Monday, 3 November 2014

Posttraumatic Stress Disorder (PTSD)



Image: nation.time.com

 


           Facing frightening situations is a part of life, and the brain is ready to respond to such situations resulting the body 's “fight-or-flight” response to ensure survival (Connie & Rossouw, 2013). Signs of this are expected as an adaptive reaction to intensely stressful moments that eventually fade away after a short time, without long term psychological consequences (Grawe, 2007). Posttraumatic Stress Disorder (PTSD), however, differs in intensity and duration, interfering in the person's normal daily functioning (Fritzsche, McDaniel & Wirsching, 2014). PTSD is a psychological injury, a reaction to the traumatic event and may be developed when a person witnessed, personally experienced, or learned that a relative or close friend has experienced a single or repeated traumatic experience, with the threat of possible injury or death (Romero, 2011). The emotions generated in such cases are experienced as overwhelming for the human coping mechanisms (Fritzsche, McDaniel & Wirsching, 2014). Co-morbidity may also occur (Fritzsche, McDaniel & Wirsching, 2014) as trauma maximises the chances of other mental illnesses developing (Fritzsche, Abbo,Frahm, Monsalve & Chen, 2014).

          In DSM-V, PTSD is found in Trauma and Stressor-Related Disorders instead of in the previous Anxiety Disorders category of DSM-IV. PTSD diagnostic criteria is established in the DSM-V as follows:

Diagnostic Criteria - 309.81 (F43.10)
Posttraumatic Stress Disorder

Note: The following criteria apply to adults, adolescents, and children older than 6 years. For children 6 years and younger, see corresponding criteria below.

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.
4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).
Note: Criterion A4 does not apply to exposure through electronic media, television, movie, or pictures, unless this exposure is work related

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
Note: In children, there may be frightening dreams without recognisable content.
3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)
Note: In children, trauma-specific re-enactment may occur in play.
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to internal or external cues that symbolise or resemble an aspect of the traumatic event(s).

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).
3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
5. Markedly diminished interest or participation in significant activities.
6. Feelings of detachment or estrangement from others.
experience happiness, satisfaction, or loving feelings).

E. Marked alterations in arousal and reactivity associated with the traumatic
event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
1. Irritable behaviour and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.
2. Reckless or self-destructive behaviour.
3. Hyper vigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

Specify whether:
With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following:
1. Depersonalisation: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).
2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted).
Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts, behaviour during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

Specify if:
With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate).

Posttraumatic Stress Disorder for Children 6 Years and Younger
A. In children 6 years and younger, exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others, especially primary caregivers.
Note: Witnessing does not include events that are witnessed only in electronic media, television, movie, or pictures.
3. Learning that the traumatic event(s) occurred to a parent or care giving figure.

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
Note: Spontaneous and intrusive memories may not necessarily appear distressing and may be expressed as play re-enactment.
2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).
Note: It may not be possible to ascertain that the frightening content is related to the traumatic event.
3. Dissociative reactions (e.g., flashbacks) in which the child feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Such trauma-specific re-enactment may
occur in play.
4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolise or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions to reminders of the traumatic event(s).

C. One (or more) of the following symptoms, representing either persistent avoidance of stimuli associated with the traumatic event(s) or negative alterations in cognitions and mood associated with the traumatic event(s), must be present, beginning after the event(s) or worsening after the event(s):
Persistent Avoidance of Stimuli
1. Avoidance of or efforts to avoid activities, places, or physical reminders that arouse recollections of the traumatic event(s).
2. Avoidance of or efforts to avoid people, conversations, or interpersonal situations that arouse recollections of the traumatic event(s).
Negative Alterations in Cognitions
1. Substantially increased frequency of negative emotional states (e.g., fear, guilt, sadness, shame, confusion).
2. Markedly diminished interest or participation in significant activities, including constriction of play.
3. Socially withdrawn behaviour.
4. Persistent reduction in expression of positive emotions.

D. Alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
1. Irritable behaviour and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects (including extreme temper tantrums).
2. Hypervigilance.
3. Exaggerated startle response.
4. Problems with concentration.
5. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

E. The duration of the disturbance is more than 1 month.
 
F. The disturbance causes clinically significant distress or impairment in relationships with parents, siblings, peers, or other caregivers or with school behaviour.

G. The disturbance is not attributable to the physiological effects of a substance (e.g., medication or alcohol) or another medical condition 
 
Specify whether:
With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and the individual experiences persistent or recurrent symptoms of either of the following:
1. Depersonalisation: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).
2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted).
Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts) or another medical condition (e.g., complex partial seizures).

Specify if:
With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate).” (First, 2014, 309.81- F43.10).

