Deciphering PTSD

With the recent disastrous fires spreading through NSW, Mr Simon Andrews, a volunteer from the Rural Fire service, is seeking millions of dollars in compensation as he claims to suffer from PTSD and alcohol abuse after attending over 700 critical incidents and is now unable to work. The NSW Rural Fire Service “failed in the duty of care, was negligent and failed to take any or any adequate care for the safety of the plaintiff”, yet he continued to be deployed. (please find other lawsuits related to PTSD at the end of the article).

A/Prof Cristina Morganti-Kossmann

Lex Medicus Publishing Director

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PTSD caused by bush fires

With the recent disastrous fires spreading through NSW, Mr Simon Andrews, a volunteer from the Rural Fire service, is seeking millions of dollars in compensation as he claims to suffer from PTSD and alcohol abuse after attending over 700 critical incidents and is now unable to work. The NSW Rural Fire Service “failed in the duty of care, was negligent and failed to take any or any adequate care for the safety of the plaintiff”, yet he continued to be deployed. (please find other lawsuits related to PTSD at the end of the article).

So, what is happening to Mr Andrews? What is PTSD? At times of catastrophic accidents, exposure to natural disasters, attendance to emergency calls and dramatic changes of life circumstances people undergo unusually profound levels of stress, which is around 10% of individuals will trigger a mental health condition named post-traumatic stress disorder or PTSD. The most common traumatic events leading to PTSD include military deployment, political conflicts, detention, child abuse and sexual violence.

PTSD has received much attention particularly within the defence forces when soldiers deployed to extreme conflicts in remote areas like Vietnam, Afghanistan and Iraq returned with an array of symptoms rendering them incapable to rejoining the community in a functional manner. Recognising this condition and formulating a suitable treatment protocol is critical to resolving the problem.

Defining PTSD

According to Phoenix Australia, Centre for Posttraumatic Mental Health, PTSD is a set of reactions that can occur after someone has been through a traumatic event whether directly or as a witness. The chance of developing PTSD depends on the type of event experienced, but up to 10% of Australians will suffer from PTSD at some point in their lives.

In Australia the prevalence rates for PTSD are 4.4% (over 12 month) and 7.2% (lifetime). Rates are higher after specific interpersonal traumas whereby rape and torture may lead to lifetime prevalence rates up to 50%. It is estimated that one million Australians suffer from PTSD.

Some of the general symptoms of PTSD include reliving the traumatic events, avoiding reminders of the traumatic event, having negative thoughts and emotions (fear, anger, feeling numb), difficulties in sleeping and concentrating, being irritable, displaying risk behaviours and typical mental health problems such as depression and anxiety often combined with alcohol and substance abuse. The risk of suicide is possible when these symptoms are protracted over a long period of time.

The most common traumatic events leading to PTSD include military deployment, political conflicts, detention, child abuse and sexual violence.


Who are the PTSD sufferers?

Phoenix Australia began with studying post-traumatic mental health in the veteran population, which was later expanded to include the wider community. They have developed a set of guidelines, each one targeting a specific risk group so that the identification, diagnosis and treatment of PTSD respect the characteristics intrinsic to the problematics of each one.

These guidelines are approved by the National Health and Medical Research Council and focus on the military and ex-military personnel, emergency services personnel, Aboriginal and Torres Strait Islander People, refugees and asylum seekers, and victims of assault, motor vehicle accidents, natural disasters, terrorism, trauma and crime.

Such communities are particularly susceptible to developing PTSD due to their extreme and/or continued exposure to trauma. In regard to the military, it is estimated that 8.3% of Australian Defence Force (ADF) members have experienced PTSD in the past 12 months, which compared to the 5.3% of the general Australian population is significantly higher.

PTSD is also more prevalent in groups such as the emergency services: police, fire and rescue, and ambulance, and additional voluntary emergency organisations including State Emergency Services (SES), coast guard, rural fire service and lifesavers. Workers of these organisations are on the front-line to traumatic incidents as part of their daily work or volunteer activities. Although most individuals recover quickly following one or more events, some will develop mental health problems.

In the case of ambulance personnel, a meta-analysis publication reporting on 30,800 ambulance workers from 18 internationally published studies demonstrated rates of 11% for PTSD, 15% for depression, 15% for anxiety, and 27% for psychological distress, all of which is considerably higher than the general population.


