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Post Traumatic Stress Disorder

Conditions such as post traumatic stress disorder (PTSD) usually coexist with depression and anxiety. The treatment of these conditions require versatile methods to deal with dissociative aspects that influence the intensity of depression and anxiety with the traumatic stress condition.

Traumatic Shock
How to minimise, manage and recover from it
By Michael Burge - Director Australian College of trauma Treatment

Traumatic shock response is caused when an individual is exposed to a single or series of traumatic events, another term used is traumatic stress reaction.

Similar to daily stress traumatic stress reaction is subject to interpretation by different people. That is, different people will be more or less adversely affected depending on their perception and perspective of the traumatic events. Even so, substantial and prolonged traumatic shock traumatises everyone. For example, during the Port Arthur massacre the survivors reported that they believed they were going to be killed and had this belief for a number of hours. At the same time they witnessed the brutal killing and mutilation of others around them. The shock of this terrible experience was made more severe due to the unexpectancy of the attack and the invasion of what was thought to be previously a safe tourist destination.

The above example would most likely cause an intensive traumatic stress reaction. Other examples could be drawn from war. The Vietnam war created similar if not much worse trauma in victims, be they soldiers or civilians. In this war victims were faced with repeated experiences like Port Arthur. The soldiers were shot at, had parts of their bodies severed and witnessed the death and mutilation of their comrades and enemies. They had to engage in dead body identification tasks and perform a function called "Jig Saw" to gather the body parts into a recognisable state and many other similar traumatic experiences. On the other hand a traumatic incident may involve a minor accident leading to a traumatic stress reaction in the case of more fragile people. Some people can be traumatised even by being pushed or being subject to prolonged verbal attack or gross humiliation of a psychological nature.

Other examples of traumatic events, apart from crime and war, include the following: natural disasters, ie earthquakes, flooding, cyclones, bush fires; divorce; redundancy; child sexual, physical and psychological abuse… and many others too numerous to be named. Perhaps most relevant to security guards or police could be traumatic events such as being involved in an armed robbery, bank robbery, hold up or assault, or any threat to themselves or others whilst on duty.

It is important at this point to focus on the shock itself and its peculiar characteristics. The purpose of this focus is to assist in the understanding of the shock response phenomenon, as it has been shown that the greater the understanding, the greater the immunisation against the shock reaction, therefore less likely to develop symptoms associated with traumatic stress reaction. Following this description I will return to an evaluation of the impact of traumatic stress reaction and its potential to cause psychological symptoms. I will also discuss prevention management and recovery later.

Perhaps a useful way of understanding the traumatic shock response is by looking at its bodily and psychological consequences. Shock triggers what is called the fight-flight response. When the fight-flight response is triggered our mind and body is prepared to stay and fight or run away. The heart beats quicker, breathing increases, glucose and adrenaline are pumped into the system to assist us to respond effectively so as to maximise our chance for escape and survival.

However, as mentioned previously, the effects on the individual vary widely. Some people are not as shocked as others. Although many psychological events can be potentially stressful only those that are interpreted as being adverse or challenging will ultimately become a psychological stressor. This in turn effects the shock and fight-flight response.

Other factors that can effect the level of shock following a traumatic event include the health of the person or victim exposed to the event, existence of any alcohol or dependency, the individual's level of fitness, accumulative stress related to work or the family, even the absence of stress or arousal all contribute too traumatic stress vulnerability.

Although the intensity of traumatic shock depends on individual differences there are many common responses, for example, an individual tends to go into a state whereby there is a sense of disbelief that the traumatic events are occurring. The victim often reports later that they couldn't believe it was happening or why it was happening. It was as though the experience was like a movie, or as though they were floating above themselves watching the events. In the case of trained personnel such as security guards, police, soldiers, fire officers, ambulance officers, crisis workers or doctors and nurses the duties can still be performed so as to minimise risk to themselves or others, however this sense of disbelief or unrealness is still apparent, and is called dissociation. In severe cases (more likely non trained personnel) amnesia can take place at this time. For example, rape victims have often reported seeing the perpetrator about to attack them, then having a blackout for a number of hours, remembering only wandering around aimlessly some time later. Nevertheless, no matter how well trained people are, they will still have the traumatic shock reaction, including the fight-flight response to some extent.

Researchers have noted that during the traumatic shock people tend to behave in one of two ways. Firstly either hysterically/or very active; and secondly in a stunned inactive and depressed state. In the first and active state people tend to display the following: agitation, wringing of hands, loud screaming or crying, hyperactivity, nausea, vomiting, rapid speech, rapid breathing, flushed face and emotionally out of control.

In the second, inactive state, people display the following: fainting, nausea/vomiting, staring into space, dull eyes, low blood pressure, rapid pulse, sweating, cold clammy skin, pale skin and wandering around aimlessly.

It is worth noting that people exhibiting signs of the first state could possibly put your life or other's lives at risk because of their erratic behaviour. They may, for example, run back into a burning building, or tackle a gunman. They may need restraining or close observation.

One of the things that individuals can do to minimise all of these above shock responses is to be aware of their natural response to shock. This helps reduce being shocked by the shock. Moreover it is possible to use several strategies to further reduce the shock impact, eg the method of self talk. In this method one might tell one's self during or shortly after the traumatic event that there will be a restoration of equilibrium, tell one's self it is like a wave in a pond when a rock has been dropped. The chaos will subside and calmness will emerge. Practice observing all the various stress reactions like clouds on a stormy day. Psychologically this can provide a buffer for what is happening around a person.

