by Dr Dennis Trent, Chartered Clinical Psychologist Midlands Psychological Services. One of the hardest mental health diagnoses to make is that of Posttraumatic Stress Disorder (PTSD).
Part of the reason is its popularity in the press. Almost everyone knows the symptoms and I even recall one patient coming in with a check-list of symptoms of which he stated he had every one. Since many of the symptoms are self reported, prior knowledge of the symptoms can lead to an easily mistaken diagnosis by someone who may have the best of intentions, but lacks the skill to tease out the real from the feigned.
Although many accounts of what would later become known as PTSD have appeared in the literature, the term became an issue following World War II. Stories and books about the American Civil War such as The Red Badge of Courage, depict clear accounts of what would later be classified as PTSD. In World War I the condition was commonly referred to as “shell-shock”, but was then pretty much ignored until WWII. During WWII the terms “Battle Stress” and “combat fatigue” were commonly used to describe the condition. Following WWII, or at the close of the war, when the horrors of the holocaust became known it was realised that the condition was not solely the result of war directly. The 1952 Edition of the Diagnostic and Statistical Manual (DSM) published by the American Psychiatric Association did not list the condition as such. It did, however, give a code of 000-x81 Gross Stress Reaction. It stated, “Under conditions of great or unusual stress, a normal personality may utilize established patterns of reaction to deal with overwhelming fear. The patterns of such reactions differ from those of
neurosis or psychosis chiefly with respect to clinical history, reversibility of reaction, and its transient character”.
It went on to say, “This diagnosis is justified only in situations in which the individual has been exposed to severe physical demands or extreme emotional
stress, such as in combat or in civilian catastrophe” The alternative diagnosis was that of Adult Situational Reaction. Based on reports of holocaust experiences it was also noted that the reaction was stronger when it was the result of human actions.
When DSM was re-issued in 1968 as DSM-II, the term Gross Stress Reaction was removed and replaced by the more generic Transient Situational Disorder, under which the sub-category of Adjustment Reaction to Adult Life contained the descriptor, “Fear associated with military combat and manifested by trembling, running and hiding”. It was not until 1980 with the publication of the third edition , commonly referred to as DSM-III, that the term Posttraumatic Stress Disorder was used as an official diagnostic term. It also divided the term into Acute, Chronic or Delayed. Other significant changes to the diagnosis included a fuller listing of the criteria for diagnosis. In the 1987 revised edition, or DSM-III-R, it extended the trauma to observing trauma to others so that the individual no longer had to suffer the trauma directly.
The Diagnostic and Statistical Manual is now in its fifth edition, DSM-5, and the diagnosis has remained relatively consistent over the past years. While efforts have been made to integrate the DSM system with that of the World Health Organization’s International Classification of Diseases (ICD), it was not until the publication of ICD-10 Classification of Mental and Behavioural Disorders in 1992 that the concept of PTSD was included in their nosology.
The hallmark condition for the application of the diagnosis is that the person has experienced or has been exposed to an event in which the individual is exposed to an actual or threatened death, serious injury or sexual violence. There is probably no place in which this is more likely to occur than in the military forces. Combat, by its very nature is life threatening and over the years Hollywood has done little to bring the true horror of combat out in the open. The lack of support from family and friends also plays a part. While many will look back at their time in the military with fondness due to the intense relationships formed in times of stress, the lack of support from those loved ones left behind can have an isolating effect on a person. Add to this the refusal for many years of the incapacitating effect of stress in such events (remember General Patten’s famous slap?), it is little wonder why the armed forces has recently focussed on identifying and
treating PTSD along with other stress disorders.
In World War II, the average solder saw limited direct action as they would take a position and hold it to be ‘leapfrogged’ by a new battalion who would take the next objective and then hold it, only to be ‘leapfrogged’ by yet another group and so on. Since then, however, from Korea and Viet Nam through Iraq and Afghanistan, the common soldier has had to face extended periods of uncertainty direct threat in combat. Insurgency raises questions of trust and we have seen numerous incidents in which someone we thought was fighting on ‘our side’ turned and caused death and destruction to those with whom he or she had been working. Add to this the uncertainty of Improvised Explosive Devices (IEDs), Suicide Bombers and general acts of terror, and the probability of PTSD increases, to the point where it is a wonder more individuals in the military do not suffer the effects of a PTSD.
