POST-TRAUMATIC STRESS DISORDER (PTSD)

Post-Traumatic Stress Disorder (PTSD)

Classified as an anxiety disorder, Post-Traumatic Stress Disorder (or PTSD) is a serious condition that may develop after being expose or witness to one or more traumatic events. Though most people who experienced a traumatizing event may not developed PTSD, women are more likely to develop PTSD than men as women are more likely to be victims of domestic violence, abuse and rape. Children less than 10 years old tend to suffer less from PTSD than adults. Family members, friends or those in close contact with the victim can develop PTSD as they can be experiencing the paranoia of the sufferers. Their support or help given to the sufferer following the trauma can likewise influence the development of the trauma or reduce the severity of the symptoms, meaning that any confrontational attitude displayed by them can further exacerbate or re-traumatized the conditions of the sufferers. 

Those who do develop PTSD, the trauma may have lasting consequences causing many problems ranging from emotional issues like anger, intense fear, anxiety or irritability to psychological problems like survivor’s guilt, paranoia to panic attacks. Sufferers of PTSD is very wide ranging, while many victims do have direct experience of events like survivors of disasters, war, suicide attacks, accidents, violent personal assaults, rape or sexual abuse. But there are also many like those performing rescue work or disaster relief activities seeing the horrible situations, develops into PTSD as well. Children can develop PTSD after witnessing events like violent quarrels between parents leading to a divorce, drunken parent assaulting their spouses or seemingly as trivial as the death of a pet (like the death of a gold fish maybe trivial to adults, it may not be for the child). PTSD sufferers usually get depressive further isolating themselves from those around them, leading it to a vicious cycle of isolation. It is quite common for sufferers to use alcohol or substances initially to numb themselves but their inability to control the consumption of such intoxicants can eventually lead to becoming an abuser of such intoxicants instead. 

What Are the Symptoms of PTSD?

The severity and duration PTSD varies from individual to individual. Some people recover within six months, while others suffer much longer, even years if left untreated. Symptoms are often grouped into three main categories, including :

·         Disturbing recurring flashbacks – Many with PTSD will repeatedly re-experiencing the ordeal in the form of flashback episodes, memories, nightmares, hallucinations or frightening thoughts especially when the events or objects they experienced reminiscent of the trauma. Anniversaries of events can also trigger PTSD symptoms

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·         Avoidance or numbing of memories of the event – Sufferers of PTSD experiences emotional numbness, sleep disturbance, depression, anxiety, irritability or outbursts of anger. Feelings of intense guilt are also common among many sufferers. They may avoid certain people, places, thoughts or situations that remind them of the trauma leading to further feelings of detachment and isolation, even from their own family and friends. They may even lose interest in certain activities that they may have enjoyed previously.

·         Hyper arousal (high levels of anxiety) – includes excessive emotions, problems relating to other people including abilities to show affections or feelings, difficulty falling asleep, irritability, outbursts of anger, inability to concentrate and being “jumpy” or easily startled. Sufferers may also show physical symptoms like increased blood pressure, headaches, gastrointestinal distress, immune system problems, dizziness, rapid breathing, cheat pains, discomfort in other parts of the body or even diarrhoea. 

Children suffering from PTSD with risk increasing exponentially if their exposure to the event increases. They may suffer from delayed development in areas of toilet training, motor skills and language.

An example of post-traumatic stress disorder was the Oklahoma City bombing in the United States. Over a third of the bombing survivors developed PTSD, with half showing signs of anxiety, depression and alcohol abuse. After a year later, Oklahomans in general had a marked increase in the use of alcohol and tobacco products, as well as PTSD symptoms. As for children, even after two years later, 16 per cent of the children in a 100 mile radius of Oklahoma City with no direct exposure to the bombing had increased symptoms of PTSD. It could be due to weak parental response to the event, having a parent suffering from PTSD symptoms or increased exposure to the event via media coverage, i.e. TV reports, newspaper, posters, etc. or even photographs of the event, all increases the possibility of the re-traumatizing the child to develop PTSD symptoms as young children cannot distinguish between the actual event and the repeated viewing of the event in the media. 

How To Treat PTSD Sufferers?

