Recognising And Dealing With Post-Traumatic Stress Disorder

By Tony McHugh.

Post-Traumatic Stress Disorder (PTSD) is a psychiatric consequence of exposure to potentially traumatic events (PTEs); that is, events where the person experienced, witnessed, or was confronted by an incident involving actual or threatened death, serious injury or threat to the self or others. Such events include war and war-like occurrences, physical and sexual assault, serious accidental injury and (natural and man-made) disasters.

Who Gets PTSD?

While exposure rates to such events within the general community are often as high as 60-65% , and in some populations have been reported to be as high as 84% , these rates increase considerably in (serving and retired) members of organisations whose role routinely involves exposure to PTEs. This includes military personnel, security officers and members of emergency service organisations such as police, ambulance and fire services.

The prevalence of PTSD following exposure to PTEs is much less common than the occurrence of trauma. However, that can vary, with lower rates between 5-10% reported following non-interpersonal events, such as accidental injury and natural disaster. Higher rates of between 25-50% can occur following interpersonal traumas, such as combat and assault, with the highest rates being among those exposed to sexual assault . It is important to note, however, that the likelihood of developing PTSD increases with repeated exposure to PTEs .

Recognising The Signs And Symptoms Of PTSD

The Formal Definition

PTSD is understood to be characterised by three sets of symptoms. The first relates to the re-experiencing of the traumatic event and includes such phenomena as intrusive thoughts and images of the event, recurrent nightmares and physical and emotional distress at exposure to reminders of the event.

The second symptom set comprises avoidance and numbing symptoms. These include active avoidance of thoughts and feelings related to the event and places, or activities that act as event reminders, and interpersonal detachment and the numbing of feelings.

The final symptom set relates to the hyper-arousal symptoms. These include disturbances in sleep and concentration, exaggerated startle, hyper-vigilance and increased anger .

What People Typically Report

People can be reluctant to report such reactions, be it to a GP, work colleague, family member or friend. This reluctance can be motivated, among other things, by embarrassment, fluctuating wellness, difficulty in describing symptoms and clinician attitude.

Thus, people are more likely to admit to or exhibit clear signs of:

  • Disrupted sleep and consequent loss of concentration and problem-solving ability
  • Being unusually irritable
  • Relationship problems
  • Physical illnesses of a psychosomatic origin (e.g. gastro-enteric problems — a particularly noteworthy example being Irritable Bowel Syndrome)
  • Pain conditions (from physical injuries associated with or exacerbated by trauma)
  • Co-morbid problems or behaviours (e.g. alcohol abuse or problem gambling)
  • Risky behaviours (e.g. reckless driving or sexual encounters)

Co-Morbidities Of PTSD

While PTSD is a critical, Trauma-Related Mental Health Disorder (TRMHD), its symptoms rarely exist in isolation. In reality, co-morbidity is the norm rather than the exception. For example, co-morbidity rates in the often-studied military and veteran populations have been reported to be as high as 90% (Kulka et al., 1990; O’Toole et al., 1996).

The most common co-morbidities include depression, other anxiety disorders and substance use disorders. A range of broader, psychopathological features are also associated with PTSD. Such features include trauma-related guilt and anger.

Understanding How PTSD Works

PTSD will be more or less likely to occur depending on the operation of the following factors:

Trauma Characteristics

Trauma(s) can fall into any of four descriptive categories. That is, those relating to human-caused trauma, where acts are either intentional (e.g. crime) or accidental (e.g. road traffic accidents), and nature-related trauma that are complicated by human actions or not. Human-caused or complicated traumatic events are well known to have greater potential for traumatisation. Thus, person-implicated events that are horrific, prolonged or repeated, deliberate and malevolent, have the greatest capacity to negatively affect people.

Personal Characteristics

There are certain members of the community who are at greater risk of negative, psychological and functional outcomes following trauma. Known high-risk groups include women, the young and elderly, those with chronic illnesses and diseases (especially pain and mental health conditions), people who are economically, materially or socially disadvantaged and, as mentioned, those who have experienced cumulative, traumatic events.

Individual Response Characteristics

It is well known that response styles will help or hinder people in dealing with PTEs. For example, those who have highly-anxious, pre-trauma response styles and tend to avoid (especially through the abuse of substances or engaging in unhelpful behaviours such as problem gambling), and those with rigid response styles, are less likely to recover speedily or easily.

Those who have cynical response styles or who are self-critical and hence unable to respond to advice or offers of assistance with an open mind, are unlikely to aid their recovery process. Very angry, post-trauma response styles are also likely to interfere. Anger is known to be a powerful predictor of recovery — the greater the anger, the more difficult and delayed will be the coping and the process of recovery.