Aboriginal and Torres Strait Islander
peoples have been suffering from historical traumas due to the separation from their land, their families and cultural identities, protracting the traumatic legacy to the next generations. Sadly, Indigenous Australians are twice as likely to be the victims of violence or threatened violence than other Australians. They also suffer twice as much from mental health conditions with a higher rate of suicide, particularly in young males. People from these communities often present too late to health care facilities when the development of PTSD consequent to traumatic events has overlapped with pre-existing psychological disorders and substance abuse. PTSD can be confused with other mental health conditions and not diagnosed properly; a detriment to swift treatment.

Victim of assault resulting in PTSD

With sexual assault, the picture of the victim suffering from PTSD is quite complex as the trauma may range from an isolated adult event of rape to repeated sexual abuse during childhood or a combination of both. Symptoms vary depending on these different experiences as well the type and frequency at which they have been perpetrated. Often presentation to a health professional by an adult may occur years to decades following sexual abuse in childhood. Sadly, sexual assault in children can have a significant impact on their development and attachment. An additional factor in the context of sexual assault is the reluctance of some survivors to disclose the traumatic experience due to the intimacy of the events and the disbelief of what they may have endured when recounting their trauma to family members or law representatives.

Approximately 10% of adult refugees and asylum seekers suffer from PTSD, rising to 25% in those that had endured torture. Children form almost half of the refugee’s population and one-third of the asylum seekers with an 11% chance to suffer PTSD. It is recognised that prolonging detention of children and adolescents will correlate with increased mental health conditions.

For other communities refer to the Phoenix Australia website.

Approximately 10% of adult refugees and asylum seekers suffer from PTSD


Diagnosis

Diagnostic and Statistical Manual of Mental Disorders (DSM)

In 1980, the American Psychiatric Association added PTSD to the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-III) classification scheme. However, PTSD is quite distinct compared to other psychiatric illnesses because “the etiological agent is outside the individual (traumatic event) rather than an inherent individual weakness (traumatic neurosis)”. Thus, in formulating the diagnosis of PTSD the psychiatrist needs to give priority to understanding the traumatic stressor.

With the fifth edition of DSM (-5) released in 2013, significant changes were introduced to the way PTSD is classified and diagnosed in a more definite manner.

DSM-5 provides the following criteria for the diagnosis of PTSD:

“A” stressor criterion: a person is exposed or witnessed a catastrophic event involving actual or death threats or injury or threat to physical integrity of oneself or others.

“B” Intrusive recollection criterion: the traumatic event remains, sometimes for decades or a lifetime, a dominating psychological experience that retains its power to evoke panic, terror, dread, grief, or despair. Nightmares, and vivid re-enactments or PTSD flashbacks. Trauma-related stimuli trigger recollections of the original event and induce mental images, emotional responses, and physiological reactions associated with the trauma. Researchers can use this phenomenon to reproduce PTSD symptoms.

“C” or avoidance criterion: behavioural strategies PTSD patients use in an attempt to reduce the likelihood that they will expose themselves to trauma-related stimuli.

“D” or negative cognitions and mood criterion: persistent alterations in beliefs/mood that have developed after the traumatic event. PTSD sufferers have erroneous cognitions about the causes or consequences of the event and have negative emotional states such as anger, guilt, or shame. Dissociative psychogenic amnesia involves cutting off the conscious experience of trauma-based memories. Individuals suffer from persistent negative emotions and are unable to experience positive feelings.

“E” or alterations in arousal or reactivity criterion: panic and generalised anxiety disorders. While insomnia and cognitive impairment are generic anxiety symptoms, hypervigilance and startle are more characteristic of PTSD. Irritable and angry outbursts expressed as aggressive behaviour. Finally, reckless and self-destructive behaviour such as impulsive acts, and suicidal behaviour.

“F” or duration criterion: symptoms must persist for at least one month before PTSD is diagnosed.

“G” or functional significance criterion: the survivor must experience significant social, occupational, or other distress as a result of these symptoms.

“H” or exclusion criterion: exclude that symptoms are not due to medication, substance use or other illnesses.

Longitudinal expression: PTSD can become a chronic condition and last for decades or a lifetime. In some cases, it takes months to years for a full diagnosis.

Co-occurring conditions: PTSD may coexist with major affective disorders, dysthymia, alcohol or substance abuse, anxiety disorders, or personality disorders. The frequency of these comorbidities makes it difficult to prioritise the time of intervention of PTSD and concurring conditions.


