PRACTICE DIAGNOSIS

Anxiety Disorder: PTSD

Happy Three Friends ‘Flippy’

Summary of the Movie

Happy Tree Friends is an American adult animated web series created by Aubrey
Ankrum, Rhode Montijo, and Kenn Navarro. After its internet debut in 1999, Happy Tree
Friends became an unexpected success, getting over 15 million hits each month along
with screenings at film festivals.

Being an adult cartoon disguised as a kids cartoon, the series features

cartoon anthropomorphic forest animals, who are suddenly subjected to very extreme
and cruel graphic violence in any episode. Each episode revolves around the characters
enduring accidental or deliberately inflicted pain, murder or mutilation.

In early episodes, most characters played the roles of children playing childish
games. However, as the series progressed, the age concept was dropped, and now
characters act variously like children, teenagers, and adults in different episodes. At the
beginning of each episode, the characters are typically found in everyday situations.
However, these situations always escalate into violence, and the inevitable deaths of
those involved and/or "innocent" bystanders, mostly because of very unfortunate,
surprising accidents with otherwise harmless instruments. Some of the characters have
mental illnesses, like Flippy, who has post-traumatic stress disorder from a war and will
become a killer in certain situations.

Evil Flippy, or Flippy, is the main antagonist in the internet series Happy Tree
Friends. He also appears in its spinoff miniseries Ka-Pow! He is considered to be one of
the most popular characters of the series. However, Flippy's appearances are rare, to
keep his behavior from becoming repetitive. According to writer Warren Graff, Flippy is
based on John Rambo. Flippy fought in the Weaponized Animal Regiment (The W.A.R),
and he has an obsession with making booby traps inspired by the Viet Cong. Flippy has
no memory of anything he does during his 'flip-outs'. In the episode Double Whammy,
Flippy sought professional help and defeated his evil self in Part 2. For a while, fans
believed Evil Flippy was gone for good, but his flip-out in the short On My Mind dispelled
the rumors and it has not been a one-off incident. Flippy always carries a bowie knife and
multiple grenades but often improvises his weapons from everyday objects or uses Viet-
Cong-style booby traps. He has the second highest kill count in the series, beaten only
by Lumpy with over 300 kills. However, he has the highest average kill-count at 6 per
episode, and no other character in the series intentionally murders other characters.

Available in YouTube.

MENTAL STATUS EXAMINATION

Client Name: Flippy Date: 09/31/21

OBSERVATIONS:

Appearance  Neat  Disheveled  Inappropriate  Bizarre  Other

Speech  Normal  Tangential  Pressured  Impoverished  Other

Eye Contact  Normal  Intense  Avoidant  Other

Motor
 Normal  Restless  Tics  Slowed  Other
Activity
Affect  Full  Constricted  Flat  Labile  Other
Flippy always wear his military uniform neatly, but every time he flips out
it’s always being disheveled, dirty and bloody. He eyes people around
Comments:
him quite aggressively. He shows some fine expressions of what he truly
feels.

MOOD:

 Euthymic  Anxious  Angry  Depressed

 Euphoric  Irritable  Other

Comments: Flippy is always anxious, paranoid and disturbed.

COGNITION:

Orientation Impairment  None  Place  Object  Person  Time

Memory Impairment  None  Short-term  Long-term  Other

Attention  Normal  Distracted  Other

Remember all the things that had happened once his
Comments: Flippy can’t
trauma was triggered.

PERCEPTION:

Hallucinations  None  Auditory  Visual  Other

Other  None  Derealization  Depersonalization
Flippy hears and sees things that he had heard and seen during his time
Comments:
in army, which is a nonexistent.

THOUGHTS:

Suicidality  None  Ideation  Plan  Intent  Self-harm

Homicidality  None  Aggressive  Intent  Plan

Delusions  None  Grandiose  Paranoid  Religious  Other

Flippy always put his safety first and is willing to kill anyone at sight, he
Comments:
is even creating a great plan for it.

BEHAVIOR:

 Cooperative  Guarded  Hyperactive  Agitated  Paranoid

 Stereotyped  Aggressive  Bizarre  Withdrawn  Other

He is very aggressive and guarded to almost everything, he can’t stay
Comments:
put and won’t stop being aggressive not unless everyone’s dead.

