TRAUMA
& PTSD
Prof Derrick Silove, MD FRANZCP
Prof Zachary Steel, PhD, [Link]
School of Psychiatry UNSW
Posttraumatic Stress Disorder -
Origins
American Civil War ‘Da-Costa’s Syndrome”
Soldiers Heart,
UK description of Railway Spine
His thoughts are confused; he often mixes
up one thing with another. He is very
nervous and easily frightened. He dreams
much, and is told that he talks and cries out
in his sleep. (Erichsen, 1867, p. 32)
Clinicalnotes from the French psychiatrist, Charcot,
identified traumatic neuroses amongst combat
veterans from the Franco-Prussian war (1870/71)
Posttraumatic Stress Disorder -
Origins
1917 introductory lectures on psychoanalysis, Freud provides the
following account of traumatic neuroses:
The closest analogy to this behaviour of our neurotics is afforded
by illnesses which are being produced with special frequency
precisely at the present time by the war - what are described as
traumatic neuroses. Similar cases, of course, appeared before the
war as well, after railway collisions and other alarming accidents
involving fatal risks… The traumatic neuroses give a clear
indication that a fixation to the traumatic accident lives at their
root. These patients regularly repeat the traumatic situation in
their dreams … we find that the attack corresponds to a complete
transplanting of the patient into the traumatic situation. It is as
though these patients had not yet finished with the traumatic
situation, as though they were still faced by it as an immediate task
which has not been dealt with (Freud, 1917/1973, pp. 274-275)
Historical trend to over- or under-
estimate trauma
Freud changed his mind…first incriminated actual
childhood abuse but then only fantasies of abuse
in the causation of adult psychiatric problems.
Posttraumatic Stress Disorder
th
20 Century
-WWI – traumatic neurosis – shell shock
substantial toll on the operational capacity of British forces,
80,000 cases of mental disorder being diagnosed between 1914-
1918; Two years after Armistice, approximately 65,000 ex-
servicemen were drawing disability pensions for
neuropsychiatric disorders including “shell shock”
WWII – Combat fatigue
1952 DSM-I “Gross Stress Reaction” individual has been exposed
to severe physical demands or extreme emotional stress, such as
in combat or in civilian catastrophe (fire, earthquake, explosion,
etc.)”
On the fringes of psychiatry discussion continued
- Concentration camp syndrome (K-Z) - Eitinger, 1961; Krystal,
1968; Niederland, 1964, 1968; Venzlaff 1963
Victims of Hiroshima nuclear bomb - Lifton, 1967
Posttraumatic Stress Disorder
th
20 Century
1968 – DSM-II - Adjustment Reaction of Adult Life
e.g combat; unwanted pregnancy
Nancy C. Andreasen, who would later be responsible for drafting
the PTSD criteria for DSM-III:
One might have expected a description of it in DSM-II when it
appeared in 1968. On the country, however, the [DSM-I] Category
of gross stress reaction was inexplicably dropped….No category
was provided in its place….The fate of the category seems to have
been tied to the history of warfare. DSM-II was compiled during the
relatively tranquil interlude between World War II and the Vietnam
conflict.
Perhaps in the absence of military conflict and in the presence of a
rather foolish optimism that did not contemplate its recurrence, the
category no longer seemed necessary, the Vietnam War…provided
convincing evidence for such a need. (Andraesen, 1980, p. 1518,
cited in Young 2004, p. 111)
What is a trauma?
DSM 5 defines as
an event that threatens life, serious injury,
or sexual violence
Directly expereincing
Witnessing the events occurring to others
Learning that the event occurred to a close
family member or friend
Experiencing repeated exposure to traumatic
events
Major categories of trauma
(Potentially Traumatic Events)
Civilian: Accidents, assaults, sexual
abuse/domestic violence, terrorism, natural,
professional
War-related: combat, bombings, torture and
related forms of victimization and abuse
More important distinction may be Human
Instigated Trauma Vs Natural Disaster &
Accidental Trauma
Posttraumatic Stress Disorder
Exposure to life threatening event
Intrusions: reliving images and memories, nightmares,
flashbacks, dissociation, triggers
Avoidance: of memories, social withdrawal, numbing,
phobias
Negative alterations in mood and cognition (change in
trauma beliefs, persistent negative emotional states)
Arousal: insomnia, poor memory and concentration,
startle, anxiety, physiological arousal, irritability
Prevalence: 3-8% in Australia, US, New Zealand; 15 –
40% in conflict-affected communities
Major contributor to global burden of disease
Acute Stress Disorder
Introduced in DSM IV for acute reaction
after trauma exposure (within one month of
incident)
Main symptomatic difference is emphasis
on dissociation symptoms: “being out of
touch, derealized, depersonalized”.