Classification and subtypes

PTSD is no longer considered an Anxiety Disorder but a Trauma and Stressor-Related Disorder because it has a number of clinical presentations. Two new subtypes have been included in the DSM-5.

Dissociative Subtype: adult individuals who meet full PTSD criteria but also exhibit either depersonalisation or derealisation (e.g. alterations in the experience of one’s self and the world).

Preschool Subtype: children six years old and younger; it has fewer symptoms (especially in the “D” cluster because it is difficult for young children to report on their inner thoughts and feelings) and has lower symptom thresholds to meet full PTSD criteria.
Diagram showing the brain regions where structural and/or functional changes have been found in PTSD patients
Diagram showing the brain regions where structural and/or functional changes have been found in PTSD patients


Neurobiology of PTSD

PTSD is a state of heightened responsivity to threatening stimuli and a state of deficient inhibitory control over-exaggerated threat-sensitivity. In the pathophysiology of PTSD, the “hypersensitivity to threat” is a critical characteristic (such as hypervigilance and hyperarousal).

Medical research has shown that PTSD is associated with ongoing neurobiological alterations in both the central and autonomic nervous systems. The psychophysiological alterations include hyperactivity of the sympathetic nervous system, increased sensitivity and amplification of specific reflexes, and sleep abnormalities.

PTSD is characterised by abnormal regulation of hormones in the hypothalamic-pituitary-adrenal axis, the centre of the mammalian neuroendocrine stress response. Neuroendocrine abnormalities may be responsible for the physiological effects such as increased pulse and blood pressure, startle response and levels of arousal.

Neurochemical changes have also been demonstrated in PTSD sufferers. GABA, a neurotransmitter with inhibitory action in the brain is decreased in PTSD sufferers, explaining their inability to mitigate physiological reactions to stress and anxiety. Conversely, the excitatory neurotransmitter glutamate, regulating the consolidation of memories, is enhanced contributing to the consolidation of trauma recollections.

Brain structural and functional changes detected with neuroimaging show volume reduction in some areas such as the prefrontal cortex, amygdala, and hippocampus. These changes have profound effects on behaviour. Neuroimaging has also shown exaggerated activity in the amygdala and reduced activation of the prefrontal cortex and hippocampus.

From these studies, it seems that PTSD could result from over-learning of trauma memory and a failure of memory elimination, the process that creates new, competing inhibitory memories that dissociate from the traumatic memory. In simple words “The brain’s stress response pathway stays in this hyperaroused state.” As a result of failure of elimination, patients with PTSD constantly re-experience fear in stressful situations or in response to an unconditioned stimulus.

Chronic PTSD

Having a pre-existing mental health condition including anxiety and depression increases the likelihood of developing PTSD. In some people, PTSD can become a chronic psychiatric disorder and persist for decades and even a lifetime, alternating periods of remissions and relapses. There is also a delayed variant of PTSD in which individuals exposed to a traumatic event do not exhibit the full PTSD syndrome until months or years afterwards.

PTSD Treatment


Treatment 

The US Department of Veterans Affairs (VA) recommends beginning PTSD treatment with counselling rather than pharmacotherapy. Counselling approaches for PTSD include trauma-focussed cognitive behavioural therapy (CBT) and eye movement desensitisation and reprocessing (EMDR).

Psychotherapy will focus on:

  • Learning to confront and come to terms with painful memories, thoughts and images, so the individual does not feel as distressed
  • Learning strategies to help to get back into activities or visit places that have been avoided since the trauma because too distressing
  • Learning tools to relax when becoming too anxious or wound up
  • Exploring thoughts that may be making memories of the event more painful

This strategy will enable the patient to confront the distressing traumatic memories, manage the avoidance responses, and facilitate reduction and management of the associated arousal. Evidence-based psychological treatments usually involve 8–12 sessions, although more or longer sessions may be required for complex presentations.


Australian guidelines

The Australian guidelines for PTSD treatment are very much in agreement with those from the US Department of Veterans Affairs. According to Phoenix Australia Guidelines, treatment for PTSD in adults includes psychological and medical interventions, but the cornerstone of treatment involves confronting the traumatic memory and addressing thoughts and beliefs associated with the experience. Trauma-focussed interventions can reduce PTSD symptoms, lessen anxiety and depression and improve quality of life. They are also effective with people who have experienced prolonged or repeated traumatic events.