 Comments:
Flippy tried
INSIGHT  Good  Fair  Poor
fixing his
disorder.
 Comments:
Flippy still keep
his fashion
JUDGMENT  Good  Fair  Poor towards military
despite his
occasional
trauma attack.

Evaluated by: Ria Joy Soriano

Theories – causal factors

 Many factors in a person’s psychological and biological makeup, relationships and
resources, and life experiences, including nontraumatic and supportive experiences as
well as traumatic stressors, that influence the path or trajectory that will lead a person to
encounter traumatic stressors and to resist, recover from, or persistently suffer from
PTSD. Risk and protective factors, including genetics, personality, anxiety-proneness,
intelligence, education, and social support, influence the likelihood and severity of PTSD
in addition to trauma exposure. There might be some theory that may explain why Flippy
exhibits this symptom. It should be noted that acquiring PTSD is not only from being
expose to traumatic stressor, and that there are a lot of factors that may contribute.

As he fought for years, Flippy was promoted to the rank of Sergeant. According to
the first episode, Private Flippy didn't start out as a well-honed killing machine. He
accidentally threw a slice of pizza at the enemy commander rather than his knife,
demonstrated an inability to throw his knife straight while under pressure, killed both of
his teammates, and hid in the carcass of one of his dead teammates in fear. Maybe it is
due to this guilt that caused his stress which develop to PTSD after being continuously
exposed to people dying around him. From a cognitive point of view, guilt is an emotion
that people experience because they’re convinced, they’ve caused harm. In cognitive
theory, the thoughts cause the emotions. The emotion of guilt follows directly from the
thought that you are responsible for someone else’s misfortune, whether or not this is the
case. Flippy felt guilty due to his comrade’s death, that he thinks it is his fault, the stress
from this guilt might had consumed him, his comrade died during their war with an enemy,
maybe he had linked the sight and sound of war to the death of his comrade, it causes
him a trauma every time he heard a gun-shot-like sounds.

According to constraint theory when we feel our behavioral freedom is threatened

by elements in the environment, we form a certain degree of reactant in order to escape
the stressor or cope with the stressor. Maybe every time Flippy found himself in a situation
that resembles his time during his military service, he cope up with it by doing what he is
usually doing every time there’s a war, due to what war had put his life in danger, his
reaction is to fight until he felt he is no longer in danger. Every time he hears a sound that
resemble a gun shot or a sight that makes him remember his time in military, the first
thing he do is to be violent and then kill everyone insight, this shows that his way of coping
with the stress is to keep himself safe by not letting everyone around him stay alive. It has
been mentioned that acquiring PTSD requires not only being exposed to traumatic
stressor but also other stressor that may induced or reduced the stress. Flippy does not
only experience his comrade dying because of him, he had also experience being captive
of enemy, thus, whenever he felt he is cornered, the memory of being a captive will come
back to him which will make him violent. So aside from guilt, he had been pre-exposed to
stressors that might had triggered a PTSD.

Lang’s Fear Conditioning theory, assumes that frightening events are stored in a
broader cognitive framework and that they are represented within memory as
interconnections between nodes in an associative network. These networks function as
a kind of prototypes for recognizing and coping with meaningful situations. Three types
of information were proposed: stimulus information about the trauma, such as sights and
sounds, information about the emotional and physiological response to the event, and
meaning information (most importantly about the degree of threat). These nodes are
interconnected, so if the person encounters one sort of information belonging to the
traumatic event, the other modes of information would be activated automatically. In
Flippy’s case, his stimulus information about his trauma is the sound of war, guns and
bombs, once this is being triggered, information about emotional and physiological
response to this stimulus will follow, which is him fighting and killing the opponent during
war, and the meaning information or the degree of threat that event had is his life being
in the line. Once Flippy heard any sounds that sounds like gun shot or bombs, his reaction
is to fight because he remembers his time during war that his life is in threat. The sounds
of war and how his life being in danger had stored in his memory that had result to him
having violent reaction whenever he remember those times.

