Post Traumatic Stress Disorder Dr. Craig Jackson Senior Lecturer in Health Psychology School of Health and Policy Studi

1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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%

8. 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

9. Acute Stress and Chronic Stress Common After-effects Leave behind Life threatening One-off Ever-present By proxy

10. 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

11. 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

12. 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

13. 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.

14. 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.

15. 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."

16. 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

17. 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

18. 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

19. 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

20. 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”

21. 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

22. 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

23. Modern Day Reasons for Uses of Victim Support Mayou & Farmer 2002

24. 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

25. 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

26. 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

27. 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 ?

28. 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

29. 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?

30. 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

31. 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

32. 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

33. 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

34. Secondary Gain Pre-disposition • Non-economic motivation • Loneliness • Difficulty expressing emotional pain • Previous history of attention seeking when ill • Depression • Anxiety

35. 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

36. 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

37. 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

38. 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 )