A History of Post Traumatic Stress Disorder
Psychological trauma has a long history dating back to Homer – the “first teacher” of tragedy. As an etiological factor in mental disorders, “trauma” was first reported by Janet in the 19th century (Van der Kolk, 2004) which pointed to the theory that a person stored traumatic memories differently to ordinary memories.
Breuer and Freud (1895) study of “hysteria” largely agreed. Although the two men’s views differed about how and where a patient stored traumatic memories, Breuer- ‘misplaced and inaccessible’, Freud – ‘repressed’ (Leys, 2000), they both agreed that ‘hysteria’ whilst pathogenic in nature was a result of trauma.
In recent years ‘hysteria’ has been re-branded as PTSD and the American Psychiatric Association (1980) say that “controversy has haunted the diagnosis of posttraumatic stress disorder ever since”. Spiegel in Yehuda (1999) is pragmatic however, prompting that ‘progress in the field has rarely been “linear: but instead comes from unexpected sources’ – hence the fundamental need for therapists to stay abreast of new findings.
Defining Post Traumatic Stress
In physics ‘stress’ is described as “an applied force that tends to strain or deform a body” (Gaylin, 2003) which ‘cannot be measured directly but only inferred from measurements of strain’. Likewise, in human biology; a person’s stress can only be measured by the amount of strain they show externally via behavior, illness or words.
The word ‘trauma’ is derived from the Greek word for ‘wound’ and trauma is numerously termed a physical injury or a psychological injury caused by “severe emotional shock” (Lehmkuhl, 1996).
Amongst the many definitions of post-traumatic stress, the one that sits most comfortably with my personal humanist ethos is:
“The normal reaction of normal people to abnormal events.”
(Everly, Everly and Lating, 1995).
The term ‘post-traumatic stress’ therefore, describes the after-effects of a life-endangering or shocking event on a person’s psychological, physiological, and social constructs. Of course, ‘how threatening or intense an experience may be, is also to some extent a matter of individual subjectivity’ (Spiers, 2001. P.45).
Debate persists as to the exact nature of ‘stress reactions’ (Freyd & DePrince, 2001) and when a treatment intervention can (or should) be offered.
Selye’s (1956) three phase model describes how in the early stages after a shock or trauma a person may experience an acute response followed by resistance and then either recovery or exhaustion.
She goes on to explain that symptoms may include, disorientation, restricted responses to surroundings and fatigue. Symptoms can appear within minutes of the actual event and can either dissipate or continue and from approximately two days forward are described from a psychiatric perspective as ‘Acute Stress Disorder’.
This may be present through to the end of the ‘natural’ biological healing period, purported to be one month, whereupon if symptoms continue a diagnosis of PTSD may be offered.
Post-traumatic stress disorder
PTSD is described by Jackson (2003) as ‘the development of characteristic symptoms’; listed in the DSM as the predetermined conditions or diagnostic criteria for PTSD.
They are threefold:
- evidence of intrusive recollections
- avoidance of associated trauma stimuli
- symptoms of increased arousal (Van der Kolk, 2004).
Symptoms can be re-experienced days or months after the event triggered by sounds, sights and smell or unexpectedly without warning. The intrusive recollections may be experienced as flashbacks or nightmares and the sufferer may also start to avoid things that remind them of the event such as going near ‘the scene of an accident’. In hyper-arousal they may appear jumpy, irritable or hyper-vigilant and this, in turn, may affect their sleep or concentration. People suffering from PTSD often present to the GP with physical symptoms such as headaches, tiredness, and chest pain and in some cases an increase in drinking or smoking habits is reported.
Early distress indicator
One of the most common reactions to trauma reported by clients is one of dissociation; summed up by Waites (1993) as ‘a psychobiological mechanism that allows the mind to ‘‘flee’’ what the body is experiencing’ (Austrian, 2003).