The main goal of the treatment is to reduce the emotional and physical symptoms. Improving the sufferer’s daily functions can help the person to better cope with the event that triggers the disorder. Treatment for PTSD may involve medication, psychotherapy, non-verbal therapy ( expressive work ) and stress management.

In psychotherapy, it involves helping the sufferer to learn skills to manage symptoms and develop ways to cope with it. The treatment also aims to teach the person’s family members about the disorder but the main approach is to help the sufferer work through their fears associated with the traumatic event and the approaches used to treat sufferers includes the following :

·         Cognitive Behavioural Therapy – involves the sufferer learning to recognize and change thought patterns leading away from the troublesome emotions, feelings and behaviour.

·         Transformational Therapy – change therapy. 

·         Exposure Therapy – a type of CBT involving the sufferer reliving the traumatic experience or exposing the sufferer to objects or situation that cause the anxiety but it must be done in a well-controlled and safe environment. This form of therapy helps the sufferer to confront their fear, leading them to gradually become more comfortable with the situation that frightens them and causes the anxiety. This technique has been employed very successfully in the treatment of PTSD sufferers.

·         Psychodynamic Therapy – this method focuses on helping the sufferer examine their own personal values and the emotional conflicts caused by the traumatic event.

·         Family Therapy – an alternative way to treat the sufferer as the behaviour of the PTSD sufferer can have an effect on other family members.

·         Group Therapy – could be helpful to those suffering from PTSD by allowing them to share their thoughts, fears and feelings with other people who have experienced traumatic events.

·         Eye Movement Desensitization and Reprocessing (EMDR) – a complex form of psychotherapy that is designed to alleviate distress associated with traumatic memories.

CASE STUDY - POST-TRAUMATIC STRESS DISORDER (PTSD)

Case Study – A Child Who Suffered PTSD From The Death Of A Care-Giver

Apart from attending school, Winnie had to attend private tuition classes at her tutor’s home. She had been taking tuition classes for the past three years. Each time she was there, the tutor’s husband would play with her or cook for her. He treated her like his own daughter as they do not have a daughter of their own. She had grown very close to him. When she was around 12 years old, he was involved in a car accident and passed away. 

His death had traumatized her very much but she still had to go to the tutor’s house for her tuition. In the tutor’s home, a memorial altar was set up to honour the memories of him. Each time, she would be seeing the memorial altar with a picture of him adorned with flowers and candles. But it was his picture re-traumatizing her giving her a lot of fear. She tried her best to avoid looking at his picture. In her mind, she tried her best to believe that he is still alive and kicking. She even told her mother about her fears of going there, but her explanation was rejected and she was forced to go to the tutor’s home for her tuition. After repeated exposure, Winnie started to have flashbacks whenever she reached the doorstep of her tutor’s home, she would become very depressed and cried a lot. She was very angry at her mother as she felt that her mother didn’t care for her and for accusing her of lying.

Her condition may not have developed into PTSD, but from a very young age, her mother due to her own belief in ghostly manifestations would be talking to her and others, filling her mind with such things. She started to see his ghostly appearance first in the tutor’s home, but as time progresses, she began to see his ghost appearing in her own home as well. Her behaviour started to become very erratic, refusing to go anywhere within the house or even to the toilet if no one accompanies her at all. Her condition caused her mother to panic and her mother started to consult me about it. Before that they even brought Winnie to see some mediums  in the hope that their spiritual powers could exorcise his ghost and restore her back to her sanity. Instead, this was added on to her trauma. Apart from the run-around by her mother,  visitations to mediums . All this made Winnie develop a strong sense of helplessness and added on more impact in PTSD . 

Treatment Plan

Winnie’s treatment started off with some sessions that allowed her to share her story and let out her frustration pent up inside of her. As she was constantly being reminded that she was fabricating the story of seeing the ghost of her tutor’s late husband, these sessions were meant to communicate and build trust. So by listening and accepting her story as she told it demonstrates respect and acceptance of her. As she was over-protected by her parents, she lacked the space and privacy needed for her to grow and it affected her sense of belonging. She needs to feel that she is not going to be stigmatized in the same manner by them and she eventually develop her confidence in me. 

