The Aftermath of Trauma

Understanding post-traumatic stress

Using “Nashville” to Demonstrate the Truth About Flashbacks

An authentic depiction of a troubling psychiatric symptom

I think it would be fair to say that most mental health professionals groan when watching how mental illness is represented on T.V shows. Too often popular culture portrays the lives of individuals living with mental illness (or the symptoms of psychiatric disorders) in a one dimensional way that lacks nuance or, worse, is outright misleading and only serves to perpetuate the many myths and misperceptions about psychiatric illness that already exist in our society.

Image Credit: ABC
http://beta.abc.go.com/shows/nashville
Last month, whilst watching episode 19 of Season 2 of the hit TV show Nashville, I could not help but be pleasantly surprised at the show’s careful depiction of the psychiatric symptom known as a “flashback.” In this episode the musical prodigy, Scarlett O’Connor, (played by the Australian actress Claire Bowen) experiences a flashback of childhood trauma whilst performing live on stage in front of tens of thousands of people.

Whilst the term “flashback” is used loosely in everyday culture to describe casual recollections of memories from earlier on in life, mental health professionals have a different definition of the word flashback. When we use the word flashback, we use it to describe a phenomenon where an individual experiences involuntary recurrent memories. The experience is often sudden and usually a powerful re-experiencing of a past experience or elements of a past experience. The term is used particularly when the memory is so intense that the person “relives” the experience, and this reliving contributes to a serious disruption in the person’s life.

From my perspective, as a Posttraumatic Disorder (PTSD) expert, I find this psychiatric symptom particularly fascinating as it is commonly associated with the traumatic experiences associated with PTSD.

Definition of flashback

In the DSM V, references to flashbacks are to be found under the heading that describes PTSD, i.e. it is a symptom typically associated with PTSD. A flashback is an example of a dissociative reaction – i.e. when the individual feels or acts as if the traumatic events were recurring. Such reactions occur on a continuum, with the most extreme expression being a complete loss of awareness of one’s present surroundings.

A related quote from DSM V: (please note, this text refers to the definition of flashback as it pertains to adults)

“The individual may experience dissociative states that last from a few seconds to several hours or even days, during which components of the event are relived and the individual behaves as if the event were occurring at that moment. Such events occur on a continuum from brief visual or other sensory intrusions about part of the traumatic event without loss of reality orientation, to complete loss of awareness of present surroundings. These episodes, often referred to as “flashbacks” are typically brief but can be associated with prolonged distress and heightened arousal”

There are surprisingly few empirical publications on flashbacks and even fewer articles on the phenomenology of flashbacks. Flashbacks are a defining feature of posttraumatic stress disorder (PTSD), but there have been few studies of their neural basis. But the study of flashbacks is becoming important, as they are given an increasingly prominent role in the diagnosis of posttraumatic stress disorder .

Indeed, the precise definition or clinical nature of a flashback remains a matter of debate, even amongst neuroscientists and mental health professionals, and this was part of the reason I was so impressed with the depiction in Nashville.

What does it feel like to have a flashback?

If you were experiencing a flashback of a traumatic experience it could be so realistic that it feels as though you are living through the experience all over again. You experience the flashback in your mind, but may also feel the emotions and physical sensations – fear, sweating, smells, sounds, and pain – associated with the original trauma.

Flashbacks are often triggered by some kind of reminder of the original trauma; it can be something as simple as a sensory experience associated with the original trauma e.g. the scent of a particular perfume, the feel of raindrops on a wet day, or a sudden loud street noise.

I have witnessed patients who are having a flashback of psychologically traumatic memories and the depiction in Nashville was pretty authentic.

The Nashville episode was classic not only for the scenes that depicted the actual flashback, as experienced by Scarlett O’Connor, but the narrative leading up to the terrible event was equally compelling and authentic. The weeks and months leading up to the “meltdown” on stage shows a Scarlett who is working hard on a serious music album; she writes about her complicated, and often tortured, relationship with her mother. Whilst her creative output is good, the process has been stressful and she has isolated herself from her closest friends and her maternal uncle—the key emotional supports in her life. She starts to take illegally diverted prescription stimulants to help her stay awake so she can finish the album, this combined with the stresses and strains of an intensive tour schedule start to take its toll.

The “trigger” for Scarlett is the surprise arrival of her mother when she is on tour in San Francisco. Her mother, Beverly, is the main perpertrator of her childhood abuse. Initially Beverly is civil but we soon start to see the side of her which is emotionally abusive and physically intimidating toward Scarlett. Scarlett starts to experience brief flashbacks of childhood physical abuse and neglect where she was locked in cupboards for hours at a time with no food, water, or access to a bathroom. Startled by the flashbacks and under pressure to perform on stage she starts to consume alcohol to “deal” with the flashbacks.

This is common amongst individuals experiencing symptoms of posttraumatic stress – they “self medicate” their symptoms with alcohol or illicit drugs. Unfortunately, intoxication often contributes to an overall worsening of symptoms, and this is what happens to Scarlett.

The weeks of stress, lack of sleep, and abuse of prescription stimulants combined with the pressure of performing on stage and a grueling tour schedule make her susceptible to experiencing mental health distress. The arrival of her mother in “real life,” who is the perpetrator of the childhood abuse, combined with Scarlett’s alcohol intoxication triggers a horrifically intense flashback which, unfortunately, occurs whilst she is on stage.

The episode is particularly valuable as it shows the experience of a flashback from Scarlett’s perspective. She is no longer the country music star performing on stage for a live audience, she is a seven year old girl, locked in a closet, terrified for her life as she listens to her mother full of rage, ranting and raving outside the door. As a result Scarlett behaves that way, retreating from light and noise and eventually curling up under her grand piano.

There are problems with the storyline – the episode is tactlessly titled, “Crazy” and Scarlett’s brief “hospitalization” where she is admitted to “get everything out of her system” returns the storytelling to the familiar levels of inaccurate and overly simplistic portrayals of mental illness that I am used to groaning and moaning about. Nonetheless, when it comes to mental health issues in TV shows, Scarlett’s performance scene was a refreshingly truthful depiction of a flashback, and one that I had nothing to groan about.

Copyright: Shaili Jain, MD. For more information, please see PLOS Blogs.

Shaili Jain, M.D., a professor of psychiatry at Stanford, is the Medical Director of the Primary Care-Behavioral Health Team, VA Palo Alto.

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