While the military clearly deserves a mark of credit for their efforts, and while the incidence remains low in the overall, it is increasing. Any gain in reporting incidents of PTSD in active duty personnel, however, is often offset by the non-reporting of those who have left the military and for whom the symptoms do not appear until weeks, months or even years after discharge. The recent popularity of American Sniper and the subsequent trial of Eddie Ray Routh, the man
convicted of killing Chris Kyle and Chad Littlefield, have again raised concerns about the recognition, impact and treatment of those veterans who left service with undiagnosed PTSD along with their attempts at self-medication.
Even a brief review of the literature indicates a strong link between the presence of a PTSD and a substance abuse disorder (SUD) as well as that between the presence of a PTSD and suicide. With both the NHS and Social Services currently stretched due to financial constraints and a growing number requiring their services, an increasing number of individuals with undiagnosed PTSD are attempting to self-medicate with drugs and alcohol. This clearly indicates a vulnerability again for those in the military and those recently leaving the military. While the military itself has made strides in the recognition and treatment of PTSD, those who leave the services with undiagnosed PTSD face increased vulnerability to both substance abuse disorders and mood disorders leading to suicidal gestures or attempts. Additionally, those with PTSD have a stronger link with violence than is found in the general population. Acts of violence within a population with undiagnosed PTSD are more likely to occur, especially when disinhibited by alcohol or drugs. The need for the proper and qualified intervention for both the diagnosis and treatment of PTSD becomes apparent to even the most casual observer.
Again, the problem is to differentiate those who truly have a PTSD from those who know the symptoms. There is, therefore, a strong need for professional expertise in the accurate diagnosing of the condition. This is especially true in cases where those deciding the fate of an individual have limited or ‘popular’ knowledge of the disorder.
Once the diagnosis is confirmed, the next task is to obtain the appropriate treatment. While this sounds obvious, it is not always as easy as one would wish it
to be. As PTSD is included in the Mental Health /Mental Illness arena, it suffers from all of the difficulties of mental illness in general, that is prejudice and ignorance on both the part of the general public and the individual with the condition. Too often individuals are ‘embarrassed’ and deny the existence of the condition not only to others, but also to themselves. They will tend to externalise the reasons for their behaviour to others while often internalising responsibility. Guilt may often occur, especially in situations in which the individual is involved in the same incident in which someone else has died or been severely injured.
They will often feel guilty for having survived or remained uninjured when another did not. Equally, a sense of guilt for having placed another in harms way may occur.
Stress is based on perception of an event, or events, and a PTSD, as its name implies, is an extreme form of stress. Changing that perception, therefore, is
crucial to the resolution of a PTSD. This may occur either due to an unexpected immediate occurrence or a buildup of events over a period of time such as the case of military personnel who, while perhaps have never been confronted with a traumatic event, are in positions where that possibility is predominant over an extended period of time.
In such cases trust in the environment, others and their own decision making ability can be eroded over a period of time. While medication may give a window within which the individual can change that perception, in the majority of cases the perception will remain unless challenged in a professional, non-judgmental and objective manner. Although it takes only an instant to change one’s mind, it can be a difficult and daunting task for one to challenge that belief on one’s own. Hence the need for professional intervention. There are a number of ways to help the individual to challenge those beliefs and perceptions and each psychologist, psychiatrist, therapist, or counsellor will bring their own personal approach to which ever theoretical orientation they take. Finding someone the individual feels comfortable with is often the first task as trust is often difficult for a person whose ability to trust has been shattered by events.
There is no ‘magic bullet’ for the resolution of a PTSD. Although there are commonalities in the symptoms expressed by those with PTSD, since each individual reacts uniquely to stress, the diagnosis requires unique skills and the resolution of a PTSD must be tailored to the individual. The psychologist is uniquely placed to provide both the diagnosis and the treatment. Being trained across all four major schools of psychological theory, a psychologist is able to adjust the theory, and therefore the treatment style, to the individual rather than trying to fit the individual into a pre-determined theory or set of interventions.