primary care management of the returning veteran with PTSD
Ptsd
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 [email_address]
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. 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 performance stress
5. 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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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 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.
14. 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.
15. 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."
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. 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 Denied Exaggerated Understood Forgotten
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
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?
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 )
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