POST TRAUMATIC STRESS DISORDER

The label Post traumatic Stress Disorder (PTSD) was first used in 1980 when the Diagnostic and Statistical Manual of Mental Disorders (DSM), third edition was published by the American Psychiatric Association. This manual provides a common language and standard criteria for the classification of mental disorders. This provides clear criteria for the diagnosis and classification of PTSD. This manual has been subsequently updated, the latest edition being DSM-5 which was published in May 2013 (DSM-5, 2013).

 


Historical context

Pierre Janet – a colleague of Sigmund Freud, the forefather of psychoanalysis, first described this collection of symptoms (Van Der Kolk, 1989). In World War One it was called ‘Shell Shock’ but the condition was often not considered (Shepherd, 2000). Many soldiers who, in retrospect, were clearly suffering from PTSD were executed for ‘cowardice in the face of the enemy’. During the Second World War the label ‘Combat Fatigue’ (Saul, 1945) was attached and then after that ‘Post-Vietnam Syndrome’ (Friedman, 1981).

Diagnosis of PTSD requires the taking of a history and also direct questioning of the patient. DSM-5 has rigid conditions that need to be satisfied before a diagnosis of PTSD is made.

I have considerable experience in the diagnosis and treatment of PTSD. I have contributed sections in books on this subject (Degun-Mather, 2006; Brann, et al. [Eds.] 2011) and also had an article on the treatment of PTSD published in a peer reviewed journal (Ibbotson and Williamson, 2010). I, also, regularly run training workshops on the diagnosis and treatment of PTSD.

Many think that PTSD is only a problem with military personnel or veterans. However PTSD can occur after experiencing or witnessing traumatic events such as 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 (Ibbotson and Williamson, 2010).

How common is PTSD?

One important finding is that PTSD is relatively common, affecting around 5% of men and 10% of women at some point in their life (Kessler et al., 2005). Within the emergency services (fire, police and ambulance) the incidence of PTSD can be as high as 15 per cent (Kinchin, 2005). It was found that PTSD had an incidence of 23% four to six months following road traffic accidents in the UK (Holeva et al., 2001). 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%. (Scragg et al., 2001).

Other problems associated with PTSD

PTSD may be associated with depression, anxiety disorders or alcohol or substance abuse. The presence of these associated factors can complicate the treatment of PTSD.

“The diagnosis of PTSD remains controversial 30 years after its ratification in the third edition of the Diagnostic and Statistical Manual of Mental Disorders. This is perhaps because, unusually among the anxiety disorders, PTSD implies categories of victim and perpetrator that often entangle moral and scientific discourse. When someone develops PTSD, there is often someone to blame. When someone develops panic disorder, there is no one to blame. This entangling of the scientific, the political and the moral ensures that the diagnosis of post-traumatic stress disorder remains controversial” (Rosen, 2004).

Symptoms

There are four main elements to the clinical syndrome PTSD (DSM-5)

Intrusion symptoms such as nightmares, flashbacks or psychological distress induced by contact with external triggers.
Avoidance of stimuli associated with the traumatic event(s).
Negative alterations in cognition and mood associated with the traumatic event(s).
Marked alteration in arousal and reactivity associated with the traumatic event(s).

Flashbacks

During a flashback an individual 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 an individual develops the ability to dissociate as a coping mechanism during trauma. However this is an academic distinction – what is important is that hypnosis is an extremely effective tool in the treatment of PTSD.

 

 Treatment

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.

Antidepressants are widely used for symptom control in PTSD. However successful treatment also requires talking therapy such as dissociated imagery for PTSD. The therapist requires specialised training in order to safely and effectively treat those who are suffering from PTSD.

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.

Specialised therapy allows the client to reprocess the unconscious links to the trauma and hence allows resolution of the condition. Such interventions can only be undertaken if the client has stability in their social situation and is no longer exposed to trauma.

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 – ‘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.

References

Brann, L., Owens, J. & Williamson, A. (Eds.) (2011) The Handbook of Contemporary Clinical Hypnosis; Theory & Practice. ISBN 978-0-470-68367-5 Wiley-Blackwell, Oxford.
Degun-Mather, M. (2006) Hypnosis, Dissociation and Survivors of Child Abuse. Wiley, Chichester.
DSM-5. (2013) Diagnostic and Statistical manual of mental Disorders – Fifth edition. American Psychiatric Association, Washington, DC.
Friedman, M. (1981) Post-Vietnam Syndrome. Psychosomatics, 22, 931-942.
Holeva, V., Tarrier, N. & Wells, A. (2001) Prevalence and Predictors of Acute Stress Disorder and PTSD Following Road Traffic Accidents: Thought Control Strategies and Social Support. Behavior Therapy, 32, 65-83.
Ibbotson, G. & Williamson, A. (2010) Treatment of Post-traumatic Stress Disorder Using Trauma-Focussed Hypnosis. Contemporary Hypnosis, 27, 257-267.
Kessler, R. et al. (2005) Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602.
Kinchin, D. (2005) Post Traumatic Stress Disorder: the invisible injury, ISBN 0952912147. Success unlimited, Didcot, Oxfordshire, UK.
Rosen, G. (Ed.) (2004) Posttraumatic stress disorder. Wiley, Chichester.
Saul, L. (1945) Psychological Factors in Combat Fatigue. Psychosomatic Medicine, 7, 257-272.
Scragg, P., Jones, A. & Fauvel, N. (2001) Psychological problems following ICU treatment. Anaesthesia, 56, 1, 9-14.
Shephard, B. (2000) A war of nerves: Soldiers and Psychiatrists. Jonathan Cape, London.
Van Der Kolk, B., Brown, P. & Vanderhart, O. (1989) Pierre Janet on post-traumatic stress. Journal of Traumatic stress, 2, 365-378.