From a purely psychological perspective Cash (2006) citing Bessel van der Kolk proposed that dissociation has a more natural function in that it allows the trauma victim ‘to observe the experience from a safe, less intense distance, serving as a form of protective detachment’. Hobson’s (2001) theory aligns somewhat, although he describes this neurobiological process “as a natural propensity of normal brain-mind states” for example sleeping and dreaming being two normal, natural, dissociated states.
At the other end of the spectrum, a person may experience a full-blown “disruption of consciousness, memory, identity, and perception of the environment” (Scaer, 2005 P.177). In essence, a person can become so detached or disconnected to ‘the event’ or ‘their life’ that their reality becomes distorted leaving them feeling fragmented, lost or in extreme cases feeling invisible or dead.
Rosen’s (2004) research found that dissociation plays a role in PTSD development in some individuals but not in others and Carr’s (2001) work confirms this, concluding that people exposed to repeated trauma ‘may cope by dissociating their consciousness from the experience of the trauma by entering a trance-like state’ and that the habit of dissociation is strengthened simply because it brings relief from distress.
Treatment of PTSD
By 1980 the need to recognise ‘trauma’ as a condition requiring psychological intervention determined its reintroduction to the DSM-III; this time termed Post Traumatic Stress Disorder. Van der Kolk (2004) stated that the mere inclusion of PTSD in the DSM-III in 1980 ‘marked a major turning point’ for the identification and treatment of client trauma in medical health settings.
The aforementioned symptoms are the basis for the three ‘clusters of symptoms’ described in the current DSM-IV (1994) as the criteria required for a diagnosis of PTSD which must include, exposure to a traumatic event, meeting two criterion from five and displaying symptoms from each of the three symptoms clusters; intrusive recollections; avoiding/numbing symptoms and hyperarousal symptoms.
In treatment, it is always important to explore a person’s cognitive coping strategies i.e. “how I am supposed to deal with trauma”. Parkinson’s (1993) research found that “certain attitudes and beliefs of the society in which we live in can actually make it more difficult for us to cope with loss”, and social support is perhaps the most important factor of all in the treatment process. It is generally acknowledged that people with more developed social networks are far less likely to develop PTSD. Van der Kolk (1996) research shows that in actuality “during acute trauma, the social environment tends to respond with generosity….and every society seems to have evolved social and religious structures that are geared to helping severely distressed people”.
The breadth and depth of theory and research around PTSD is immense but almost all existing models sprung from and owe something to Horowitz’s (1976, 1986) ‘stress response theory’ which suggests polar opposite responses in a person’s reaction to stress; one being normal the other abnormal. Its psychoanalytical roots describe ‘two opposing processes at work’ (Brewin & Holmes, 2003) one which defends (by suppression of information) the individual; the other which promotes ‘the working through’ of the traumatic material by bringing it to mind. Horowitz theory posits the effects on a person of intrusion and avoidance (denial) hence it became known as the two-factor model and was adopted by the APA as ‘the framework for the new concept of PTSD’ (Joseph, Williams, Yule. 1997).
In clinical practice these days, the measurement scales most widely used are Subjective units of distress (SUDS) an 11-point scale where 10 reflects the highest level of distress or disturbance and 0 the lowest level or absence of distress/disturbance (Thyer et al., 1984) and the Clinician-Administered PTSD Scale (CAPS). Data from a large-scale psychometric study of the CAPS-1 have provided impressive evidence of its reliability and validity as a PTSD assessment tool (Blake et al 1995).
An individual’s response to ‘trauma’ can be likened to responding to a lightning bolt; an event that is really powerful and which could wound or kill. A person responds to threat instinctively and the primitive part of the brain sends out the fight, flight or freeze message to the body. Physiological responses in the body can include sweating, fast heart rate, shaking legs, shallow breathing and one of the complications of PTSD can be what Scaer (2005) describes as ‘body memory’. Van der Kolk (1994) research confirms ‘body memory’ as a phenomenon saying “the inability of people with PTSD to integrate traumatic experiences and their tendency, instead, to continuously re-live the past are mirrored physiologically and hormonally in the misinterpretation of innocuous stimuli as potential threats” Flynn and Norwood (2004) study showed that the majority of people, when exposed to traumatic events, do not develop PTSD; many people will experience PTSD-like symptoms, but these subside after a few weeks and only a small percentage go on to develop full-blown PTSD.