The sessions didn’t involve the use of psychotherapy because she was full of fear, overwhelmed by her negative emotions and pressures from her family. Also what she told me fell outside the purview of our sense of reality, e.g. ghosts or ghostly manifestations. It was better to work on her thought processes and how she could move on. In this case, I used Psychodynamic approach as well as Humanistic approach to help and support her with a lot of empathy. Added on to her treatment was the use of non-verbal therapies or expressive techniques as it allowed her to express her anger, fear, feelings and tears (for the trauma caused her to cry a lot). 

At this moment, she was still at the grief and loss stage. It made her very vulnerable, showing signs of depression and anxiety with the occasional outburst of anger. The non-verbal therapies allowed her to externalize her grief and loss. Slowly she started to feel relieved and then feeling good and regain her confidence towards herself. She eventually accepted the death of her tutor’s late husband. Apart from treating her condition, I had to rebuild her communication and bonding back with her parents because the support from her family is very important.

She eventually moved forward with her life happily, preoccupying herself with a lot of activities. She is much closer to her mother and since her mother’s realization of her trauma she was allowed to stop going to the tutor’s home to end her re-traumatizing herself. Even when she is off her treatment, I’m still giving her support. It is with my support and her re-bonding back to her mother that Winnie can move on ultimately.

COMPLEX POST-TRAUMATIC STRESS DISORDER (C-PTSD)

Complex Post-Traumatic Stress Disorder (C-PTSD)

Known also as “Multiple Interrelated Post Traumatic Stress Disorder” (compounding of different types of traumas occurring at different times and places) or “Developmental Trauma Disorder” (trauma experienced during child developmental milestone), it is a psychological injury resulting from prolonged exposure to social and/or interpersonal trauma while being kept in confined state (a situation lacking viable escape route for the victim).  This results in feeling helplessness, lacking or losing control, and deformations of identity and sense of self. 

American Psychiatric Association (APA) accepts PTSD as a mental disorder while it does not accept C-PTSD. This is because PTSD is caused by a single and major life threatening incident like war veterans and survivors of disasters while C-PTSD is a catch-all term for anxiety disorder that doesn’t fall into existing categories of APA classification.  Mental health professional label C-PTSD sufferers as exhibiting personality disorder, especially Borderline Personality Disorder (BPD). The problem is, PTSD, complex or otherwise, is a psychological injury and that has nothing to do with personality disorder. Many psychiatrists, psychologist or other mental health professional will label C-PTSD sufferers as having personality disorder. If this happens to be the diagnosis, then it is advisable to change to another, more competent professional. 

Traditional psychiatry sees C-PTSD sufferers as being weak and slow to recognize that the abuser is having Sadistic Personality Disorder (SPD) as the abuser enjoys bullying or inflicting cruelty on others. PTSD descriptions fail to capture some of the core characteristics of C-PTSD. These elements include captivity, psychological fragmentation, and loss of a sense of safety and self-worth, as well as the tendency to be re-victimized. Most importantly, victims suffer from a loss of a coherent sense of self.  It is this loss and its symptom profile that differentiates C-PTSD from PTSD. 

C-PSTD sufferers differ from PTSD sufferers as it is psychological injury resulting from continual abuse. Victims are people who were not allowed to have control of their lives and experiences many unpleasant feelings. There’s no escape because the initial abuser is usually a parent or a spouse. It involves a history of prolonged totalitarian control, including sexual abuse (especially child sexual abuse), physical abuse, emotional abuse, domestic violence or torture – chronic repetitive traumas actual or perceived inability for the victim to escape.

Symptoms Of C-PTSD

Children and Adolescent Symptoms can be characterized into seven areas :

        1.  Attachment and Relationships – abused or neglected, have difficulty developing strong healthy attachment to caregiver. More vulnerable to stress, trouble controlling and expressing emotions, reacts violently or inappropriately to situations. Have problems in romantic relationships, friendships and with authority figures.

        2.    Physical Health – under constant or extreme stress, the immune system and body’s stress response may develop abnormally. Later on, even with ordinary levels of stress, the system responds as if under extreme stress. Brain and nervous system development may be impaired while neglectful environment may limit brain development. Individual may engage in risky behaviours and addictions.