How To Help People Who May Be Suffering With PTSD

Exposure to trauma, as highlighted throughout this commentary, is common. Most people will have some psychological reaction(s) to trauma — fear, sadness, guilt and anger are common, possible feelings. The majority of people, however, re-establish functioning quickly. Similarly, the vast majority recover over time and only a small proportion go on to develop TRMHDs.

Health professionals, who are experienced in the treatment of TRMHDs, use the following simple questions as preliminaries to deciding whether someone who has been exposed to a PTE has PTSD:

  • Do you have vivid memories of an event?
  • Do you avoid things which remind you of the event?
  • Do you feel emotionally cut off?
  • Are you irritable or constantly on edge?

These are important signs for us all to consider when a colleague, friend or family member is not functioning normally after a stressful event. However, the task of the caring observer in the workplace, and beyond, is typically not that of a mental-health professional. There are, instead, vitally important roles we can all play after a colleague, friend or family member has experienced trauma. These are best summarised as:

  1. Respectful and watchful waiting — as emphasised throughout this article, although most people will recover without the need for treatment after experiencing a PTE, some will not. It is important that those with a role to play in assisting people exposed to trauma, maintain an awareness of their variable needs. Some will display a lesser ability to cope to the point where specific assistance may be required. Some of the signs of the need for assistance are described below.
  2. Making Psychological First Aid (PFA) available — we should not under-estimate the power of simple acts of caring to people who have experienced a significant stressor. The power of the cup of tea and metaphorical shoulder-to-lean-on to help, is a repeated finding from studies of refugees and disaster-survivors.

Psychological First Aid Overview

Emphasising the importance of maintaining normal functioning  — presenting for work, engaging in family and social activities and even going dancing, to the movies or exercising, etc; etc; are not minor matters in maintaining wellbeing.

How To Reduce The Likelihood Of Vicarious Traumatisation

Knowing when to refer — interactions with workplace colleagues who are showing persistent signs of stress (see below) should, however, alert us to the importance of a referral to a professional who is an expert in the assessment and treatment of TRMHDs. Often, early referral can result in impressive gains after small amounts of treatment.

What Sort Of Support Will Help Someone Suffering From PTSD?

It is important to emphasise that people demonstrate, time and again, the capacity to survive traumatic/significant, stressful events and continue to live meaningful and satisfying lives. Thus we speak of PTEs, rather than traumatising events.

One of the most important factors in being able to come to terms with trauma and traumatic loss is what is known as resilience. Individuals who are resilient have been found to experience lower rates of depression, substance abuse and post-traumatic stress following traumatic events than their less-resilient counterparts.

Resilience is defined as the capacity of people to effectively cope with, adjust to, or recover from stress and adversity. Resilient people will not typically need a great deal of assistance post-trauma.

It is important to accurately identify the resilient from those who will need more assistance, without any sense of discrimination or judgement. Such assistance may include PFA or any or all of the five psychological recovery skills.

Skills For Psychological Recovery

For this group, it may be necessary to sensitively encourage them to seek treatment from a health practitioner who is an expert in the treatment of TRMHDs. Such action should be considered if the person, weeks after the event:

  • Still feels upset or jumpy most of the time;
  • Persistently exhibits changed behaviour compared to pre-trauma;
  • Has difficulty with normal activities
  • Has worsening relationship issues –especially because of anger
  • Has disturbed sleep
  • Keeps dwelling on the event(s)
  • Seems unable to enjoy life and appears numb or withdrawn
  • There is evidence of depression, persistent high anxiety or risky alcohol and/or drug use
  • There are concerns about risk to self/others or capacity to care for self and/or others

Tony McHugh is the Manager of the Psychological Trauma Recovery Service (PTRS) at Austin Health. Before that, he was the Manager, and principal psychologist of the Post-Traumatic Stress Disorder (PTSD) Programme at Austin Health.

In these roles, Tony has been responsible for the set-up and development of comprehensive psychological treatment programs for severely traumatised ADF personnel, combat veterans and members of the public. He has also acted as a psychological advisor to the Australian Centre for Post-Traumatic Mental Health and to the Transport Accident Commission of Victoria.

Tony has routinely provided workshops across Australia on the topics of psychological treatment of post-traumatic reactions (including PTSD and other anxiety disorders), depression and, most often, problematic anger. He has also written a number of articles about traumatic stress.

Prior to his time at Austin Health, Tony held various significant appointments, including Assistant Director for the Early Psychosis Prevention and Intervention Centre (EPPIC).
He also runs, part-time, a small but busy, private psychology practice.

Through these various experiences, he has attained considerable experience in the treatment of a range of post-traumatic conditions, including severe anxiety and mood disorders. A special focus of his work has been the treatment of problematic anger. Tony can be contacted at tony.mchugh@austin.org.au