          Concerning the prevalence of PTSD, DSM-V states that it may vary depending of culture, developmental stage, demography and type of risks involved in the person's profession (First, 2014). In Australia, 5 to 10% of the adults, and 1 to 6 % of children are expected to suffer PTSD in their life-time (Australian Centre for Posttraumatic Mental Health, 2013). Additionally, “6% of women may suffer PTSD after obstetric procedures” (Cockburn & Pawson, 2007). Comorbidity is found in 86% of males and 77% of females (Australian Centre for Posttraumatic Mental Health, 2013). Research affirmed that in the United States, the prevalence of PTSD throughout lifetime is 8%, while in Germany, it is 1.3% and in Algeria 37.4% (Davidson, 2001). Survivors of war and rape are among the highest percentage, while elderly adults present the lowest percentage (First, 2014). A study utilising a sample of 379 respondents who survived the attack on the World Trade Centre on September 11 revealed the prevalence of PTSD in more than a third of those who were directly exposed, 20% in those who just witnessed the traumatic events on that day, and 35% of those who learned that a close relative or friend was directly exposed to the events (Worcester, 2011).

         Moreover, Cuffe, Cuffe, Addy, Garrison and Waller's (1998) research concerning the prevalence of PTSD in 490 older adolescents ranging from 16 to 22 year of age and from different ethnic groups demonstrated that a fraction of 49.37% female suffered rape or sexual abuse in childhood, and 85.02% were witness to a traumatic incident (Cuffe, Cuffe, Addy, Garrison & Waller, 1998). PTSD was found frequently in those who suffered rape or were victims of crime (Cuffe, Cuffe, Addy, Garrison & Waller, 1998). Family attachment and living with the family or by themselves were not considered to raise the risk of PTSD development (Cuffe, Cuffe, Addy, Garrison & Waller, 1998). In addition, Ditlevsen and Elklit's (2012) study showed that gender and type of trauma differences influence PTSD prevalence. From 5520 subjects interviewed, 20.6% or 1075 participants, 25.6% of which were female and 13.2% males, met the DSM criteria for PTSD (Ditlevsen & Elklit, 2012). Due to gender inherent differences, females demonstrated twice the number of incidences of PTSD than males (Ditlevsen & Elklit, 2012). “Disaster and accident” were the type with the “highest gender difference”, while “violence was the lowest gender difference”, but the highest PTSD prevalence (Ditlevsen & Elklit, 2012). Females are more susceptible, firstly, to “disaster and accident” types of trauma, and secondly, to “chronic illness and loss”(Ditlevsen & Elklit, 2012).

         Clinicians find PTSD presentation of symptoms in “acute, chronic, delayed, complex, or even masked forms” (McHugh & Treisman, 2007). The type and duration of symptoms indicate the severity level (McHugh & Treisman, 2007). Soon after an unexpected traumatic incident, the person may act as if what happened was not real, feel agitated, and not eating or sleeping well during the first hours or days after the event (McHugh & Treisman, 2007). Following this, the person will recall the event with high anxiety, may feel “sadness, fear, guilt, anger, irritation, numbness, depersonalisation, hypervigilance, have nightmares and flashbacks” and avoid what is
connected with the trauma (Australian Centre for Posttraumatic Mental Health, 2013). Dave & Mehta's (2008) research indicated that women with PTSD show more low energy, anxiety, depression and suicidal ideation than men.

         During the interview, some clients find it difficult to begin speaking about the traumatic event aiming to avoid the “horror and helpless” feelings, which arise shortly after they begin to report the incident (Yehuda, 2002). Others show disengagement from the conversation or clearly refuse to talk about the subject, which does not mean that the client is unwilling to cooperate with the treatment, but instead, it is a sign that talking about the trauma causes extreme distress (Yehuda, 2002). Some become very agitated or show pessimism and a “negative mood”. Moreover, being unable to arrive on time for the session due to lack of organisation, forgetting the address, “emotional absence or detachment”, as well as forgetting parts of the episode, are examples of dissociation (Yehuda, 2002). In general, the client's family may often complain that their relationship becomes “superficial and distant” (Yehuda, 2002). As PTSD impacts the brain's function not only during the event, but also during the reexperiencing as a result of the activation of the “limbic-system and pre-frontal shuts down”, the client experiences difficulty in verbally expressing themselves, processing new information, comprehending and “finding meaning” for what occurred (Hartley, 2009).

         The mental heath professional must note that PTSD symptoms such as ‘‘difficulty falling or staying asleep, difficulty concentrating, diminished interest or participation in significant activities, restricted range of affect and irritability can also be caused by other disorders instead of the related trauma” (McHugh, & Treisman, 2007). Clinicians may also find cases of malingering (when the person intentionally fakes their PTSD symptoms in order to receive financial compensation) and factitious (when the person misunderstands their conceptualisation of their traumatic event) presentations of PTSD symptoms (Rosen & Taylor, 2007).

         Although it is known that the most common symptoms of PTSD are “reexperiencing, avoidance/numbing, and hyperarousal” (Cloitre, Courtois, Charuvastra, Carapezza, Stolbach, & Green, 2011), DSM-V states that the predominance of “clinical presentation varies”(First, 2014). For instance, while some people present more “emotional and behavioural symptoms with fear-based re-experiencing, others show anhedonic or dysphoric mood states and negative cognitions”(First, 2014). Some display more “arousal and reactive-externalising symptoms, while others show, dissociative symptoms”(First, 2014). The combination of these symptoms can also be found (First, 2014). Further studies are needed to know how to differentiate and better understand the effects caused by pre and post-migration stressors, acculturation, chronic grief, discrimination and other difficulties experienced by immigrants and refugees upon PTSD symptom presentation.

