Maggie Stiefvater’s Shiver Does Sam have PTSD

First, let me just say that I love Maggie Stiefvater's Wolves of Mercy Falls books. I've read both Shiver and Linger. As soon as the third book, Forever, comes out next year, it's mine, baby. Her writing is just so darn lyrical, and all the characters are well-drawn and real. Well, as real as werewolves can be.

I'm not going to review the books, though. Lots of people have done that, and Ms. Stiefvater's work has received well-deserved praise. All I'll say is: if you haven't read them, I highly recommend you do so.

Sam, the reluctant werewolf and hero of the stories, is melancholy, touching, adorable, and utterly crush-worthy. He also has a major trauma history, and as a result, a pretty startling and persistent fear of ... bathtubs. He can't look at them. When he's forced to, he has a major reaction that includes reliving what happened to him.

Traumatic event. Flashbacks. Could our beloved Sam have Posttraumatic Stress Disorder (PTSD)?

You didn't think I was going to give you a simple yes or no, did you? I'm just not capable (and that would be kind of anticlimactic and an insult to your intelligence).

So, let's analyze:

When I diagnose, and I do this on a daily basis, I consult my trusty DSM-IV-TR. I don't just diagnose from the hip when someone has a few symptoms associated with a particular disorder (you know, like "Oh, this kid doesn't make great eye contact and lines things up! He MUST be autistic!"). Nope, that's not how it's done. Diagnosing someone is serious business and should be treated as such.

Now of course, in this case, we're talking about diagnosing a fictional character and only have the information the author has given us. Keeping that limitation in mind, here are the DSM-IV-TR criteria for Posttraumatic Stress Disorder (I'll be paraphrasing some of these--the actual, word-for-word criteria are here):

Category A. There has to be a trauma--and both of the following have to be present:

1. The person sees or experiences an event that involves actual death or a threat of death or serious injury
2. The person's response is intense and includes fear, horror, or helplessness

Did Sam experience a trauma that met those criteria? Yep. Absolutely. No question about it.

But wait, there's more! To be diagnosed with PTSD, you also have to have:

Category B. Re-experiencing of the event in at least one of the following ways:

1. Recurrent and intrusive upsetting recollections of the trauma
2. Recurrent upsetting dreams
3. Acting/feeling like the event is recurring (this might be a flashback)
4. Intense distress when exposed to cues that symbolize or resemble an aspect of the traumatic event
5. A physical reaction when exposed to those cues

Does Sam re-experience the event in at least one of those ways? Yes, totally. In fact, he exhibits B3, B4, and B5. However, he does not appear to exhibit B1: his recollections only seem to occur in the presence of the cue (bathtub), and there's one other instance in Shiver where he experiences a recollection in response to something else that reminds him of the trauma. No upsetting dreams are mentioned (I believe), but that doesn't necessarily mean he doesn't or hasn't had them. Either way, though, he meets this part of the diagnostic criteria.

But then there's:

Category C. Avoidance of things related to the trauma AND numbing of general responsiveness--you have to have at least 3 of the following:

1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma
2. Efforts to avoid people, places, or activities that lead to memories of the trauma
3. Inability to remember some important aspect of the trauma
4. Reduced interest or participation in important activities
5. A feeling of detachment or estrangement from others
6. A restricted range of feelings—like the inability to have loving feelings
7. Limited sense of the future (doesn’t expect to have a career, marriage, children, etc.)
 

So, does Sam exhibit avoidance AND numbing? Um, no. I don't think so.

Now, here's where clinical judgment comes into play. Another clinician might make a slightly different call on some of these. From where I sit, though, Sam only exhibits C2 for sure. He avoids bathrooms with bathtubs. But as far as I could tell, he does not exhibit ANY of the other criteria in category C here. He tells Grace about what happened and doesn't make any attempt to dodge it at all. He seems to remember it perfectly. He doesn't seem to show reduced interest in important activities. He doesn't seem to be detached or estranged from others--he's cautious about others knowing his secret, but he can and does form close relationships. He has a range of intense feelings, including his deep love for Grace (*sigh, heart aflutter*). And although he does have a limited sense of the future at some points, that appears entirely due to his werewolf dilemma as opposed to related to the trauma.

