CHAPTER THIRTEEN
Post-Time War Stress Disorder
KRISTIN ERICKSON AND MATT MUNSON, WITH STEPHEN PRESCOTT AND TRAVIS LANGLEY
“We lost. Everyone lost. They’re all gone now. My family. My friends.”
—Tenth Doctor1
“Guilt is perhaps the most painful companion of death.”
—psychiatrist Elisabeth Kübler-Ross2
A person can experience trauma without developing posttraumatic stress disorder (PTSD). In fact, soldiers, first responders, and people living in war zones can experience many traumatic events without developing it, although their odds certainly increase.3 When the television program Doctor Who returned after a long period of cancellation, the Doctor returns as a man suffering a deep psychological wound after a great trauma. The mere suggestion of the Time War nearly brings the Ninth Doctor to tears.4 Avoiding or getting upset by a topic or a stimulus can indicate many different difficulties with or without PTSD.5 Actual diagnosis requires much more information. Details emerge over time, but it is not until the War Doctor, the incarnation of the Doctor who participates in the Time War, appears that viewers learn how he decided he would have to destroy all Daleks and Time Lords to end the war and save the universe,6 and it is this cataclysmic event that ultimately shapes the modern Doctor into the person he becomes from the Ninth Doctor onward.
Diagnostic Criteria: Who Suffers from PTSD?
Myths and misconceptions about PTSD abound. Despite the volume of available information, many people misunderstand what posttraumatic stress disorder is, along with the when, where, why, who, and how of it.7 For one thing, the majority of people exposed to events that qualify as severe trauma do not develop it, and not all traumas affect people equally. Tragedy of human design (e.g., murder, rape, war) leads to PTSD more often than do other traumatic events (e.g., accidents, natural disasters).8 Survivor guilt (feeling guilt for surviving when others did not) and other forms of trauma-related guilt make PTSD more likely and complicate its treatment,9 although guilt can help some individuals experience posttraumatic growth in that they find purpose, grow as people, and accomplish good things.10 Impressed by how well the Tenth and Eleventh Doctors handle a UNIT/Zygon conflict, the War Doctor speculates that guilt may make the Doctor a better man and save many lives.11
The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (a.k.a. the DSM-5 for its fifth edition12) lists a specific set of criteria that must be met for a person to qualify as having PTSD. The event that ends the Time War is clearly traumatic (meeting criterion A), but so are many other events in the Doctor’s millennia-long life. Whether he then has PTSD therefore depends on his personal reactions in terms of how often, how severely, and how many of the other criteria (listed as B through H in the DSM-5) he meets:
A. The patient has experienced or witnessed or was confronted with an unusually traumatic event.
B. The patient repeatedly relives the event.
C. The patient repeatedly avoids trauma-related stimuli and has a numbing of general responsiveness.
D. Negative alterations in cognitions and mood are associated with the traumatic event.
E. The patient has symptoms of hyperarousal that were not present before the traumatic event.
F. The duration of the symptoms is longer than one month.
G. The symptoms cause clinically important distress or impair functioning in occupational, social, or personal aspects of life.
H. The disturbance is not attributable to the physiological effects of a substance or any other medical condition.
Many of these symptoms have a number of qualifiers (the applicable ones are discussed below) that can limit when a professional would consider them symptomatic in the Doctor or anyone else.
A. Trauma
The DSM-5 lists qualifiers for this criterion: The event involves actual or threatened death or serious physical injury to the patient or to others, and the patient felt intense fear, horror, or helplessness. War is undisputedly traumatic. Combat, carnage, and potential catastrophe for the entire cosmos13 ultimately push the War Doctor to make a decision that brings an end to the war and seems to result in both sides of the conflict being wiped from existence.14
B. Reliving the Trauma
For a PTSD diagnosis to apply, the DSM-5 requires that the patient relive the event repeatedly in at least one of a set of specific ways. The Doctor experiences at least two of them: flashbacks and intrusive, distressing recollections. A flashback consists of mentally reliving trauma, however briefly, so vividly that the individual feels as though the traumatic event is recurring.15 According to Clara Oswald, the Eleventh Doctor talks about the Time War “all the time,”16 indicating that the version of the Doctor who tries hardest to forget actually has frequent recollections. Deliberately trying to avoid thinking about something can at times paradoxically make an individual think about aspects of it even more while keeping that person from finding a healthy way to process distress.17 These do not appear to happen to him as often as other intrusive recollections, which are also distressing.
Combined, the Doctor’s occasional flashbacks18 and having recollections about the Time War “all the time” meet this criterion for PTSD.