Strong predictor of subsequent development
of PTSD or other Psychiatric Disorder
Complex PTSD
Proposed for ICD-11: consists of elevated PTSD
symptoms + disturbances in self-organization;
affective dysregulation, negative self concept, and
interpersonal problems.
Long history of attempts to codify CPTSD over
last 30 years
DESNOS – Disorders or Extreme Stress NOS for
DSM-IV (excluded because of lack of
pathospecificity);
ICD-10 – Enduring Personality Changing follow
exposure to Catastrophic Experience (included but poor
uptake in field)
Fear learning: a dynamic balance
Cognitions
Ecosocial signals
medial
prefrontal
cortex
Hippocampus Dynamic
(Context)
Balance
Amygdala
Hypothesised neural circuitry of PTSD
Thalamus (the gateway for sensory input),
Hippocampus (active in short-term memory
processing and fear-related associative learning)
Amygdala (centrally involved in conditioned fear
responses)
Posterior cingulate, parietal and motor cortex
(which appear to be involved in visual processing
and assessment of threat)
Medial prefrontal cortex, including the anterior
cingulate, orbitofrontal, and sub-callosal gyrus
(which are hypothesised to play a critical role in
extinguishing primitive subcortical responses)
Hypothesised neural circuitry of PTSD
Hypothalamic-Pituitary-Adrenal (HPA) axis -
cortisol and catecholamine dysregulation;
adrenocorticotropic hormone (ACTH)
Family heritability in mediating risk to PTSD
documented in number of studies with Serotonin
transporter genotype (5-HTTLPR) as a candidate
mediator
Causes of PTSD
Classical learning theory: accounts for avoidance
and arousal but not intrusions
Information processing models: Intrusion
represents a core mechanism whereby the
organism can assimilate the traumatic material
into modified schemata
Cognitive behavioral models: Key role of threat
appraisal in maintaining PTSD
Evolutionary: Natural survival response to threat –
intrusions enhance learning of sources of novel
threat allowing rapid survival responses of
avoidance, hypervigilance – why does the reaction
persist and becomes dysregulated in some
individuals?
Course and outcome
Majority of people have symptoms immediately after
trauma exposure
Most show rapid improvement in early days and weeks
10-25 percent develop PTSD
Survival analysis indicates that between 30% and 40%
of cases remit within the first 12 months, but the median
time to remission for all cases is approximately four
years
Prospective survey of soldiers: 38% at one year; 25% at
3 years; 19% at 20-years
Prospective survey of civilian disaster: 32% four
months after the disaster, 27% at 11 months; 30%, at 29
months; 4% at 8 years
Risk factors
Pretraumatic: neuroticism, prior trauma or
abuse, past psychiatric illness, gender
Peri-traumatic: type of trauma (rape,
torture), extent and repetition (trauma load),
perceived life threat, proximity, effects on
others, controllability, dissociation
Post-traumatic: level of support and safety
in recovery environment
Intervention
Prevention: trauma inoculation – mixed evidence
Early intervention: controversy about debriefing
and awareness raising; difficulty predicting
vulnerable group
Timely detection of established PTSD at GP level:
identification, explanation, engagement
Medications: SSRIs and tricyclics are first line;
mood stabilizers, short-term benzodiazepines,
clonidine, beta blockers. Note comorbidity
CBT (treatment of choice): Prolonged exposure
therapy (imaginal and in vivo) + cognitive
processing; anxiety depression SUD, EMDR Eye
movement desensitization and retraining
Mass conflict, disasters and refugee
mental health
Natural Disasters: tsunami, earthquake
Human instigated trauma: war, persecution,
torture, incarceration, mass rape, restriction
in access to food, water and health care,
displacement, terror attacks: over a billion
persons affected world-wide
Impact of Refugee policies on
mental health of displaced persons
Australia accepts 13,000-20,000 off-shore refugees for
permanent resettlement each year – apply in other
countries
Variable number of persons seek asylum after they enter
the country: on-shore asylum seekers held in detention or
in insecure settings in community. Even if recognized as
refugees, offered temporary protection only
