Post-Traumatic
Stress Disorder
Dr. Craig A. Jackson
Occupational Psychologist
Research Director
Health Research Consultants
ResearchConsultants.co.uk
Some Stress is good
Keeps one alert
Keeps one alive
performance
Evolutionary perspective:
Too little stress = extinction
Too much stress = extinction stress
Balance stress = evolution
Pressure is good - - Stress is bad
Common Experience
Minor trauma is a part of everyday life
For most people these injuries are only transient
Some have psychiatric and social complications
Most people experience major trauma at some time in their lives
Psychological Behavioural, and Social factors
all relevant to
Subjective intensity of physical symptoms
and
Consequences for work, leisure, and family life
Disability may become greater than might be expected from the severity of
physical injuries alone
Traumatic Events are Common
Lifetime prevalence of specific traumatic events (n=2181)
Type of trauma Prevalence
Assault 38%
Serious car or motor vehicle crash 28%
Other serious accident or injury 14%
Natural disaster 17%
Other shocking experience 43%
Diagnosed with a life threatening illness 5%
Learning about traumas to others 62%
Sudden, unexpected death of close friend or relative 60%
Any trauma 90%
Immediate Effects of Frightening Trauma
Anxiety, numbness, dissociation and sometimes inappropriate calmness
“Innocent victims” often angry and frustrated
“Acute Stress Disorder" is now used
Occurs in 20-50% of those who have suffered major trauma
The severity of emotional symptoms is much more closely related to how
frightening the trauma was than to the severity of the injury
Even uninjured victims may suffer considerable distress
Severe distress is usually temporary but indicates a risk of long term post
traumatic symptoms
Acute Stress and Chronic Stress
Common
After-effects
Leave behind
Life threatening
One-off
Ever-present
By proxy
Post Traumatic Stress Disorder (PTSD)
Response to specific traumatic / extreme event
DSM IV Diagnostic condition & ICD-10 Diagnostic condition
1. Experience intense fear
2. Persistent re-experience
3. Avoidance of associations
4. Persistent increased arousal since event
5. Flashbacks
6. Hyper-arousal – sleep, irritability, concentration, hyper-vigilance, startle
History
Associated most with Disasters and Warfare
Not new - 6th Century BC
Every conflict since American Civil War in 1863
“Shell-Shock” “Battle Fatigue” “Combat Syndrome”
THIS IS NOT GULF WAR SYNDROME
History
40 Conflicts in world at any one time
1% of world pop are refugees
American Civil War – “Nostalgia”
More casualties than dysentery
WWI 13,000 cases of “shell shock” in Brits
200,000 cases by 1918
Case History 1
During active service in Northern Ireland the patient was involved in a
helicopter crash. The patient was strapped in but the blood and brains of his
"best mate" spattered him. Four months of psychological help was deemed
successful. Later, in the Gulf war, observation of troop transport helicopters
awakened his memories of the incident. He carried on successfully until he
was demobilised in 1994, when the support of regimental camaraderie was
lost. Helicopter transport of troops in a film, Bravo 2 Zero, forced his mind
back to the crash. Subsequently any reference to helicopters led to re-
experiencing the trauma. The diagnosis of post-traumatic stress disorder was
straightforward when his military history was taken as part of an assessment
of fatigue, impaired memory, nocturnal sweating, rashes, musculoskeletal
aches, dyspnoea, and dyspepsia.
Case History 2
A young nurse was woken by a missile exploding to her left. Terrified and
claustrophobic she vomited and evacuated her bowel and bladder. Her
protective kit could not be removed until tests allowed the all clear to be
sounded about five hours later. She became too frightened to shower because
being naked would have prevented her running to a shelter. She took
accelerated discharge from the air force. She could not keep jobs because of
poor time keeping, irascibility, and disproportionate emotional responses to
minor adversity. Distressing recall of terrified anticipation of her death
occurred by day and night. She developed fatigue and anorexia and solitary
alcohol bingeing. She became claustrophobic when shopping or on public
transport where she vomited and screamed. Civilian consultations proved
unhelpful because no one asked about her experiences during the conflict to
learn the origins of her dysfunction.
Case History 3
A major aged 37 years directed some of the clear up of battle field carnage. He
saw and smelled many remains of Iraqi people but thought that he was not
affected. He became uncommunicative but irritable; his love of life and the
army diminished. Two years after his early retirement he saw a television
documentary on the Gulf and dramatically recalled the events of six years
previously. The smell of off-fresh chicken meat focused memories of rotting
flesh. Repeated recall of half-burnt Iraqi corpses forced him to re-experience
the initiating trauma. His nightmares, insomnia, poor memory, fatigue, and
irascibility became worse, and he developed headaches, musculoskeletal
aches, and dyspepsia. His decision making and attendance at work suffered.
