POST TRAUMATIC STRESS DISORDER

Historical Context

Pierre Janet – a colleague of Sigmund Freud, the forefather of psychoanalysis, first described this collection of symptoms. In World War One it was called ‘Shell Shock’ but the condition was often not considered. Many soldiers who were clearly, in retrospect, suffering from PTSD were executed for ‘cowardice in the face of the enemy’. During the Second World War the label ‘Combat Fatigue’ was attached and then after that ‘Post-Vietnam Syndrome’. The label PTSD was only used in 1980 when the Diagnostic and Statistical Manual of Mental Disorders, third edition was published.

Diagnosis

For meaningful discussion it is important that there are agreed definitions of what is meant when using diagnostic labels for medical or psychological conditions. The American Psychiatric Association publishes the Diagnostic & Statistical Manual of Mental Disorders which is widely used throughout the world. This is updated on a regular basis. The latest edition is DSM-IV-TR which was published in 1994. DSM-V is in preparation at the moment.

DSM-IV-TR defines the trauma necessary to cause the condition. It describes the symptoms which fall into three groups - re-experiencing, avoidance and arousal. It also covers other factors such as time frames.

In order to make the diagnosis the event or events must involve ‘actual or threatened death, or serious injury, or a threat to the physical integrity of self or others’. The person’s response must ‘involve intense fear, helplessness or horror’.

The traumatic event can be re-experienced as intrusive thoughts, nightmares, flashbacks or distress following internal or external cues.

The sufferer may avoid thoughts or feelings, activities places or people that are associated with the event. They may have poor recall of aspects of the trauma, marked diminished interest in significant activities or feelings of detachment from others. They may have a restricted range of feelings or a sense of a foreshortened future.

Symptoms of arousal include sleep problems, irritability or anger, difficulty in concentrating, hypervigilance or an exaggerated startle response.

Some or all of these symptoms are common after trauma. However the diagnosis of PTSD can only be made after one month has elapsed.

The diagnosis PTSD should only be used with those who fulfil all of the necessary diagnostic criteria. However there are those who suffer trauma not as severe as that necessary to fulfil the diagnostic criteria or who do not have sufficient symptoms as set out in the criteria. Such individuals may be referred to as suffering from ‘symptoms of PTSD’ as a working diagnosis. Their treatment should be in a similar manner to those suffering from PTSD.

Symptoms of PTSD

There are three main elements to the clinical syndrome PTSD

  1. Re-experiencing events as nightmares, flashbacks and intrusive thoughts following internal or external cues.
  1. Avoidance and emotional numbing. The sufferer may avoid thoughts or feelings, activities places or people that are associated with the event. They may have poor recall of aspects of the trauma, marked diminished interest in significant activities or feelings of detachment from others. They may have a restricted range of feelings or a sense of a foreshortened future.
  1. Hyperarousal. This includes difficulty in falling or staying asleep, irritability & anger, difficulty in concentrating, feeling constantly ‘on guard’ as if danger is lurking around every corner and being ‘jumpy’ or easily startled.

Some or all of these symptoms are common after trauma. However the diagnosis of PTSD can only be made after one month has elapsed.

Other Problems Associated with PTSD

Some individuals also suffer from other conditions such as depression, other anxiety disorders, alcohol or substance abuse or violence issues

Computer Analogy

When using a computer it is possible to minimise a programme. This programme then is in the background but can continue to function. The only way in which you can know that the programme is in the background is that an icon is visible on the taskbar of the computer. Clicking on this icon will bring the programme back into the foreground.

In PTSD it is as if the sensitizing event is a programme running in the background. Something that the client experiences in the present may then link to the sensitising event. This, in effect, clicks the icon and the sensitising event comes into the foreground and may be experienced as a flashback or an emotion attached to the sensitising event. Treatment of PTSD requires, in effect, the shutting down of the background programme.

This phenomenon of running more than one programme concurrently is a normal state of affairs.  If the times to which our attention is called are pleasant and positive then this causes no problems. However in PTSD the intrusive emotions and flashbacks may be extremely distressing.

Flashbacks

During flashbacks the subject is experiencing, in a very realistic way, sensations, memories and feelings things that are from a different time and place. It is, in fact, a trance experience. Research shows that those suffering from PTSD are very good trance subjects. It is unclear whether the trauma causes the increase in ability to enter trance or whether those who are good trance subjects are more susceptible to develop PTSD. My opinion is that it is the trauma that increases the ability to dissociate. However this is an academic distinction - what is important is that hypnosis is an extremely effective tool in the treatment of PTSD.

Prevalence of PTSD

PTSD can occur after experiencing or witnessing traumatic events such as in military combat, during natural disasters, following serious accidents, terrorist attacks and violent deaths. It can also follow personal assaults such as rape and other situations in which the person felt extreme fear, horror or helplessness. Police, fire brigade or ambulance workers are more likely to have such experiences as they often have to deal with horrifying scenes.

One important finding, which was not apparent when PTSD was first proposed as a diagnosis in 1980, is that it is relatively common.

  1. PTSD affects around 5% of men and 10% of women at some point in their life. Within the emergency services (fire, police and ambulance) and the armed forces (army, navy and air force) the incidence of PTSD can be as high as 15 per cent. Approximately 30% of men & women who have spent time in a war zone experience PTSD.
  1. It was found that PTSD had an incidence of 23% four to six months following road traffic accidents in the UK.
  1. The incidence of PTSD was 27.5% in a study of patients who had had treatment in Intensive Care Units compared with a prevalence of PTSD in the general population of 2.7%.

Treatment of PTSD

One of the aims of treatment of PTSD is to deal with the vivid memories of the event. What is needed in PTSD is to be able to go to the memory of the event and change that in some way in order to make a learning and then separate off the attached negative emotions.

The original method of treatment was regression and abreaction where the client is regressed back in order to re-experience the event and let out the emotions that need to be released. Whilst this is still an effective technique, the client (and the therapist) found the technique distressing. If the client does not have any more emotional reserves than they had at the time of the original incident then they are re-traumatised and may even be made worse. In my opinion a counselling approach to trauma is inappropriate as that may also take the client back into the event in a similar way to regression and abreaction.

Newer techniques in order to treat PTSD and other sequelae of trauma have now been developed. This is the technique of dissociated imagery. The essence of this approach is that a metaphor is used in order to allow the client to be dissociated from the event by, for example, either floating above it or by seeing it as a projected film. This ‘distance’ or ‘dissociation’ serves to separate the client from the emotional impact of the event. Hence they do not re-experience the vivid distressing emotions. Negative emotions reduce our ability to respond with flexibility. The re-evaluation of the event ‘from a distance’ allows the client to develop new attitudes to the event and to change the memory in such a way that the strong negative emotions are not re-experienced as nightmares or flashbacks.

Treatment of PTSD is usually quick if undertaken by a therapist who is experienced in the use of dissociative imagery. However I do not feel that a client should be treated for this condition by an inexperienced therapist.

My expectation when I treat clients for PTSD is that they will have total resolution of nightmares and flashbacks and also return to their normal level of functioning. This is usually achieved within three or four treatment sessions.

I have considerable experience both in the treating of PTSD but also in training Health Professionals in the diagnosis and treatment of this condition. I undertook an outcome audit when I treated clients for PTSD when I was working in an NHS setting.

In order to see the abstract of my treatment audit please click here

If you wish to discuss treatment then please phone me on 01706 373825 for a free confidential assessment, or click here to e-mail

Poem

Poem – ‘I am Free’

I wrote the poem “I am Free” as a reflection of my observations of the effects of use of dissociative imagery in those suffering from PTSD. 

Click here to see the poem.