C. Avoiding Reminders
Avoiding trauma-related stimuli is practically a core competency for the Doctor. When a representative of the Forest of Cheem expresses her sorrow over the Ninth Doctor’s distress because she knows that he is the last of his people, he shows only a flash of sadness before he snaps back to the task at hand of saving the station.19 This Doctor, more than any other, tries to live in the moment. Present-focused people experience less depression than do those who ruminate over the past and less anxiety than do those who fret about the future.20 For some people who are trying to avoid depression and anxiety without distorting reality, focusing on the present can be a coping strategy21 Focusing on the present while refusing to think about a prior trauma may provide some short-term relief, but it can worsen symptoms in the long term when an individual has avoided facing stressful facts and feelings—as is seen in too many combat veterans.22
The Ninth Doctor’s first line of dialogue on screen is telling: “Run!”23 Running from the past and from things that bother him has been a consistent part of the Doctor’s behavior to the point that it is a central trait, a defining quality that affects much of an individual’s behavior.24 In childhood, he runs from secrets he learns in the Time Lords’ Matrix25 and from “the raw power of time and space” he beholds in the Untempered Schism at age eight. “I never stopped.”26 The theme of running via the physical action of running or the Doctor’s request to run can be interpreted as an indication of his ongoing desire to avoid trauma-related stimuli. While a preexisting avoidant trait would not be a posttraumatic symptom, avoidance could cause the person to experience a severe stress reaction to specific trauma.
Avoidance can take numerous forms and can even involve lying to avoid an uncomfortable truth. When the Tenth Doctor explains to Martha some of the nature of the war and its effects on him, he acknowledges that he has been lying about his people so that he “could pretend, just for a bit. I could imagine they were still alive underneath the burnt orange sky.” The Tenth Doctor has not been delusional about them because he does not convince himself of a falsehood that is grossly inconsistent with his reality, nor is he experiencing a psychotic degree of denial27 because he admits the truth to himself and knows when he is pretending.34
JEREMY J. MANCINI
“We’re not the same! I’m not the— No, wait, maybe we are.”
—Ninth Doctor to Dalek28
“By positing a ‘me-us-them’ distinction, we live with the illusion of moral superiority….”
—psychologist Philip Zimbardo29
Falsely believing that “I am not that kind of person” comes from the human inclination to separate one’s identity from those whose behavior runs contrary to what is “right.”30 Psychologist Philip Zimbardo, having spent his career investigating how circumstances bring out the worst31 or best32 in people, argues that we are all born with “mental templates” to become good or evil. When faced with reminders of the recent Time War, the Ninth Doctor shouts at a Dalek (then believed to be the last one), saying it should kill itself, to which it responds, “You would make a good Dalek.”33 The hero’s unheroic behavior arises from his hatred of Daleks, desire to separate himself from them and possibly from the version of himself that warred against them, and need to believe he could never be like them. A false sense of identity prevents a person from seeing his or her similarities to the enemy, the “other.” Zimbardo explains that we have the ability to adapt to the situation in order to survive even if to survive means to destroy. The Doctor shows this not only when he tries to exterminate this Dalek but also when he finally sees its better qualities. Both Doctor and Dalek change.
D. Negative Changes in Thought and Mood
The DSM-5 provides a list of items related to negative alterations in cognitions and mood associated with the traumatic event, two of which must be present to satisfy this criterion. The Doctor easily satisfies at least that many.
Detachment or isolation. Perhaps the most prevalent of the seven possible conditions, this pertains to feeing distant and disconnected from other people, one of the most frequently reported symptoms among combat veterans with PTSD.35 The Doctor makes a choice at times to stay detached and isolated in an attempt at self-preservation. The Tenth, Eleventh, and Twelfth Doctors all spend long periods traveling by themselves, more so than any pre–Time War Doctors.
Negative self-evaluation. PTSD sufferers may hold persistent, exaggerated beliefs or expectations about themselves. Before he enters the Time War, “the good man” and “the Doctor” are the same thing in the Eighth Doctor’s mind.36 Later, though, the Eleventh Doctor hates himself37 and believes he is not a good man.38 When negative self-evaluation becomes ingrained in a person’s self-concept, it does not easily subside. Even after rectifying the things he did as the War Doctor,39 the Twelfth Doctor doubts that he is good, but he still tries.40
E. Elevated Arousal
The criterion of hyperarousal (excessive arousal inappropriate for current circumstances, markedly increased from pre-trauma levels) can be satisfied with two of the six specifiers listed in the DSM-5. Of those six, the Doctor meets several. Whether he shows posttraumatic changes, demonstrating them to a degree not present before the trauma, may be open for debate.
• Irritable behavior and angry outbursts. Anger intensification has become one of the most widely recognized adjustment problems for many war veterans.41 The Doctor has some angry outbursts or episodes of irritability, such as when the Ninth Doctor succumbs to the weight of his Time War experiences and yells, “The Daleks have failed. Why don’t you finish the job and make the Daleks extinct. Rid the universe of your filth! Why don’t you just die!”42 Earlier incarnations of the Doctor, even the crankier ones, did not explode as readily into upset, shouting rants. Arguably, though, these examples might not meet this qualifier because provocation is apparent in every instance.