Psychological Disorders
Symptoms
Post-traumatic stress disorder symptoms may start within one month of a traumatic
event, but sometimes symptoms may not appear until years after the event. These
symptoms cause significant problems in social or work situations and in relationships.
They can also interfere with your ability to go about your normal daily tasks.

Included symptoms are:

Criterion A (one required): The person was exposed to: death, threatened death, actual
or threatened serious injury, or actual or threatened sexual violence, in the following
way(s):

• Direct exposure
• Witnessing the trauma
• Learning that a relative or close friend was exposed to a trauma
• Indirect exposure to aversive details of the trauma, usually in the course of
professional duties (e.g., first responders, medics)

Criterion B (one required): The traumatic event is persistently re-experienced, in the

following way(s):

• Unwanted upsetting memories

• Nightmares
• Flashbacks
• Emotional distress after exposure to traumatic reminders
• Physical reactivity after exposure to traumatic reminders

Criterion C (one required): Avoidance of trauma-related stimuli after the trauma, in the
following way(s):

• Trauma-related thoughts or feelings

• Trauma-related reminders

Criterion D (two required): Negative thoughts or feelings that began or worsened after
the trauma, in the following way(s):
 • Inability to recall key features of the trauma
• Overly negative thoughts and assumptions about oneself or the world
• Exaggerated blame of self or others for causing the trauma
• Negative affect
• Decreased interest in activities
• Feeling isolated
• Difficulty experiencing positive affect

Criterion E (two required): Trauma-related arousal and reactivity that began or

worsened after the trauma, in the following way(s):

• Irritability or aggression
• Risky or destructive behavior
• Hypervigilance
• Heightened startle reaction
• Difficulty concentrating
• Difficulty sleeping

Criterion F (required): Symptoms last for more than 1 month.

Criterion G (required): Symptoms create distress or functional impairment (e.g., social,
occupational).
Criterion H (required): Symptoms are not due to medication, substance use, or other
illness.
Two specifications:

1. Dissociative Specification. In addition to meeting criteria for diagnosis, an

individual experiences high levels of either of the following in reaction to
trauma-related stimuli:
• Depersonalization. Experience of being an outside observer of or
detached from oneself (e.g., feeling as if "this is not happening to
me" or one were in a dream).
• Derealization. Experience of unreality, distance, or distortion
(e.g., "things are not real").
2. Delayed Specification. Full diagnostic criteria are not met until at least six
months after the trauma(s), although onset of symptoms may occur
immediately.
Symptoms from DSM-5

Diagnosis

Flippy is generally friendly and sociable. But whenever he is being reminded of his
time during war, it is causing him to flip out or to be violent. Flippy is showing symptoms
of severe Post-Traumatic Stress Disorder (PTSD). He experiences life and death
situation during his service in military, he witnesses hi friends dying in front of him.

Whenever Flippy sees or hears something that reminds him of war, like gunshot-
like sounds or crackling campfires, even sharp objects, his pupils will dilate, his irises
become yellow-green, his voice goes from squeaky to a deeper, darker voice, and he
becomes extremely aggressive and violent, he becomes delusional and losing any shred
of empathy he had and committing murder. He is reenacting his time during war when he
is reminded of those time. It is not only symbols of war that is triggering his trauma, he
also might "flip out" due to anger or stress as seen to some episodes.

Flippy experiences recurrent, intrusive thoughts of the traumatic event. These

include nightmares and flashbacks as well as distressing memories of his time during in
his service in military, it is making him actually feel like the event is happening all over
again. Due to his tendency to flip out at any moment, he can’t make a stable relationship
with other people, he either will kill them on sight or he had put enough fear towards other
people that even he is in his normal state, people doubt his actions. Flippy is a member
of military, it should be given that he is always vigilant and on guard, but on Flippy’s case,
he is not only vigilant but anxious as well, that is why he can be startled and be surprised
at any time by anything. A simple pop of a balloon can make him remember changing
bullets with enemy, a simple sharp object can make him remember killing his enemy, and
a simple rope can make him remember him being captive of his enemy.

