Post Traumatic Stress Disorder by Professor Kevin Gournay

Post Traumatic Stress Disorder, (PTSD), is an age-old complaint but has only been labelled as such in the last 20 years or so. Previously it was called many things, including shell-shock, battle fatigue, anxiety reaction, etc. Over the years there have been many attempts to define this problem and recently the World Health Organisation and the American Psychiatric Association, who publish the two main classification systems in psychiatry, have agreed on the principles included under this term.

There are probably many members of No Panic who have one form or another of PTSD. They may have developed this as a result of a car accident, a physical assault, mugging or a range of other frightening events including, major accidents and disasters. Over the years I have seen many patients suffering from this condition, ranging from victims of the ‘Moorgate’ tube disaster, the ‘Kings Cross’ fire, the ‘Herald of Free Enterprise’ sinking, the inner city riots of the 1980’s, various terrorist atrocities, victims of armed robbery, etc. However, perhaps most commonly, I see people who have been involved in accidents on our roads and motorways. In PTSD the person involved has to have experienced, witnessed or have been confronted with events that have involved actual or threatened death or serious injury or a threat to the physical integrity of others. Therefore, in order to be traumatised, the person may not actually have suffered a real physical injury, but nevertheless has developed a great deal of fear or horror. (The above definition is derived from the diagnostic criteria of the American Psychiatric Association which is similar to the World Health Organisation definition).

Thus the condition may start with a trauma which involves, for example, a belief that one is about to die by being trapped in a life-threatening situation or being seriously injured. However, one may also be traumatised by witnessing an horrendous event. An example of this was the post traumatic stress suffered by people who witnessed the tragedy at ‘Hillsborough’ football stadium.

The symptoms of PTSD are manifest in three distinct categories. First of all there is a re-experiencing of the event, typically by the person suffering recurrent dreams or nightmares. There may also be vivid flashbacks occurring during waking times or the victim may be reminded of the trauma and this may also trigger intense distress. For example, a patient I saw who had been involved in a particularly horrendous armed robbery, had a panic attack whenever she heard gunfire on the television or saw anything which resembled the event in which she was involved. Reminders of the traumatic event will often lead to tremendous physical distress which may culminate in a panic attack.

People with PTSD often have considerable avoidance behaviour, often avoiding anything connected with the trauma and going to extreme lengths to avoid places or people connected with the trauma. Sometimes, there is a loss of memory of the events which is in effect a “blocking out” of the horror, or alternatively the person detaches or disengages themselves from others and, may appear aloof. In association with this avoidance behaviour, the sufferer may have a very bleak outlook on life in general and complain that they are unable to experience emotions such as love or joy towards others. There are a whole range of other symptoms which can be experienced, including problems with sleep, outbursts of anger for no apparent reason, being very jumpy and going through periods of acute depression.

Many cases of PTSD come to the attention of mental health professionals because the person who has suffered the stress takes to self-medicating drink or drugs in order to alleviate the distress. This has occurred most graphically in the case of war veterans from Vietnam and many of these people, who have experienced horrendous incidents, are still in a combined state of addiction and traumatic stress reaction, perhaps now in a state of permanent disablement.

What can be done about such conditions? First, it is important that this condition becomes much more recognised so that people can take preventative action. Thus, for example, after a road traffic accident, it is very important for the person involved to start travelling again as quickly as possible. In the case of this, and indeed other traumatic incidents, it is also important for the person to be able to ventilate their feelings and to have some time with somebody who is a good listener. Very often, going over the story of the incident is therapeutic in itself and the person, in a sense, exposes themselves to the original trauma thus, reducing their fear. However, in some cases, the trauma itself can become a total preoccupation obsession and this can be the reason why people are referred to professional services. In these cases, thoughts of the incident may fill every waking moment and be the sole topic of conversation. However, for most people quick re-exposure to the environment where the trauma took place and the opportunity to talk about the trauma (sometimes called debriefing) is very helpful.