        3.     Emotional Regulation – have difficulty identifying, expressing and managing emotions and may have limited language for feeling states. Often internalize stress reactions resulting in significant depression, anxiety or anger. Emotional response may be unpredictable or explosive triggering intense emotional responses like trembling, anger, sadness or avoidance. Alternatively, may “tune out” (numbing emotionally) to threats making themselves vulnerable to re-victimization. 

        4.    Dissociation – overwhelming and terrifying experience may dissociate or mentally separate them from the experience. May feel like a dream or lose all memories or sense of the experiences having happened to them, resulting in memory gaps. On extreme end, cutting off or losing touch with the self, affecting learning, behaviour and social interactions. 

        5.     Behaviour – easily triggered and reacts very intensely, struggling with self-regulation, impulse control or ability to think through consequences before acting. Behaves in ways that appear unpredictable, oppositional, volatile and extreme, often appearing dissociated, “spacey”, detached or out of touch with reality. Also more likely to engage in high-risk behaviours, and excessive risk-taking. 

        6.     Cognition – problems thinking clearly, reasoning or problem solving. Weak in planning, anticipating and acting accordingly. Difficulty in acquiring new skills or take in new information, deficits in language development and abstract reasoning skill.

        7.   Self-Concept & Future Orientation – abuse and neglect makes them feel worthless, despondent, self-blame, shame, guilt, low self-esteem and poor self-image. Violence teaches not to trust, the world is not safe and powerless to change the circumstances. Becoming more incompetent. When operating in “survival” mode, lives from moment-to-moment without pausing to think about, plan for or even dream about a future.

Adult symptoms may begin as children and the trauma will prolong into adulthood. The criteria to identify adult sufferers with C-PTSD include :

·         Repressing or suppressing memories of traumatic events and/or dissociation, feeling detached from them.

·         Feelings of sadness, (learned) helplessness, shame, guilt, hopelessness, despair, stigma and being different from other humans.

·         Perceiving perpetrator as having absolute power.

·         Isolation, mistrust and/or search for a rescuer.

·         Nightmares and unwelcome flashbacks of the incident and/or abuser.

·         Thoughts of suicide and/or explosive or hidden anger.

While C-PTSD survivors can still attain healthy self-esteem and heal from most pain, the flashback and nightmares (recurring traumatization) remains the problem. Either a situation or the presence of the abuser can trigger unwelcome and unwanted flashbacks. In counselling, C-PTSD victims are told that the shame isn’t theirs, but is that of the abusers. Though the victims or survivors may understand this, unfortunately the flashbacks and nightmares experienced by survivors and the abusers can re-traumatize again and again.

Treatment Plans

Recovery for C-PTSD occurs in three stages: establishing safety, remembrance and mourning for what was lost, and reconnecting with the society. Recovery can only occur within a healing relationship and only if the survivor is empowered by the relationship. This relationship includes friends, co-workers, one’s relatives or children and professional-client relationship.

Treatment for C-PTSD requires multi-modal approach that focuses on problems causing the functional impairment than the PTSD symptoms. Six core components of complex trauma treatment are suggested :

        1.       Safety Issues

        2.       Self-Regulation

        3.       Self-Reflective Information Processing

        4.       Traumatic Experiences Integration

        5.       Relational Engagement

        6.       Positive Affect (Stimuli) Enhancement - Enhance self-worth, esteem and
                                                                       positive assessment of the value of self

 Among the treatment suggested are experiential and emotionally focused therapy, family systems therapy, sensorimotor psychotherapy, eye movement desensitization and reprocessing (EMDR) therapy, dialectical behaviour therapy (DBT), cognitive behavioural therapy, group therapy, and non-verbal therapy.

In children, however, the treatment for adults may not be useful for diagnosis and treatment of children. Since children are often caused by chronic maltreatment, neglect or abuse in a care-giving relationship. This not only widens the range of support for the child but also the complexity of the situation, especially when some sort of child protection agency is called into the situation. A number of practical, therapeutic and ethical principles for the assessment and intervention have been developed :

·         Identifying and addressing threats to the child’s or family’s safety and stability.

·         Develop a relational bridge to engage, retain and maximize the benefit for the child and care-giver.