Psychological intervention will focus on the following approaches:

Trauma-focussed cognitive behavioural therapy (TF-CBT) TF-CBT helps to confront the memory of their traumatic experience/s in a controlled and safe environment. It also guides patients to identify, challenge and modify any biased and distorted thoughts and memories of their traumatic experience.
Eye Movement Desensitisation and Reprocessing (EMDR) is a psychotherapy treatment designed to alleviate the distress associated with traumatic memories. The patient attends to emotionally disturbing material in brief sequential doses while simultaneously focusing on an external stimulus. EMDR therapy facilitates the accessing of the traumatic memory network, so that information processing is enhanced, with new associations forged between the traumatic memory and more adaptive memories or information. These new associations result in new learning, elimination of emotional distress, and development of cognitive insights. With these methods, people accessing treatment are encouraged to gradually recall and think about traumatic memories until they no longer create high levels of distress. 

Medications

  • Medication should not be used as a routine first-line treatment in preference to trauma-focused psychological therapy.
  • Medication can be useful if the person is not getting sufficient benefit from the psychological intervention alone.
  • Where medication is considered for the treatment of PTSD in adults, selective serotonin re-uptake inhibitor (SSRI) antidepressants are the first choice.

Comorbid conditions will receive attention following treatment for PTSD. Depression usually improves with the benefit of PTSD treatment. However, when depressive symptoms are so severe with a high risk of suicide they will have to be prioritised. Generally, rehabilitation for substance abuse will occur simultaneously to the treatment of PTSD; however it may become the first treatment strategy to make PTSD management more effective.

Another aspect of the holistic PTSD treatment is psychosocial rehabilitation as some individuals may lack self-care, independent living skills, homelessness, high-risk behaviours, interactions with family and friends, social inactivity, and unemployment.

Children with PTSD


Children and adolescents with PTSD

Firstly, young people need the assistance of their carers to address psychological therapy. Such therapy involves the family as every member will be affected by the young person’s mental health issues. Parents and caregivers are critical in reporting the circumstances of the traumatic event and the child’s symptoms; however, this recount may not always overlap with the child versions of the facts. The treating specialist may need to take into consideration behavioural and attention deficits, anxiety and affective disorders, which may contribute to the symptoms of PTSD.

There are several tests and questionnaires used to assess a child/adolescent with PTSD. They will differ in each age group (infant, preschool, or adolescent), focussing on multiple aspects of global mental health. Trauma-focussed psychological therapy is the strategy of choice for PTSD in this age group, while the effectiveness of EMDR in children is less well established. Treatment is more effective if delivered in schools and with the contribution of parents to ensure the attendance to the sessions and the implementation of the tasks advised by the treating professional. This will allow practitioners to closely follow the role of the parents’ functioning relative to the child’s improvement in their PTSD symptoms.

Please visit the links below to access additional lawsuits related to PTSD:

1. Pel-Air Aviation Pty Ltd v Casey [2017] NSWCA 32 (9 March 2017)
Personal injury – strict liability claim against air carrier for injuries sustained during aircraft accident – respondent suffered physical and psychiatric injuries including Post Traumatic Stress Disorder (“PTSD”) – whether PTSD constitutes a “bodily injury” – Article 17(1) of the Montreal Convention relating to International Carriage by Air – Civil Aviation (Carriers’ Liability) Act 1959 (Cth) sections 9B and 9E – bodily injury includes physical damage to the brain – evidence that PTSD caused chemical changes in respondent’s brain but no evidence of physical damage to the brain.

2. YZ (a pseudonym) v The Age Company Limited
Claim for damages by a journalist against employer, The Age newspaper, as a result of psychological injury said to have been suffered from being repeatedly exposed to traumatic events, as a crime and court reporter – development of Post-Traumatic Stress Disorder – whether psychological injury foreseeable – nature and extent of the complaints made by the plaintiff – state of defendant’s knowledge of risk of psychiatric injury – content of duty owed by employer – whether breach of duty – whether breach caused injury – steps the defendant could have taken to reduce risk – contributory negligence – nature and extent of psychological injury – assessment of pain and suffering damages.

3. Greenway v The Corporation of the Synod of the Diocese of Brisbane
Torts – negligence – essentials of action for negligence – where nervous shock or mental disorder – generally – where plaintiff was employed by the defendant as a residential carer for young people – where she was assaulted by a young person – where the young person’s violent history was known to the defendant – where after the assault she was required to supervise the young person alone overnight – where the plaintiff now suffers from PTSD – whether the defendant breached its duty of care to the plaintiff – whether the plaintiff’s harm was caused by the defendant’s breach.

 

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