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Post Traumatic Stress Disorder Dr. Craig Jackson Senior Lecturer in Health Psychology School of Health and Policy Studies Faculty of Health & Community Care University of Central England. craig.jackson@uce.ac.uk. Futility of stress research

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slide1

Post Traumatic Stress

Disorder

Dr. Craig Jackson

Senior Lecturer in Health Psychology

School of Health and Policy Studies

Faculty of Health & Community Care

University of Central England

craig.jackson@uce.ac.uk

slide2

Futility of stress research

“One evening we had an almost inaudible talk from…..the BBC staff doctor who told us how to recognise stress in our staff: the body sits slumped, with the head shrunk between the shoulders. At least I think that is what he said. He was difficult to hear as we were all sitting slumped with our heads shrunk between our shoulders”

Frank Muir in A Kentish Lad

slide3

Stress

Golden Age of Stress

Everyone is Stressed

BBCi - “Stress” = 16,000 finds

More people experiencing more stress

Greater demands from employers

People working longer hours

24 / 7 society

World Wars I and II

Where was stress?

Possible evidence from dud shells

slide4

performance

stress

Some Stress is good

Keeps one alert

Keeps one alive

Evolutionary perspective:

Too little stress = extinction

Too much stress = extinction

Balance stress = evolution

Pressure is good - - Stress is bad

slide5

Common Experience

Minor trauma is a part of everyday life

For most people these injuries are only transient

Some havepsychiatric and social complications

Most people experience majortrauma 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

slide6

What kids think of stress

  • STRESS
    • Looks like a flaming deamon (sic) Sounds like an eagle squaking (sic)
    • Tastes like a burnt sausage Smells like sour milk Feels like stroking a hedgchog (sic) Stress is when mum says NO!!!!!
  • by Andrew (aged 10) Year 5 Potley Hill Primary School
slide7

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%

slide8

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

slide9

Acute Stress and Chronic Stress

Common

After-effects

Leave behind

Life threatening

One-off

Ever-present

By proxy

slide10

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

slide11

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

slide12

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

slide13

Case History 1

During active service in Northern Irelandthe patient was involved in a helicopter crash. The patient wasstrapped in but the blood and brains of his "best mate" spatteredhim. Four months of psychological help was deemed successful.Later, in the Gulf war, observation of troop transport helicoptersawakened his memories of the incident. He carried on successfullyuntil he was demobilised in 1994, when the support of regimentalcamaraderie was lost. Helicopter transport of troops in a film,Bravo 2 Zero, forced his mind back to the crash. Subsequentlyany reference to helicopters led to re-experiencing the trauma.The diagnosis of post-traumatic stress disorder was straightforwardwhen his military history was taken as part of an assessment offatigue, impaired memory, nocturnal sweating, rashes, musculoskeletalaches, dyspnoea, anddyspepsia.

slide14

Case History 2

A young nurse was woken by a missile explodingto her left. Terrified and claustrophobic she vomited and evacuatedher bowel and bladder. Her protective kit could not be removeduntil tests allowed the all clear to be sounded about five hourslater. She became too frightened to shower because being nakedwould have prevented her running to ashelter. She took accelerated discharge from the air force. She could not keep jobs because of poor time keeping, irascibility, anddisproportionate emotional responses to minor adversity. Distressingrecall of terrified anticipation of her death occurred by dayand night. She developed fatigue and anorexia and solitary alcoholbingeing. She became claustrophobic when shopping or on publictransport where she vomited and screamed. Civilian consultationsproved unhelpful because no one asked about her experiences duringthe conflict to learn the origins of herdysfunction.

slide15

Case History 3

A major aged 37 years directed some of theclear up of battle field carnage. He saw and smelled many remainsof Iraqi people but thought that he was not affected. He becameuncommunicative but irritable; his love of life and the army diminished.Two years after his early retirement he saw a television documentaryon the Gulf and dramatically recalled the events of six yearspreviously. The smell of off-fresh chicken meat focused memoriesof rotting flesh. Repeated recall of half-burnt Iraqi corpsesforced 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 medicaland rheumatological consultations were unhelpful. Post-traumaticstress disorder was diagnosed only after his battlefield and psychiatrichistories were considered. Many symptoms had not previously beendiscussed. His wife felt "trapped in a tunnel with no lights"and commented "I wish this Rupert could go to the Gulf and bringmy old Rupert back . . . I don't know how to helphim."

slide16

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 Sasson

Repressed Trauma ?