In those cases where the PTSD has become a problem, referral to a specialist in cognitive/ behaviour therapy is essential. There is some evidence that in addition to cognitive/behaviour therapy, some patients need to be prescribed antidepressant drugs. These are sometimes helpful for dealing with the profound depression which occurs but there is also evidence that in some patients they are genuinely helpful in reducing the very high level of physical symptoms. Also, it is important that people who have been involved in accidents have thorough physical investigations as sometimes head injury itself can complicate the psychological reaction. In the case of people who have experienced head injury with loss of consciousness and who have developed PTSD, it is probably essential for them to be seen by a specialist neurologist or perhaps even a psychologist who specialises in neurological injury before they embark on a course of treatment. Sometimes, such head injuries can cause damage to the central nervous system and this of course needs to be identified. Today, we have at our disposal a range of techniques which allows us to study the brain and this new generation of scanners, in particular magnetic resonance imaging (MRI) scans can be very helpful in assisting diagnosis in cases where brain injury may have occurred.

Treatment for PTSD, carried out by a cognitive/behaviour therapist, normally consists of several strands. First of all, it is essential that the person be given adequate time to describe their feelings and, as mentioned above, this can be therapeutic in itself. Indeed, an extension of this approach may be to ask the person to write a detailed account of their problems. In some cases I have asked patients to compile a scrapbook of the event, drawing upon photographs, newspaper clippings, film and video or even asking for the assistance of the police to supply photographs. The compiling of such background information can often be very distressing for the patient but, the re-exposure involved can be extremely helpful. It is usually important to help the person break their avoidance behaviour by exposing them to the original environment where the trauma took place or, for example, travelling by the means of transport in which they suffered their accident. One family I treated from the ‘Herald of Free Enterprise’ needed to travel on a cross-channel ferry before their treatment was complete. This particular family made an excellent recovery from their symptoms. Treatment may also incorporate anxiety management training and homework exercises aimed at repeated exposure. As mentioned earlier, treatment may or may not be given in combination with antidepressant drugs and in some cases these drugs have to be taken over a period of many months.

I must mention the new technique for treating PTSD, which has recently been the source of considerable debate among health service professionals. This is called Eye Movement Desensitisation (EMDR). The procedure involves getting the person to imagine the original trauma and at the same time asking the person to perform specific eye movements by following the therapist’s finger movement with their eyes. This technique is apparently based on the idea that the brain can be “reprogrammed” and there are now several dramatic claims in journals regarding its effectiveness. In my opinion it is probably too early to say whether this technique can be widely applied as there is necessity, as in all treatments, for further research to determine its outcome. I would however go as far as to say that this treatment looks promising and provided it is offered by a properly trained psychiatrist or psychologist, I see no reason why the patient should not take advantage of the offer of treatment. If this procedure is going to work, it seems it will do so fairly quickly and therefore, bearing in mind the probability that there is very little risk attached to the procedure, it would be well worth trying if it is offered.

I must mention an emerging area where PTSD is a significant feature. It has been increasingly recognised that people who have been subjected to sexual abuse during childhood may develop  a state which is no different from conventional PTSD and is very similar to the state shown by women who have suffered rape. Although the post traumatic stress associated with rape is now becoming much more commonly recognised, PTSD associated with child sexual abuse is not. This is obviously a very difficult and sensitive area and my advice is that treatment for the traumatic stress associated with sexual abuse of one kind or another should be given within specialist services rather than a general psychiatric department.

In conclusion, PTSD is a commonly occurring problem which can cause considerable distress and major handicap to those who suffer it. However, the outcome with treatment is good and can be provided by specialist services. It must also be said, however, that the most effective treatment is probably very early debriefing and rapid re-exposure to the situation where the trauma took place. Readers of this Newsletter may be interested to know that the Institute of Psychiatry (which is attached to the Maudsley Hospital) continues to provide treatment for this condition and both Professor Isaac Marks and Professor William Yule, who work at the Institute lead teams of therapists and researchers. I am sure that, should the need arise, they would be pleased to accept referrals from patients’ GPs and it may be worth contacting them to provide further information.

Professor Kevin Gournay is an Emeritus Professor at the Institute of Psychiatry. He has more than 35 years of experience and is the author of more than 130 articles and books. He is based in Cheshunt Hertfordshire.

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