Distinct differences in psychiatric pathways between those
who receive permanent protection and those with insecure
status: eg Vietnamese show progressive reduction in
trauma-related symptoms over time while asylum seekers
show maintenance or worsening
Asylum seekers entering western countries: trauma-
affected persons living in fear of repatriation to
settings of danger…the unfortunate experiment
International policies of
deterrence
Those living in community
restricted in access and
activities
Those in detention: until
recently, prolonged period
of confinement
Figure 1: Prevalence (95% Confidence Interval) of Depression & PTSD:
Permanent Residents (n=101) and Temporary Protection Visa Hoilders (n=140)
70%
60%
50%
40%
30%
20%
10%
19% 50% 8% 44%
0%
Depression PTSD
Permanent Residents Temporary Protection Visa holders
Multilevel Model:
Temporary vs Permanent Protection
Overall
Disability R2
0.44
Ongoing PTSD
Depression
Symptoms
Past
Immigration TPV Status
detention
+ ve
Other influences
- ve
Family Integrity + ve
Pre-migration - ve
trauma / abuse
Hence need a wider, ecosocial framework for understanding
trauma in these populations: Adaptation and Development
After Persecution and Trauma (ADAPT) Model
Safety: Social: restoring peace, ensuring stability, end to
violence, secure housing, etc. Clinical: treatment for PTSD
Attachment: Social: Tracing, keeping families together,
reuniting, returning, consolidating communities, cultural
grieving rituals, remembrance; Clinical: treat complicated
grief
Identity Role: Social:Jobs, new roles, re-establishing
new identities, national aspirations, etc; Clinical: deal with
alienation, loss of direction
Justice: TRC, fair laws, tribunals; Clinical: deal with
anger
Meaning and Faith: religion, spirituality, political and
communal action; Clinical: deal with existential challenges
Mental Health in postconflict/resource
constrained environments eg East Timor
Combination of underdevelopment (artificial), mass
violence, displacement and persecution
Multiple unmet health needs: tropical, malnutrition,
physical trauma, neglect, maternal and child, etc.
No or poorly developed mental health services, “old”
institutional models, few or no MH professionals, poor
health infrastructure, doubts and stigma assoc. with MH
Debate whether to focus on: psychosocial programs that
build resilliency in population as a whole, on those with
trauma and grief reactions, or on the severely mentally ill
Situations of chaos: those who are bizarre or
incapable are at risk of exploitation, violence, head
injury, misadventure, malnutrition, disease, coercive
constraint
EAST TIMOR
35 y.o. man, chained to wall of house for 15 years,
psychotic, beaten almost to death by militia, released
and able to work in rice fields with family after 2
months treatment by PRADET.
18 y.o woman raped repeatedly in Emergency, locked in
burnt out “room”, mother caring for babyin open, no
food, Mo built high fences around ruins to safeguard
daughter: manic depression and PTSD
Tripartite Perspective
Severe
M.I
Psychosocial Trauma
Recovery
Comparison of Average Number of
Consultations by Disorder in Kakuma Camp,
1997-1999
16.0
Number of Consultations
14.0
12.0
10.0 1997
8.0 1998
6.0 1999
4.0
2.0
0.0
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Disorder
Principles of Intervention
Early post-emergency phase: Advise about importance of
restoring psychosocial stability based on ADAPT
principles: “the best therapist”
Emergency, community-based mental health service
working closely with primary care: based on urgency of
social need rather than diagnostic groupings:
PTSD: not too early and not too late: minority at social risk
tend to be selectively referred
Commence training and policy development, promote
community consultation and indigenous leadership
Reconstruction and Development
Phase
Establish community-wide network of mental
health services: equity, access, culturally-
appropriate, non-institutional, family-based
Incorporate indigenous and international concepts
and interventions
Ensure that special groups are attended to
including those with chronic traumatic/grief
syndromes who often are hidden from view
Promote mental health within the general health
agenda!