• Reckless or self-destructive behavior. People who have suffered trauma may engage in risky or harmful behavior,43 particularly if they feel self-loathing or guilt for having survived when others did not (survivor guilt).44 Exhibiting reckless or self-destructive behavior is almost the hallmark of any Doctor adventure. Typically, his regeneration is prefaced by a choice to sacrifice himself by entering willingly into a deadly situation. Before the Time War, the Doctor regenerates eight times over the course of many centuries, but in a mere six years after the war,45 he burns through what should be his final four regenerations (War Doctor to Ninth, Ninth to Tenth, Tenth’s Meta-Crisis, Tenth to Eleventh46).
• Hypervigilance. Extreme alertness to danger can be appropriate for people in dangerous professions. Nearly one-third of Vietnam War veterans eventually experienced PTSD, and many felt an ongoing sense of threat.47 The Doctor is alert to the possibility of danger but does not tend to show excessive vigilance given his lifestyle and therefore does not satisfy the requirements for this qualifier. In fact, he often needs to show greater vigilance.
• Problems with concentration. Posttraumatic difficulties with concentration and attention are visible not only in combat participants but also in people living in warn-torn environments.48 War can make it hard for people to think straight. Although poor concentration seems to be another constant with the Doctor, it grows worse after the Time War. During his building of a makeshift TARDIS, the Eleventh Doctor exhibits acute poor concentration as he argues with Idris (the personification of his own TARDIS) while work needs to be done with no time to spare.49
• Sleep disturbance. Insomnia (a pattern of frequent and extreme difficulty falling or staying asleep) or restless sleep is common among PTSD sufferers. When his companions sleep, the Eleventh Doctor goes off on extra adventures.50 This may be because his species simply requires less sleep, and so the greater issue is whether his sleep is notably poorer after the Time War than before. For each of these qualifiers and criteria, there must be alterations from previous behavior. To be posttraumatic they must differ dramatically after the trauma. Long before the War Doctor ends the Time War, the Fourth Doctor says, “Sleep is for tortoises.”51
Comparing pretrauma functioning with posttrauma functioning is essential. In the Doctor’s case, not every arousal disturbance is new to him after the trauma. Showing at least two of the criteria in ways clearly different from before the trauma, though, is sufficient for a diagnostic assessment of this qualifier.
Symptoms must persist for more than one month to qualify as PTSD. The duration of the symptoms is difficult to quantify, as many of the Doctor’s adventures happen off screen, his age is reported inconsistently, and the post–Time War Doctor never indicates which world’s years he means when he refers to his age. Nevertheless, more than a month goes by.
G. Impaired Functioning
With PTSD, the disturbance causes impairment in social, occupational, or other areas that are important to the individual.52 The Doctor’s lack of social grace and awareness worsens in the Twelfth Doctor, whose social deficiency is so pronounced that he takes to using apology cue cards with prewritten phrases and expressions to help him navigate the murky waters of social interaction. When he uses a card that reads, “I’m very sorry for your loss. I’ll do all I can to solve the death of your friend/family member/pet,”53 he is effectively using the kind of social cue card that has helped some children with autism spectrum disorders improve and maintain their social skills.54 This becomes necessary as a method of compensating for his impairments.
H. Disturbance Not Attributable to Substance Abuse or Other Medical Condition
Victims of PTSD suffer a high rates of substance abuse.55 For so many, alcoholism and other substance disorders are consequences, not the cause, of their PTSD symptoms. Substance abuse has never been the Doctor’s forte, though, meaning we cannot attribute his PTSD symptoms to an external agent. The Tenth Doctor takes credit for inventing the banana daiquiri56 but we have no evidence of him consuming one; the Eleventh drinks a sip of wine but promptly spits it out, uncertain whether he has ever tasted wine before;57 and while the Twelfth pours a drink for himself and a cyborg,58 nothing indicates that he drinks much. The Doctor may consume alcohol more after the Time War than before, but because these occurrences appear rare and never to excess, any posttraumatic symptoms he experiences not due to substance use.
Specifiers
To reach a full diagnosis, we must consider specifiers as set forth in the DSM-5. Does the individual show any dissociative symptoms, signs of splitting portions of mental contents away from conscious awareness? Examples include feeling a sense of unreality of self or body, of time moving slowly, or as though one were in a dream. Whether or not he sometimes shows the forms of dissociation specified in the DSM-5’s description of PTSD (depersonalization or derealization) not attributable to his circumstances, the Eleventh Doctor does split portions of mental contents away from conscious awareness when he lies to himself about the War Doctor (addressed in Chapter 8, “Dream Lords: Would the Doctor Run with Freud, Jung, Myers, and Briggs?”)—a clear example of dissociation.
