People have probably always known about the psychological effects of experiencing life-threatening events such as military combat, natural disasters, or violent assault. Literature through the ages – some of it thousands of years old – provides many vivid portrayals of these internal struggles to recover from horrific experiences.
It was not until 1980, however, that these reactions were formally recognised by the international psychiatric community. The name chosen was post-traumatic stress disorder, or PTSD, and the diagnostic criteria were agreed.
Before discussing the nature and treatment of PTSD, it's important to emphasise that human beings are generally resilient. Most people exposed to potentially traumatic events recover well with help from family and friends, and don't develop mental health problems.
For those who don't recover so well, PTSD is only one possibility, with depression, substance abuse, anxiety, and physical health problems also common. But PTSD is the only condition specifically tied to a traumatic experience.
PTSD is a serious psychiatric disorder characterised by three groups of symptoms:
- Reliving the traumatic event. People with PTSD describe vivid, painful images and terrifying nightmares of their experience.
- Avoidance. People with PTSD try to avoid reminders of what happened. They become emotionally numb and socially isolated to protect themselves from the pain.
- Being constantly tense and jumpy, always on the look-out for signs of danger. PTSD is associated with significant impairment in social and occupational functioning.
The latest Australian National Mental Health Survey reported that over 4% of the population experienced the symptoms of PTSD in the last year.
The incidence of PTSD varies considerably depending on the type of trauma, with sexual assault consistently the highest (around half of rape victims will develop PTSD). Accidents and natural disasters – events that do not involve human malevolence – tend to be the lowest at around 10%.
About half the people who develop PTSD recover over the first six to twelve months. Unfortunately, in the absence of treatment, the other half are likely to experience chronic problems that may persist for decades.
So why do some people develop these problems and not others? The answer is a combination of what the person was like before the trauma, their experiences at the time, and what has happened since.
In terms of pre-trauma factors, genetic vulnerability plays a part, along with a history of trauma, particularly in childhood, as well as tendencies towards anxiety and depression. Not surprisingly, the more severe the traumatic experience (the higher the life threat or exposure to the suffering of others) the more likely the person will develop PTSD.
The final group of risk factors appear after the event, with the most important being social support: people who have a strong network of friends and family to support them after the experience are less likely to develop PTSD. Other life stressors during this period (such as financial, legal, health, or relationship problems) can also interfere with recovery.
We have come a long way in improving treatments for PTSD and now have a large body of research evidence to guide our decisions.
The most effective treatment is trauma-focused psychological therapy. There are a few different forms, including cognitive behavioural therapies (CBT), as well as something called eye movement desensitisation and reprocessing (EMDR). The thing they share in common is providing the survivor with an opportunity to confront the painful memories, and to "work through" the experience in a safe and controlled environment. This therapy is not easy for either the patient or the therapist, but it is very effective in most cases.
Pharmacological treatment can also be useful in PTSD, especially in more complex cases and as an adjunct to trauma-focused psychological therapy. The most effective drugs for PTSD are the new generation anti-depressants – the selective serotonin re-uptake inhibitors or SSRIs. Other drugs can also be useful, depending on the clinical presentation.
The bottom line is that effective treatment is available if the PTSD sufferer can find their way to an experienced clinician.
We've come a long way in our understanding of mental health response to trauma in the last couple of decades, but many challenges lie ahead: Can we prevent the development of these problems? How should we respond with whole communities following widespread disaster such as bushfires, floods or terrorism? And can we improve the quality and availability of treatment?
As we address these challenges, we must strive to make sure the best possible care is available to those whose lives have been devastated by the experience of severe trauma.