Localised electric shock ?

Hypnosis ?

ETHICAL DILEMMA:

GET TROOPS BETTER, TO SEND THEM BACK TO TRENCHES

slide17

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
slide18

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

slide19

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

slide20

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”

slide21

Denied

Forgotten

Exaggerated

Understood

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

slide22

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

slide24

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

slide25

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

slide26

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

slide27

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 ?

slide28

Compensation Neurosis

Pending litigation

Treatment results often poor

Some overt malingering

Exaggerated illness due to:

suggestion + somatization

rationalization + distorted sense of justice

victim status + entitlement

Adverse legal / admin. systems

Harden patient’s convictions

With time, care-eliciting behaviour may remain permanent

Bellamy, 1997

slide29

Compensation Neurosis

Improvement in health.....

...may result in loss of status

Patient compelled to guard against getting better

Financial reward for illness is a powerful nocebo

Exacerbates illness

In a litigious society, will compensation neurosis become more widespread?

slide30

Accident Neurosis

  • Failure to improve with treatment until compensation issue settled
  • Accident must occur in circumstances with potential for compensation payment
  • Inverse relationship to severity of injury - Accident neurosis rare in cases of severe injury
  • Low socio-economic status favors accident neurosis
  • Complete recovery common following settlement of compensation issue
  • ? ? ?

Miller, 1961

slide31

Abnormal Illness Behaviour after Compensable Injury

Accident neurosis Accident victim syndrome

Aftermath neurosis American disease

Attitudinal pathosis Barristogenic illness

Compensatory hysteria Compensationitis

Compensation neurosis Fright neurosis

Functional overlay Greek disease

Greenback neurosis Invalid syndrome

Justice neurosis Perceptual augmenter

Post accident anxiety syndrome Pensionitis

Postaccident fibromyalgia Post-traumatic syndrome

Profit neurosis Psychogenic invalidism

Railway spine Secondary gain neurosis

Traumatic hysteria Symptom magnification syndrome

Traumatic neurasthenia Traumatic neurosis

Triggered neurosis Unconscious malingering

Vertebral neurosis Wharfie’s back

Whiplash neurosis

Mendelson, 1984

slide32

Secondary Gain Pre-disposition

  • Motivation
  • Desire for attention
  • Punish spouse / others
  • Solve life’s problems
  • Cry for help
  • Diversion from work
  • Socially approved task avoidance
  • sex with spouse
  • work
  • military duty
slide33

Secondary Gain Pre-disposition

  • Potential Claimants
  • Military patients nearing severance
  • Workers under retirement age
  • Low job satisfaction
  • Workers soon to be made redundant
  • Members of support groups
slide34

Secondary Gain Pre-disposition

  • Non-economic motivation
  • Loneliness
  • Difficulty expressing emotional pain
  • Previous history of attention seeking when ill
  • Depression
  • Anxiety
slide35

Chronic Illness Behaviour (Care Eliciting Behaviour)

  • Disability disproportionate to detectable illness
  • Constant search for disease validation
  • Relentless pursuit of “enlightened doctors”
  • Appeals to doctor’s responsibility
  • Attitude of personal vulnerability and entitlement to care by others
  • Avoidance of health roles due to lack of skills and fear of failure
  • Adoption of sick role due to rewards from family, friends, physicians
  • Behaviours which sustain the sick role - complaints, demands, threats

Blackwell, 1987

slide36

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 trauma

slide37

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

slide38

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 )