Trauma, dissociation and PTSD
What is PTSD?
Current diagnostic criteria as set out in into the American Psychiatric Association’s Diagnostic and Statistical Manual – Fifth Edition DSM-V require a person to have been exposed to one or more traumatic events where they felt that their life or someone else’s life was under threat or that they or others were going to be injured. It is the phenomenon of suddenly realising that someone is going to die or become seriously injured that produces the features of PTSD. These symptoms may appear soon after the event or at some time later. In DSM-V, the person must have been exposed to: violent or accidental death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, either by: direct exposure to self; witnessing, in person or indirectly, e.g. by learning that a close relative or close friend was exposed to trauma, or by: repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties. However, this does not include indirect non-professional exposure through electronic media, television, films or pictures.
Diagnostic criteria as set out in DSM-V require symptoms to be present for four weeks or more before a diagnosis can be made with problems emerging before this time either being described as ‘acute stress disorder’ or what are termed as ‘adjustment’ reactions or disorders. Not all patients suffering from acute stress disorder, which requires a certain degree of post-traumatic dissociation (feeling detached or distant from your body or the outside world) to be present, go on to develop PTSD and many later go on to develop PTSD without prior acute post-traumatic dissociation. If symptoms do not materialise before six months then a delayed onset is said to have occurred and if the symptoms last for more than just one month, then the disorder is described chronic.
What are the symptoms of PTSD?
There are four groups of symptoms with which PTSD sufferers present in differing combinations and at least one of each, and in some cases more, must be found to be present before a diagnosis can accurately be made. The first group of symptoms are symptoms of ‘intrusion’ occurring as nightmares or disturbing dreams, unpleasant thoughts, emotions or physiological reactions to sights, smells, sounds or other cues reminding the patient or client of the original or traumatic event or, less often, as the classic ‘flashback’ which, again, can occur in any one or more of the senses. At least one of these symptoms is required for a diagnosis.
The second group are symptoms of behavioural or cognitive avoidance (avoiding people, places or activities that remind the client of the event) or making efforts to try to avoid remembering or thinking about the traumatic event. Again, at least one symptom of increased avoidance is required by DSM-V.
The third group of symptoms concerns negative changes in thoughts and mood together with persistent distorted beliefs and emotions. People typically report memory difficulties and difficulties in concentrating on, for example, the plot of a television programme or the thread of a novel. There is often diminished interest in activities that PTSD sufferers used to enjoy before the event and sometimes there is a partial or complete inability to be able to remember some of the details surrounding the traumatic event. There is also a possibility of people experiencing posttraumatic symptoms following an event such as, for example, a road accident where there has been a loss of consciousness.
Lastly, the changes that occur after massive psychological trauma produce a number of symptoms of increased arousal. However, a number of other problems also occur including sleeping difficulties, increased hypervigilance (‘jumpiness’) and startle responses and an increase in anger control problems. These latter problems are, again, extremely difficult to treat and often require additional psychological treatment even after the nightmares and avoidance has resolved. DSM-V requires at least two symptoms of increased arousal if diagnostic criteria are to be satisfied.
The final requirement is that the person must be experiencing substantial and significant impairment in one or more areas of their life as a result of the problems which they are experiencing following their exposure to trauma. These problems may be occurring in their work, home lives, relationships, leisure activities or, indeed, in all the aspects of their post-traumatic life and that the symptoms (not caused by medication, drugs or alcohol) persist for more than one month.
PTSD is not new!
The condition known as Post-Traumatic Stress Disorder (PTSD) has been in existence as a specific diagnosis since 1980 although there are documented instances of people suffering from psychological effects of trauma dating right back to Ancient Mesopotamia and the Battle of Marathon (490 BC) as described by the historian, Herodotus. Famous people in history who have described PTSD include the playwright William Shakespeare (Henry IV, Pt 1), the diarist Samuel Pepys after the great Fire of London and the novelist Charles Dickens after his involvement in an early railway accident.
Treatments for PTSD: Cognitive Behavioural Therapy and EMDR
The primary recommended treatments for PTSD (NICE, 2005) are Cognitive Behaviour Therapy (CBT) and Eye Movement Desensitisation and Reprocessing (EMDR).
CBT has traditionally been carried out by clinical psychologists and behavioural nurse therapists but is increasingly now also being taught to psychiatrists. CBT involves relaxation training, cognitive and in-vivo exposure and, most importantly, cognitive processing and restructuring with the aim of modification of underlying beliefs and thoughts and the reduction of cognitive avoidance strategies.
EMDR involves imaginal therapeutic exposure to as much as possible of the material that has been stored (consciously or unconsciously) in the brain, achieving both in-session and between-session reduction and habituation of the fear response (a reduction of symptoms both during the session itself and between sessions) substituting unhelpful thoughts and beliefs with ones that are more adaptive and will help the client to achieve the goal of post-traumatic growth.
Professor Jamie Hacker Hughes is an HCPC Registered Clinical Psychologists and Chartered Psychologist, a Cognitive Behavioural Psychotherapist and an EMDR Consultant. He has specialised in working with victims of trauma over the past 20 years.
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