Throughout his years of research Horowitz (1976, 1986) took on a wider perspective to trauma recognising the impact of trauma on a person’s belief systems; about themselves; their world and their future. His theory is bracketed into the ‘social-cognitive’ models group and links closely with another ‘social-cognitive model; that of Janoff-Bulman (1992) ‘shattered assumptions’ theory. This theory hypothesizes that ‘we’ have a number of illusory assumptions regarding life and the world; ‘the world is benevolent, the world is meaningful, and the self is worthy’ (Brewin & Holmes, 2003). When an unexpected or horrific event happens in our life it shatters these assumptions for example; traumatic event – reaction “I thought the world was safe and now I know it’s not”; meaningful – reaction “the world is not fair, why me?”; worthy – reaction “I’m a good person, surely bad things only happen to bad people?” In ‘shattered assumptions’ theory a therapist would be seeking to help people integrate or accommodate this new knowledge. Bolton and Hill (1996) enlarge on this by looking at people’s belief systems which they concluded contain; the self as a competent human being; that the world is fairly predictable; and that the world will satisfy our needs. A traumatic event challenges these beliefs and creates feelings of helplessness in a person totally contradicting the belief system. These are all protective illusions hence, we can see that in social-cognitive theories emphasis is placed on integrating the effects of the event into pre-existing beliefs and assumptions.
As human beings we receive all our information through our senses, hearing, seeing, smelling, touching and tasting. We feel an emotional response to these sensory stimuli and attach meaning to it. In ‘information processing theory’ how we process and store that memory is an important factor in the development of PTSD. Foa et al (1989) elaborated on this idea adding that a traumatic memory has a particular structure and is represented in memory differently to a normal memory (Brewin & Holmes, 2003) and that behavioural and physiological responses are much stronger in trauma memories than in everyday memories. The early ‘fear network theory’ has since been enhanced by attention to the individual’s pre-trauma views of self. Foa et al (1993, 1996) proposed that ‘individuals with more rigid self-views either positive or negative were more susceptible to PTSD.
Treatment for PTSD
In terms of the treatment of PTSD, the National Institute for Clinical Excellence (NICE, 2005) recommend ‘patient-centred care’; that is to say that the patients ‘individual needs and preferences’ are taken into account, although the NICE guidelines are in essence quite prescriptive.
Recommendations currently include; (for the initial response to trauma) a period of ‘watchful waiting’ with a one-month follow-up appointment. Interestingly the NICE guidelines say that a single session or debriefing session should not be routine practice. Whilst I agree with NICE that patients preferences should be considered I prescribe to Parkinson’s (2000) more wide-ranging psycho-educational approach to treatment who advises that the therapist make the client aware of a range of methods of helping and includes ‘critical incident debriefing’ (to be carried out within 72 hours of the trauma), the aim of which is “to give an opportunity for people to talk and share their experiences and feelings”; self-help and awareness; group work; survivor groups; and for those that go on to develop PTSD; behavioural treatments; cognitive treatments; psychotherapy; group therapy and medication. In contrast, the NICE guidelines suggest that only those with severe symptoms be offered one of two psychological interventions; trauma-focused cognitive behavioural therapy (TFCBT) or eye movement desensitisation and reprocessing (EMDR).
