Post Traumatic Stress Disorder Dr. Craig Jackson Senior

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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_at_uce.ac.uk
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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
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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
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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
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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
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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
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Traumatic Events are Common Lifetime prevalence
of specific traumatic events (n2181) Type of
trauma Prevalence Assault 38 S
erious 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
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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
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Acute Stress and Chronic Stress
Common After-effects Leave behind Life
threatening One-off Ever-present By proxy
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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
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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
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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
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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 re-experiencing 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.
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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.
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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.
Post-traumatic 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."
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World War 1 and Developments First special
hospital CraigLockhart in Edinburgh Mausole
um 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
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• 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

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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
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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
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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
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Modern Day View Victim Identity of modern
warfare? Modern soldier seen as more
psychological than predecessors Political Cul
tural 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
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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
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Modern Day Reasons for Uses of Victim
Support Mayou Farmer 2002
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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
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Types of Modern Trauma Occupational Return to
work often slower than in other types of
injury Liaison with employer essential Compensatio
n 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
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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
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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 ?
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Compensation Neurosis Pending litigation Treatme
nt 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
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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?
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• 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
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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 Functiona
l 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 Wharfies
back Whiplash neurosis
Mendelson, 1984
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• 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

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• 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

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

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• 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
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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
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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
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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 )