Final Diagnosis
On the basis of these considerations and the various criteria exhibited by the Doctor, we can conclude that he suffers from chronic posttraumatic stress disorder with dissociative symptoms. We diagnose his PTSD as chronic because he has suffered from it for a long time. The kind of avoidance, thought and mood changes, and social impairment that some people may use to evade their suffering in the short term can prolong it in the long term by keeping them from developing other ways of coping and managing distress. The Doctor has never been one to share his past pains easily, rarely even discussing his own loved ones, and so when trauma affects him, he does not know how to express his pain. Soldiers and others who experience so much trauma may suffer silently, keeping their painful stories locked inside.
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Notes
1. Modern episode 3–3, “Gridlock” (April 14, 2007).
2. Kübler-Ross (1969), p. 169.
3. Hahn et al. (2015); Hoge & Warner (2014); Pigeon et al. (2013); Roemer et al. (1998); Stanley et al. (2016); Wilson (2015).
4. Modern episode 1–2, “The End of the World” (April 2, 2005).
5. Handley et al. (2009).
6. Modern episode 7–13, “The Name of the Doctor” (May 18, 2013); anniversary special, “The Day of the Doctor” (November 23, 2013).
7. Holtz (2015); PTSD Alliance (n.d.); Sidran Institute (n.d.); Staggs (n.d.).
8. Santiago et al. (2013).
9. Held et al. (2011; 2015); Pugh et al. (2015).
10. Dekel et al. (2016).
11. Anniversary special, “The Day of the Doctor” (November 23, 2013).
12. American Psychiatric Association (2013).
13. Christmas and New Year specials, “The End of Time,” part 1 (December 25, 2009) and part 2 (January 1, 2010); anniversary special, “The Day of the Doctor” (November 23, 2015).
14. Anniversary special, “The Day of the Doctor” (November 23, 2013).
15. American Psychiatric Association (2013).
16. Anniversary special, “The Day of the Doctor” (November 23, 2013).
17. Krebs et al. (2010); Litz et al. (1997); Wegner et al. (1987); Wisco et al. (2013).
18. e.g., New Year’s special, “The End of Time,” part 2 (January 1, 2010).
19. Modern episode 1-2, “The End of the World” (April 2, 2005)
20. Caplan et al. (1985); Eysenck et al. (2006); Fortunato & Furey (2011).
21. Boyd-Wilson et al. (2002).
22. Tanielian & Jaycox (2008).
23. Allport (1937).
24. Modern episode 9–12, “Hell Bent” (December 5, 2015).
25. Modern episode 1–1, “Rose,” (March 26, 2005).
26. Modern episode 3–12, “The Sound of Drums” (June 23, 2007).
27. Freud (1936).
28. Modern episode 1–6, “Dalek” (April 30, 2005).
29. Zimbardo (2004/2006), p. 367.
30. Zimbardo (2004/2006; 2006).
31. Zimbardo (1969; 1971; 2007).
32. Zimbardo (n.d.).
33. Modern episode 1-6, “Dalek” (April 30, 2005).
34. Modern episode 3–3, “Gridlock” (April 14, 2007).
35. Holowka et al. (2012).
36. Minisode, The Night of the Doctor (November 13, 2013).
37. Modern episode 5–7, “Amy’s Choice” (May 15, 2010).
38. Modern episode 6–7, “A Good Man Goes to War” (June 4, 2011).
39. Anniversary special, “The Day of the Doctor” (November 23, 2015).
40. Modern episode 8–2, “Into the Dalek” (August 30, 2014).
41. Gonzalez et al. (2016).
42. Modern episode 1–6, “Dalek” (April 30, 2005).
43. Dixon-Gordon et al. (2014).
44. Berger (1977); Cassell et al. (2014).
45. Sender (2014).
46. Anniversary special, “The Day of the Doctor” (November 23, 2015); modern episode 1–13, “The Parting of the Ways” (June 18, 2005); 4–13, “Journey’s End” (July 5, 2008); New Year’s special, “The End of Time,” part 2 (January 1, 2010).
47. Price (n.d.).
48. Husain et al. (2008).
49. Modern episode 6–4, “The Doctor’s Wife” (May 14, 2011).
50. Minisode, Good Night (November 22, 2011).
51. Classic serial 14–6, The Talons of Weng-Chiang, part 3 (March 12, 1977).
52. American Psychiatric Association (2013).
53. Modern episode 9–3, “Under the Lake” (October 3, 2015).
54. Caballero & Connell (2010).
55. Gros et al. (2015); Jacobsen et al. (2001).
56. Modern episode 2–4, “The Girl in the Fireplace” (May 6, 2006).
57. Modern episode 6–1, “The Impossible Astronaut” (April 23, 2011).
58. Modern episode 8–1, “Deep Breath” (August 23, 2014).