Nevertheless, we shall press on. Because if you haven't realized it yet, these criteria are hella extensive, and you gotta meet criteria in EVERY category, from A all the way down the line, to get this diagnosis.

Category D. Persistent symptoms of increased arousal (and this is not the sexy type). You have to have at least two of these:

1. Difficulty falling or staying asleep
2. Irritability or outbursts of anger
3. Difficulty concentrating
4. Hypervigilance (being constantly tense and on-guard)
5. Exaggerated startle response

So, does our Sam have at least two of the symptoms of persistent arousal (giggles from my inner, more immature self )?? Well, from what I can tell, apart from D1 (though that appears to have nothing to do with his trauma and more to do with his other worries), he doesn't appear to exhibit any of these symptoms. He might have as a child, but at the time the story takes place, he doesn't. 

Ah, wait! There's even more! For a person, even a fictional one, to meet criteria for PTSD, the symptoms have to be present for over a month (that's category E). Oh! Yes! Sam's had symptoms for years! So he does meet this criterion.

But there's one more thing. Category F: the symptoms have to cause clinically significant distress or IMPAIRMENT in occupational, social, or other important areas of functioning. Hmmmm. Now, Sam doesn't actually seem impaired in any area of functioning. However, he does experience clinically significant distress when there's a bathtub looming in front of him.

OK, does Sam have PTSD?

NO.

He might have met diagnostic criteria at some point, but he does not at the time the story takes place. What's his deal then? What's going on for him?

Well, his presentation is somewhat mixed and unique, but I will say that, if he came into my office, I would also consider whether he has a Specific Phobia of bathtubs (again, paraphrased from the DSM-IV-TR, but the word-for-word criteria can be found here).

1. Excessive fear caused by the presence (or sometimes even thoughts about) a specific object or situation (like getting a shot, certain animals, etc.)
2. Being exposed to that object or situation causes a strong, anxious response, maybe even a panic attack
3. The person understands that his fear is excessive and unreasonable.
4. The person endures the object/situation only with intense fear or distress
5. Avoidance, anticipation, or distress when in the feared situation interferes with the person’s normal routine
6. Has to last at least 6 months for kids.
7. The fear is not better accounted for by some other diagnosis (like Social Phobia, OCD, or PTSD).
   

And you know, if you think about it, a lot of specific phobias (fear of dogs, bees, etc.) come from traumatic experiences in childhood (or in adulthood--like getting in a car accident and then being afraid to drive afterward).

Does Sam meet criteria for specific phobia?

Well, he certainly has numbers 1, 2, 4, 5 (he seeks out a tubless bathroom when he has to pee, poor guy), 6, and, based on my humble analysis, 7. As for 3 ... I'll give him credit for that one. He specifically says he's embarrassed about it when Grace witnesses his reaction to a tub. So ... technically, yeah.

Now, most people with specific phobia do not have flashbacks associated with their fears. Sam is unusual in this respect. I don't really find a diagnosis of specific phobia satisfying because of these additional symptoms. And it's obvious that Sam is still affected by what happened to him--but as melancholy as he is, he does not seem to be impaired by these experiences apart from his tub phobia. So, I stand by my assessment: Sam Roth, beloved of Grace Brisbane, he of the beautiful lyrics and awesome guitar playing, maker of poignant paper cranes, who had better gather his posse and figure out what's the what in Book 3 (do you hear me, Maggie Stiefvater?!? Have mercy!!!!), does not have PTSD.

If you're wondering why this type of nitpicking might matter in real life, btw, I'll tell you: the treatment for these two disorders is different. You'd want to differentiate one from the other so you can provide some therapy that actually works. More on that another time.

What do you think? Do you disagree? Other perspectives? Other characters you'd like me to assess? Let me know!