exists to make a more specific diagnosis.”

“If a reason can be specified, e.g., dissociative trance, then Other Specified Dissociative Disorder should be diagnosed instead.” — “Unspecified Dissociative Disorders”, Trauma Dissociation

The ICD approaches unspecified dissociative disorder the same way the DSM does: “it cannot be diagnosed when a more specific diagnosis is appropriate.”

If your character is going to have experiences that would fall into the unspecified category, then go right ahead! Because people do have experiences that may fall outside of a typical presentation for a dissociative disorder, but still have a dissociative disorder. UDD just encompasses all of those cases, so be very specific with what kind of experiences you're going to be writing so it isn't unrealistic or disrespectful. Make sure you don't write something contradictory without intent!

Writing Complex Dissociation: Narrow Down What Type, Then Do Specific Research

Overall: I ask that you be very mindful of exactly what condition you're writing and why. (And where -- remember, regional differences can impact labels, perception, treatment, everything!) But if your character's story is a more complicated one, that's perfectly fine, I'd even say it's more realistic! The nature of complex dissociation is that it isn't clean and clear-cut and easy to define!

Nothing is as blatant or linear as how it looks on paper. I recommend before starting any specific writing, of course, to pinpoint which type of structural dissociation you're going to be modeling off of and what you want to achieve by doing that; we can get into all the gritty details once that foundation is established!

And again, this is a GENERAL post! I did not go NEARLY as in-depth as I could have and encourage everyone to do their own research (with discretion)!

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References:

– DID Research.

– International Society for the Study of Trauma and Dissociation.

– Trauma Dissociation.

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