It is also important to consider what action needs to be taken in the hours immediately after the traumatic event and then the following days and weeks, so as to minimise one's prospects of developing the dreaded Post Traumatic Stress Disorder (PTSD). However before this consideration it is necessary to consider the way in which traumatic events can lead to the development of post traumatic stress disorder. PTSD is considered to be in existence when a number of characteristic symptoms are present within the victim. Also, these symptoms must have persisted for at least one month after the traumatic event. If the symptoms were to persist for three months or longer PTSD is considered to be chronic. Prior to that it is in the acute category. If the symptoms of PTSD were to develop six months or longer following a traumatic event it is considered to be delayed PTSD. This later development can be quite surprising. For example, I am reminded of work I was doing with Vietnam veterans in 1993 including training of country health professionals in the area of trauma debriefing and therapy immediately after the floods in the Goulburn Valley region. At that time it was reported there were large numbers of Vietnam veterans reporting the onset of PTSD symptoms. This was apparently due to helicopters flying backwards and forwards across the flooded areas engaging in rescue missions. Prior to these triggers (helicopters flying) the veterans were apparently coping well. This delayed phenomena is particularly relevant to personnel working in a potentially high risk environment. For example a security guard or police officer might be on patrol in a warehouse and have a minor brush with an offender who is trying to escape. There may be no weapons involved and perhaps a minor scuffle ensued. The offender might be easily apprehended but it's not impossible for the guard to develop substantial PTSD which may not be related to the present scuffle, it could relate to a more severe assault many years ago, that had been dormant.

In this regard I would like to make several points that could be relevant to the training of security guards and police in relation to preventing or minimising the development of PTSD that relates to the delayed factor. However, before commencing this discussion I believe it is important here to examine in more detail the PTSD symptoms and connect this aspect to training considerations ie delayed PTSD.

The characteristic symptoms fall into 3 main areas. Firstly, the re-experiencing of the traumatic event for example: intrusive, distressing, recollections including images, thoughts, perceptions, recurrent distressing dreams of the event; a sense of reliving the experience, hallucinations, flashback episodes to cues that symbolise the traumatic event. Secondly, persistent avoidance of reminders of the trauma and numbing of general responsiveness. For instance efforts to avoid thoughts, feelings, conversations, places or people that arouse recollections of the trauma, memory gaps; diminished interests or participation in significant activities; difficulty having loving feelings and a sense of foreshortened future. Thirdly persistent symptoms of increased arousal for example difficulty sleeping, irritability or anger outbursts, difficulty concentrating, hypervigilence or exaggeration, startle response. With the presence of any of these PTSD symptoms it is advisable to seek psychological consultation, at least for assessment.

These days there is an abundant range of effective PTSD treatments/therapeutic methods available. Some can be successful in 90% of cases. The details of these are too numerous to explore in this present article. The main point is however, that if one does have PTSD help is readily at hand from specialised providers. In some cases I have noted that even though PTSD could be in existence for 20 years, recovery has taken just three weeks. Requesting help can be the main step.

Returning to the discussion of the onset of PTSD symptoms any current traumatic stress reaction can be made more potent, more horrific, if there have been past traumas that have not been resolved. Ironically, one may not be aware of this until recent stressful events occur. Therefore, in terms of training for security guards or police it may be worthwhile taking into account historical traumatic events. That is not to say that because someone has a past trauma, they will be less effective in their work. It may well be (and research supports this) that people who have resolved past trauma are less affected by current traumatic events. From my professional experience I've worked with police and others with similar occupations that have been quite damaged by the triggering of past trauma by present traumatic incidents. However, when these traumas have been treated and resolved they may come back to their work stronger than ever. They have greater personal coping resources.

The above discussion is mainly concerned about recognising and overcoming PTSD symptoms once they have developed within an individual. There are however interventions called critical incident stress debriefing CISD formulated by Mitchell (1990) to prevent or reduce the possibility of PTSD. There are two parts to this intervention. The first part is usually conducted from one to four hours after the traumatic event. This is called defusing. These defusing interventions last 30-45 minutes.

Defusings are typically managed by peer support personnel but may be led by a mental health professional if needed. The main purpose here is to reduce the level of reactions; give people a brief opportunity to talk and ask questions; provide information about possible future reactions; and provide information about traumatic stress management.

The second part is the critical incident stress psychological debriefing. This can be a structured group meeting or in some cases individual contact. This intervention emphasises the ventilation of emotions and other reactions to a critical event. In addition, they emphasise the educational and informational components which are useful if not vital in the understanding and coping with traumatic stress. CISD should not take place until 36-48 hours have passed after the incident, but can be conducted up to 8 weeks afterwards. In some cases it can be used much later. As with defusings, CISD should be confidential and conducted in a spirit of co-operation, support, compassion and choice.

It is anticipated that the employment of these interventions will minimise the development of PTSD in traumatised people. Although care should be taken in demanding personnel attend debriefing because in some rare cases the trauma could be aggravated and deepened. However, the benefits are substantial.

In conclusion, traumatic shock or traumatic stress reaction has the potential to do much damage to people's lives and those close to them. However, given the appropriate training preventative interventions, post trauma treatment and appropriate support most if not all difficulties can be overcome. There is hope!

Bibliography

Mitchell, J., and Bray, G. (1990) Emergency Services Stress. Guidelines for preserving the health and careers of emergency services personnel, Brady/Regents/Prentice Hall, New Jersey.

Diagnostic and Statistical Manual of Mental Disorders DSM-IV. Published by The American Psychiatric Association, Washington, DC.