General medical and rheumatological consultations were unhelpful. Post-
traumatic stress disorder was diagnosed only after his battlefield and
psychiatric histories were considered. Many symptoms had not previously
been discussed. His wife felt "trapped in a tunnel with no lights" and
commented "I wish this Rupert could go to the Gulf and bring my old Rupert
back . . . I don't know how to help him."
World War 1 and Developments
First special hospital
“CraigLockhart” in Edinburgh
“Mausoleum filled with the morbid slumbers of men
haunted by self- lacerating failure to achieve the impossible”
Siegfried Sassoon
Repressed Trauma ?
Localised electric shock ?
Hypnosis ?
ETHICAL DILEMMA:
GET TROOPS BETTER, TO SEND THEM BACK TO TRENCHES
World War 1 and Developments
Shell Shock recognised by War Office – 1916
(Charles Myers)
Acute incapacity NOT beyond their control
307 troops executed for cowardice
80,000 cases
80% of cases never returned to active duty
1918 - 15,000 still hospitalised
World War 1 and Developments
Ernest Jones (president of British Psycho-Analytic Association)
“An official abrogation of civilised standards' in which men were not only
allowed, but encouraged...to indulge in behaviour of a kind that is
throughout abhorrent to the civilised mind. All sorts of previously
forbidden and hidden impulses, cruel, sadistic, murderous and so on, are
stirred to greater activity, and the old intrapsychical conflicts which,
according to Freud, are the essential cause of all neurotic disorders, and
which had been dealt with before by means of 'repression' of one side of
the conflict are now reinforced, and the person is compelled to deal with
them afresh under totally different circumstances.”
Return to normal civilian mentality could spark off delayed reaction in some
World War 2 and Regression
200 psychiatrists recruited after Dunkirk
Churchill didn’t like meddling
RAF had diagnosis of LMF
Good Training and Leadership seen as the key
William Sergeant used drugs to open unconsciousness
North Africa – Battle Exhaustion high
Call for right to shoot deserters to be re-instated
Stigmatisation
Vietnam War
Seen at time to have low psychological casualties
Legacy of 480,000 vets with PTSD after 15 years
PTSD started in Vietnam War
Anti-war psychiatrists
Political Diagnosis
“Backfired”
Modern Day View
Victim Identity of modern warfare?
Modern soldier seen as more psychological than predecessors
Political Cultural Medical
context context context
Has bred a population of vets with investment in being chronic cases
Culture of trauma and compensation links military and civilian worlds
Denied
Forgotten Exaggerated
Understood
Modern Day View
Psychiatric diagnosis is not a disease
Distress and suffering is not psychopathology
PTSD constructed from political ideas
PTSD linked to changes in society and individual “personhood” of modern life
Diagnoses must be objective
PTSD lacks precision
What is subjective distress or objective disorder
Psuedocondition – transforms social ills into medical ones
Modern Day Reasons for Uses of Victim Support
Mayou & Farmer 2002
Psychological Consequences of Trauma
Acute anxiety, numbing, arousal (acute stress disorder)
Pain and apparently disproportionate disability
Anxiety disorder
Unexplained physical symptoms
Major depressive disorder
Impact on family (such as family arguments, depression in family members)
Post-traumatic symptoms and disorder
Avoidance and phobic anxiety
Types of Modern Trauma
Occupational
Return to work often slower than in other types of injury
Liaison with employer essential
Compensation issues may impede return to work
Sporting
May be associated with physical unfitness or with inappropriate activity for
age
Domestic
Assess role of alcohol, consider possible family and other problems, assess
risk of further incidents
Disasters
Fear of unpredictability and lack of control
Types of Modern Trauma
Assault (including sexual)
Assess role of alcohol, keep detailed records, suggest availability of help for
major, and especially for sexual, assault
Road traffic crash
Psychological complications may occur even if no significant physical injury.
Whiplash injuries should be treated by well planned mobilisation and
encouragement, together with alertness to possible psychological
complications
Terrorism
Fear of being killed / injured / captured
Fearful for loved ones
Recent PTSD Cases in UK
Hurley vs Gwent Constabulary
Police officer
Fearon vs Martin
Injured burglar
Armstrong vs Home Office
Prison officer in Rosemary West trial
Expansions: Witnesses and Bystanders ?
Good Samaritans ?
Early Patterns and Trends
They fuck you up, your mum and dad
They may not mean to, but they do
They fill you with the faults they had
And add some extra, just for you.