These symptoms of Flippy persisted no shorter than 1 month, it can be assumed

that Flippy took a time off form military for they are currently in a peaceful time. And the
symptoms only showed after he leave military.
 Psychotherapy

According to the current state of the PTSD treatment research (CPG, 2017),
treating PTSD using individual trauma-focused psychotherapy was recommended over
medications based. Some researches results showed that trauma-focused
psychotherapies lead to greater improvement in PTSD symptoms than medications, and
that these improvements last longer. In addition, the risks for negative side effects or
negative reactions are generally greater with medication than with psychotherapy.

Traumatic events can disrupt schemas, particularly around beliefs related to

safety, trust, power, esteem, and intimacy. PTSD results when disruptions in these
schemas manifest in inaccurate self-statements, called "stuck points", that interrupt
normal recovery from the traumatic experience. Cognitive Processing Therapy will help
Flippy to help him rebuild these schemas to make sense of the world, interpret new
information, and exert some level of prediction and control over their experiences. This
therapy is a trauma-focused psychotherapy designed to treat PTSD. It is one of the most
researched treatments for PTSD. A large number of studies show it is effective, including
in patients with complicated presentations, such as comorbid personality disorders and
other co-occurring conditions (Galovski,T.E, et al. 2019)

Another effective therapy that may be apply to Flippy is the Prolonged Exposure
Therapy, this therapy had shown to be effective in 60% of veterans with PTSD (VA.gov:
Veterans Affairs. 2009). During the treatment, repeated revisiting of the trauma in a safe,
clinical setting will help Flippy change how he reacts to his memories of traumatic
experiences, as well as learn how to master fear- and stress-inducing situations moving
forward. This therapy will teach him to gradually approach his trauma-related memories,
feelings and situations. By facing what he has been avoided, he will presumably learn
that the trauma-related memories and cues are not dangerous and do not need to be
avoided.
 If Flippy do not respond adequately to nondrug treatment alone, he may benefit
from a combination of medication and psychotherapy. Medications and psychotherapies
are used both separately and in combination to treat the symptoms of PTSD, as well as
related comorbid diagnoses. Guidelines suggest a combination may enhance treatment
response, especially in those with more severe PTSD or in those who have not responded
to either approach alone. Flippy could undergo Cognitive Processing Therapy while taking
SSRLs.

REFERENCES

American Psychological Association. (2017). Treatments for ptsd. American

Psychological Association. Retrieved September 27, 2021, from
https://www.apa.org/ptsd-guideline/treatments.

American Psychiatric Association. (2013) Diagnostic and statistical manual of mental

disorders, (5th ed.). Washington, DC: Author

Forbes D, Creamer M, Bisson JI, Cohen JA, Crow BE, Foa EB, Friedman MJ, Keane TM,
Kudler HS, Ursano RJ J Trauma Stress. (2010 Oct). A guide to guidelines for the
treatment of PTSD and related conditions.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5047000/

Galovski, T. E., Norman, S. B., & Hamblen, J. L. (2019, March 20). VA.gov: Veterans
Affairs. Cognitive Processing Therapy for PTSD. Retrieved September 27, 2021,
from https://www.ptsd.va.gov/professional/treat/txessentials/cpt_for_ptsd_pro.asp.

Mayo Clinic Staff. (2018, July 6). Post-traumatic stress disorder (ptsd). Mayo Clinic.
Retrieved September 27, 2021, from https://www.mayoclinic.org/diseases-
conditions/post-traumatic-stress-disorder/symptoms-causes/syc-20355967.

Nijdam, M. J., & Wittmann, L. (2017, January 6). Psychological and social theories of
PTSD. Neupsy Key. Retrieved October 1, 2021, from
https://neupsykey.com/psychological-and-social-theories-of-ptsd/#CR42.
Reisman M. (2016). PTSD Treatment for Veterans: What's Working, What's New, and
What's Next. P & T : a peer-reviewed journal for formulary management,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5047000/

VA.gov: Veterans Affairs. (2009, June 3). Management of Posttraumatic Stress Disorder
and Acute Stress Reaction 2017. Retrieved September 27, 2021, from
https://www.healthquality.va.gov/guidelines/MH/ptsd/.