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

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

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

Some Stress is good

Keeps one alert

Evolutionary perspective:

performance

Keeps one alive

Too little stress = extinction

Too much stress = extinction
Balance stress = evolution
Pressure is good - - Stress is bad

stress

Common Experience
Minor trauma is a part of everyday life
For most people these injuries are only transient
Some have psychiatric and social complications
Most people experience major trauma 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

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

Traumatic Events are Common

Lifetime prevalence of specific traumatic events (n=2181)
Type of trauma
Assault
Serious car or motor vehicle crash
Other serious accident or injury
Natural disaster
Other shocking experience
Diagnosed with a life threatening illness
Learning about traumas to others
Sudden, unexpected death of close friend or relative
Any trauma

Prevalence
38%
28%
14%
17%
43%
5%
62%
60%
90%

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

Acute Stress and Chronic Stress

Common
After-effects
Leave behind
Life threatening
One-off
Ever-present
By proxy

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

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

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

Case History 1
During active service in Northern Ireland the patient was involved in a
helicopter crash. The patient was strapped in but the blood and brains of his
"best mate" spattered him. Four months of psychological help was deemed
successful. Later, in the Gulf war, observation of troop transport helicopters
awakened his memories of the incident. He carried on successfully until he
was demobilised in 1994, when the support of regimental camaraderie was
lost. Helicopter transport of troops in a film, Bravo 2 Zero, forced his mind
back to the crash. Subsequently any reference to helicopters led to reexperiencing the trauma. The diagnosis of post-traumatic stress disorder was
straightforward when his military history was taken as part of an assessment
of fatigue, impaired memory, nocturnal sweating, rashes, musculoskeletal
aches, dyspnoea, and dyspepsia.

Case History 2
A young nurse was woken by a missile exploding to her left. Terrified and
claustrophobic she vomited and evacuated her bowel and bladder. Her
protective kit could not be removed until tests allowed the all clear to be
sounded about five hours later. She became too frightened to shower because
being naked would have prevented her running to a shelter. She took
accelerated discharge from the air force. She could not keep jobs because of
poor time keeping, irascibility, and disproportionate emotional responses to
minor adversity. Distressing recall of terrified anticipation of her death
occurred by day and night. She developed fatigue and anorexia and solitary
alcohol bingeing. She became claustrophobic when shopping or on public
transport where she vomited and screamed. Civilian consultations proved
unhelpful because no one asked about her experiences during the conflict to
learn the origins of her dysfunction.

Case History 3
A major aged 37 years directed some of the clear up of battle field carnage. He
saw and smelled many remains of Iraqi people but thought that he was not
affected. He became uncommunicative but irritable; his love of life and the
army diminished. Two years after his early retirement he saw a television
documentary on the Gulf and dramatically recalled the events of six years
previously. The smell of off-fresh chicken meat focused memories of rotting
flesh. Repeated recall of half-burnt Iraqi corpses forced 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 medical and rheumatological consultations were unhelpful. Posttraumatic stress disorder was diagnosed only after his battlefield and
psychiatric histories were considered. Many symptoms had not previously
been discussed. His wife felt "trapped in a tunnel with no lights" and
commented "I wish this Rupert could go to the Gulf and bring my old Rupert
back . . . I don't know how to help him."

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

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

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

World War 2 and Regression

200 psychiatrists recruited after Dunkirk
Churchill didnt 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

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

Modern Day View

Victim Identity of modern warfare?
Modern soldier seen as more psychological than predecessors
Political
context

Cultural
context

Medical
context

Has bred a population of vets with investment in being chronic cases

Culture of trauma and compensation links military and civilian worlds
Denied
Forgotten

Exaggerated
Understood

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

Modern Day Reasons for Uses of Victim Support

Mayou & Farmer 2002

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

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

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

Recent PTSD Cases in UK

Hurley
Police officer

vs

Fearon
vs
Injured burglar

Gwent Constabulary

Martin

Armstrong
vs
Home Office
Prison officer in Rosemary West trial
Expansions:

Witnesses and Bystanders ?

Good Samaritans ?

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 patients convictions
With time, care-eliciting behaviour may remain permanent
Bellamy, 1997

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?

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

Abnormal Illness Behaviour after Compensable Injury

Accident neurosis
Aftermath neurosis
Attitudinal pathosis
Compensatory hysteria
Compensation neurosis
Functional overlay
Greenback neurosis
Justice neurosis
Post accident anxiety syndrome
Postaccident fibromyalgia
Profit neurosis
Railway spine
Traumatic hysteria
Traumatic neurasthenia
Triggered neurosis
Vertebral neurosis
Whiplash neurosis

Accident victim syndrome

American disease
Barristogenic illness
Compensationitis
Fright neurosis
Greek disease
Invalid syndrome
Perceptual augmenter
Pensionitis
Post-traumatic syndrome
Psychogenic invalidism
Secondary gain neurosis
Symptom magnification syndrome
Traumatic neurosis
Unconscious malingering
Wharfies back
Mendelson, 1984

Secondary Gain Pre-disposition

Motivation
Desire for attention
Punish spouse / others
Solve lifes problems
Cry for help
Diversion from work
Socially approved task avoidance
sex with spouse
work
military duty

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

Secondary Gain Pre-disposition

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

Chronic Illness Behaviour (Care Eliciting Behaviour)

Disability disproportionate to detectable illness
Constant search for disease validation
Relentless pursuit of enlightened doctors
Appeals to doctors 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

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

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

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 )