This be the verse
A childhood where nothing ever happened – Philip Larkin
Types of Traumatic Events
Childhood abuse
physical
emotional
sexual
Neglect
Traumatic incidents War and Displacement
first-hand refugees
witness
Child-to-child (Natural) Disasters
bullying first-hand
witness / proxy
Childhood Trauma as cause of ADHD
“Disease” camp vs. “Environmental” camp
Can certain circumstances increase chances of ADHD?
522 children aged 6 - 17 280 ADHD
242 Comparisons
Early childhood trauma was a cause
Boys more functionally impaired than girls
Low social class made ADHD more likely
Maternal smoking made ADHD more likely
Greatest risk factor was family conflict
Bierderman et al. 2002 Mumme - 1 yr olds!
PTSD survivors see emotions differently
Experience can alter perceptions of emotion
Pollak et al. 2002
Studied abuse survivors (8-10 yrs)
Faces with morphed photos - combination of emotions
happy fearful sad angry
Abused and Non-abused reacted similarly to happy faces
PTSD adults more sensitive to angry faces
PTSD and Health Problems
“Male victims of sexual abuse 3 times more likely to suffer health
problems”
93 boys abused by same teacher
6 yrs after abuse survivors aged 14-16
Health problems between traumatised and non-traumatised NOT different
Trauma survivors significantly more time at GP than controls for
unexplained symptoms
Price et al. 2002
Interpretative differences of abuse studies
PTSD Markers of Self-Harm
DSH (Parasuicide)
intentional, non-suicide, non-life threatening act
Female: Male 2:1 15-24 biggest group
At risk: Female
Isolation
Negative life events bereavement abuse
Pre-existing psychiatric conditions
Family history of DSH
Intolerable stress
Impulsive, Immature, Aggressive personality
PTSD Markers of Self-Harm - Methods
• Cutting
Forearms and wrists
Legs and feet
Laterality
Genitalia (abuse survivors)
• Burning
• Pills and Toxins (detection)
5th biggest cause of hospital admissions in UK
PTSD Markers of Self-Harm – Pre-Meditation
Premeditation can be biggest sympathy inhibitor
• Saving up pills / blades
• Avoiding discovery
• Long sleeves
• Prepared excuse stories
• Bandage stockpiles
PTSD Markers of Self-Harm – Motivation
• Cry for help
have they talked to anyone prior to DSH?
• Escape from situation
control & mastery
• Punishment and Manipulation of others
loved ones
failing relationships
inferiority
Factitious Injury
Feigned physical / psychological symptoms or signs
Aim is to receive medical care
Most are female, “stable” networks, many working in healthcare
Only confront if evidence of factitious harm is established
Supportive confrontation: aware of role of behaviour in their
illness
offer psychological help with this
Patients usually stop behaviour but leave clinic
Offer of psychiatric care rarely taken up
Cognitive Behavioural Strategies for PTSD
Talking it through
Encourage victim to discuss and relive feelings about the incident
Tackling avoidance
Discuss graded increase in activities, such as return to travel after a road crash
Coping with anxiety
Anxiety management techniques (relaxation, distraction)
Dealing with anger
Encourage discussion of incident and of feelings
Overcoming sleep problems
Emphasise importance of regular sleep habits and avoidance of excessive
alcohol and caffeine
Treat associated depression
Antidepressant drugs, limited role for hypnotics immediately after
Summary
“Acute Stress Disorder” more accurate
Traumatic events can occur any time or place
Incapacity in face of fear and terror is natural
Reactions can be immediate or delayed or both
Delayed reactions triggered by any associations
PTSD was a political diagnosis
Resulted in over-reporting of effects in Vietnam vet population
PTSD Diagnoses not objective
PTSD lacks precision
References
Shell Shock: A History of the Changing Attitudes to War Neuroses by Anthony
Babington (Leo Cooper, 1997)
From Shell Shock to Combat Stress by JMW Binneveld (Amsterdam University
Press, 1997)
War Neurosis and Cultural Change in England, 1914-22 by Ted Bogacz
(Journal of Contemporary History, volume 24, 1989)
Dismembering the Male: Men's Bodies, Britain and the Great War by Joanna
Bourke (Reaktion Books, 1996)
No Man's Land: Combat and Identity in World War One by Eric J Leed
(Cambridge University Press, 1979)
Problems Returning Home: The British Psychological Casualties of the Great
War by Peter Leese (The Historical Journal, volume 40, 1997)
Female Malady: Women, Madness and English Culture 1830-1980 by Elaine
Showalter (Virago, 1987)
The Regeneration Trilogy by Pat Barker (Viking, 1996 )