·         Diagnosis, treatment planning and outcome monitoring are always relational- and strength-based.

·         All phases of treatment should aim to enhance self-regulation competencies.

·         Determining with whom, when and how to address traumatic memories.

·         Preventing and managing relational discontinuities and psychosocial crises.

Differences Between Mental Illness And Psychiatric Injury

Mental Illness	Psychiatric Injury
·      The cause cannot be identified	·      The cause is easily identifiable and verifiable, but denied by those who are accountable
·      The person may be incoherent or what they say doesn’t make sense	·      The person is often articulate but prevented from articulation by being traumatized
·      The person may appear to be obsessed	·      The person is obsessive, especially in relation to identifying the cause of their injury and both dealing with cause and effecting their recovery
·      The person is oblivious to their behaviour and the effect it has on others	·      The person is in a state of acute self-awareness and aware of their state, but often unable to explain it
·      The depression is clinical	·      The depression is reactive
·      There may be a history of depression in the family	·      There is very often on history of depression in the individual or their family
·      The person has usually exhibited mental health problems before	·      Often there is no history of mental health problems
·      May respond inappropriately to the needs and concerns of others	·      Responds empathically to the needs and concerns of others, despite their own injury
·      May suffer a persecution complex	·      May experience an unusually heightened sense of vulnerability to possible victimization
·      Suicidal thoughts are the result of despair, dejection and hopelessness	·      Suicidal thoughts are often a logical and carefully though-out solution or conclusion
·      Exhibits despair	·      Is driven by the anger of injustice
·      Often doesn’t look forward to each new day	·      Looks forward to each new day as an opportunity to fight for justice
·      Is often ready to give in or admit defeat	·      Refuses to be beaten, refuses to give up

Differences Between Paranoia And Hypervigilance

Paranoia	Hypervigilance
·      Paranoia is a form of mental illness, the cause is thought to be internal – minor variation in balance of brain chemistry	·      Is a response to an external event (violence, accident, disaster, violation, intrusion, bullying, etc.) and therefore an injury
·      Paranoia tends to endure and to not get better of its own accord	·      Wears off (gets better), albeit slowly, when the person is out of and away from the situation which was the cause
·      The paranoiac will not admit to feeling paranoid, as they cannot see their paranoia	·      The hypervigilant person is acutely aware of their hypervigilance and will easily articulate their fear, albeit using the incorrect but popularized word “paranoia”
·      Sometimes responds to drug treatment	·      Drugs not viewed favourably, except in extreme circumstances. Often drugs have no effect or can make things worse, sometimes interfering with the body’s own healing process
·      The paranoiac often has delusion of grandeur	·      The hypervigilant person often has a diminished sense of self-worth sometimes dramatically so
·      The paranoiac is convinced of their self-importance	·      The hypervigilant person is often convinced of their worthlessness and will often deny their value to others
·      Paranoia often seen in conjunction with other symptoms of mental illness, but not in conjunction with symptoms of PTSD	·      Hypervigilance is seen in conjunction with other symptoms of PTSD, but not in conjunction with symptoms of mental illness
·      The paranoiac is convinced of their plausibility	·      The hypervigilant person is aware of how implausible their experience sounds and often doesn’t want to believe it themselves (disbelief and denial)
·      The paranoiac feels persecuted by a person or persons unknown	·      The hypervigilant person is hyper-sensitized but is often aware of the inappropriateness of their heightened sensitivity, and can identify the person responsible for their psychiatric injury
·      Sense of persecution	·      Heightened sense of vulnerability to victimization
·      The sense of persecution felt by the paranoiac is a delusion, for usually no-one is out to get them	·      The hypervigilant person’s sense of threat is well-founded like in the case of a serial-bully. The hypervigilant person often cannot (and refuses to) see that the serial bully is doing everything possible to get rid of them
·      The paranoiac is on constant alert because they know someone is out to get them	·      The hypervigilant person is on alert in case there is danger
·      The paranoiac is certain of their belief and their behaviour and expects others to share that certainty	·      The hypervigilant person cannot bring themselves to believe that the bully cannot and will not see the effect of their behaviour is having; they cling naively to the mistaken belief that the bully will recognize their wrongdoing and apologize