Trauma-Focused Cognitive Behavioural Therapy was originally developed “to help address the unique biopsychosocial needs of children with Post Traumatic Stress Disorder (or other problems related to traumatic life experiences, and their parents or primary caregivers” (NCTSN, 2008). Foa et al (2008) agree with Parkinson that the first step of treatment should be psycho-educational i,e. treatment should never be a mystery. The skills the therapist teaches to the client in this model are cognitive coping; connecting thoughts, feelings, and behaviours pertaining to the trauma; behavioural strategies including relaxation which are personalised towards the client, and gentle and gradual exposure to the traumatic material. In the early stages, Van der Hart (2006) advises that we give our client some basic tools for coping introducing them to a ‘safe-place’ exercise and relaxation and that “from the outset of therapy with trauma survivors, the therapist should be aware that shame is likely operating, even though the patient does not verbalise it”.
EMDR (the working-memory account) as a treatment attempts to desensitize the client to emotive memories (Gunter and Bodner, 2008). Kavenagh et al., (2001) posit that working memory has two systems; one system that stores verbal and auditory information and a second that stores visuospatial information (VSSP). During EMDR treatment, the client is asked to bring unpleasant material to mind whilst the therapist instructs the eye movement. Andrade et al., (2001) have suggested that it is the VSSP store where memories are held during EMDR sessions and that “these images become less vivid when eye movements concurrently use up processing resources in the VSSP. This reduced vividness then cascades into reduced emotionality” (Kavanagh et al., 2001).
NICE (2005) do not advocate drug treatment as a first-line treatment but rather only for those that request it in preference to psychological treatment. ‘Paroxetine is the only drug listed with a current UK product license for PTSD at the date of publication’ (Nice, 2005). Medication is a factor that is frequently overlooked in the treatment of PTSD but which can actually be of great help. “Recently, there has been increased attention to the newer ‘selective serotonin reuptake inhibitors’ in PTSD with several SSRI’s appearing useful in open trials”. In the short term, a SSRI medication can make a positive contribution to overall health as can a healthy diet containing plenty anti-oxidants such as ‘berries, tomatoes, carrots, cherries, and grapes which are all known for their rich antioxidants content. In addition foods rich in Omega 3 such as oily fish, soya and pumpkin seeds inhibit oxidation in the body and may help to prevent damage to healthy cells.
As a society, we are becoming better equipped to deal with ‘trauma’ and in the advent of the enormous amount of research that has been undertaken over the last twenty years we now have an approach which is used particularly in the case of a large-scale disaster called ‘Psychological First Aid’ (PFA).
PFA is described as “an evidence-informed modular approach for assisting people in the immediate aftermath of disaster” (NCPTSD). It has a multi-faceted function which aims to coordinate the emergency services, first responders, critical incident teams whilst also supporting groups of distressed people and individuals with information, advice and psychological support from the very outset of the event.
There is always the danger in social terms that the therapist becomes part of the problem, for example adding to the sense of urgency and treating the person as a medical emergency when perhaps they don’t need such heavy assistance. Hobfoll and deVries (1995) advocate wariness of quick responses due to the potential to get drawn into ‘panic’ but recognising that when peoples’ own resources are depleted, outside help needs to be mobilised to compensate for their helplessness.
Van der Kolk (1996) says that the first task of psychological treatment is for patients to regain a sense of safety in their own bodies, but not to overlook the prior practicalities of the situation for example by sign-posting and supporting people through the legal system which can be important symbolically and also practical in channelling aggressive impulses (Van der Kolk, 1996).
Personal growth from trauma.
In an attempt to make meaning of tragedy they have suffered, traumatised people often come out of horror determined to make life better for others – so that they don’t “go through the same thing as me”.
This particularly holds true for parents who have lost a child in unusual circumstances such as, Leah Betts, Sarah Payne, Jamie Bulger, Stephen Lawrence’s parents have all chosen to campaign or teach the lessons learned from the death of their child in order to help others.
“Post-traumatic growth is a reminder to society at large and to helping professionals that trauma-affected people and communities have the potential for more than just survival and recovery and that they are a source of inspiration and role model for us all”. (Julian Ford, Families of September 11th.)