          For instance, Davidson's (2001) research established a high percentage of somatization and irritable bowel syndrome in people diagnosed with PTSD. Furthermore, the intense period of fight or flight survival reaction when the person is experiencing the trauma, causes muscles and joints to become very tense, the body memorises and keeps repeating this reaction, causing long term muscles and joint pain, which must be separated from the “physiological effects of a substance (e.g., medication, alcohol) or another medical condition” stated in criteria H (First, 2014). Galovski, Mott, Young-Xu and Resick's (2011) study concerning “gender differences in the clinical presentation of PTSD” with 162 woman and 45 man who suffered sexual assault or physical violence indicated that a similar percentage of females and males feel guilt, however, males feel more anger while females show more “health related symptoms”. The current results of Carleton, Mulvogue and Duranceau's (2014) study with 129 women who experienced spouse violence stated that personality attributes cause more “comorbid symptoms”, thus, influencing PTSD symptom-presentation.

         Adolescents present symptoms of reexperiencing such as “intrusive thoughts and nightmares, amnesia, detachment, sleep disturbance and hypervigilance, refusing to talk about the trauma and withdrawal from friends and activities” (Perkin, 2008). Those with chronic symptoms demonstrate “dissociative symptoms such as derealization, depersonalisation, self-harm, substance abuse, and intermittent angry or aggressive outbusters” (Perkin, 2008). Primary school children principally exhibit “re-enactment of the trauma through play, speech and drawing, instead of amnesia, avoidance, numbness and flashbacks” (Perkin, 2008). Toddlers manifest “generalised anxiety as separation fears, strangers anxiety, fear of monsters or animals, as well as sleep disturbance, and avoidance of situations, words or symbols that may be related to the trauma” (Perkin, 2008).

         For example, in Green, and colleagues' (1991) study with 600 adults and children aged 2 to 15years of age, two years after a flood experience, PTSD intrusion symptoms” such as “distressing dreams”, had the highest percentage of occurrence in children, followed by “low affect, irritability and anger outburst” (Green, Korol, Grace, Vary, Leonard, Glesser, & Smitson-Cohen, 1991). PTSD symptoms were found in all age groups with fewer occurrences in the youngest children (Green, Korol, Grace, Vary, Leonard, Glesser, & Smitson-Cohen, 1991). Gender, threat of death, parent’s depression and irritability were also contributing factors to children's PTSD development (Green, Korol, Grace, Vary, Leonard, Glesser, & Smitson-Cohen, 1991).

         Another common symptom found in people with PTSD are “flashbacks” (First, 2014). These are “dissociative symptoms” where the person feels through sensory or visual organs, intrusive pieces of the trauma experienced as if it were happening again, even though they are still aware of their current reality (First, 2014). It may last from seconds to days, causing long term “distress and arousal” (First, 2014). Children under six re-live the trauma through playing or “dissociative states” (First, 2014). Criteria C1 of DSM-V, “avoidance, is achieved when the person distract themselves in order to avoid thoughts, memories, feelings, or talking about the traumatic event”, and C2, when avoiding “activities, objects, situations, or people who remind them of the event” (First, 2014).

         One of the “negative alterations” symptoms listed in criteria D1 is called “amnesia” (First, 2014). This “inability to remember” specific moments of their past experiences was found in Graham, Herlihy and Brewin's (2014) study in which 38 asylum seekers and refugees diagnosed with PTSD, from 19 different countries were interviewed. The study also highlighted that refugees' visas have been denied by several countries' agencies as refugees with PTSD are unable to recall past life or trauma moments, which is a requirement in order to prove credibility of their situation and need for a refugee visa (Graham, Herlihy & Brewin, 2014).

         Another significant factor that is generally overlooked by clinicians is the comorbidity of PTSD and nicotine (Stewart, 2014). Stewart's (2014) study with 604 people who were 41 years old and diagnosed with PTSD found that smoking is used by them as self-medication in order to decrease stress levels (Stewart, 2014). Additionally, smokers diagnosed with PTSD are less willing to quit smoking as their energy seems to be needed to deal with PTSD symptoms rather than facing smoking withdrawal symptoms, which compromises their overall health and affects positive outcomes in reducing PTSD symptoms (Stewart, 2014).

         Regarding impacts, PTSD has been known as a common disorder in many countries, negatively affecting peoples lives for an average of 20 years (McHugh & Treisman, 2007). In the United States, research has revealed that, as people with PTSD do not seek mental health treatment, only 4% receive the appropriate diagnosis, with 19% attempting suicide (Davidson, 2001). Moreover, there is a loss of 3 billion dollars a year, with one work day a week affected by the absence of workers with PTSD symptoms (Davidson, 2001), which, therefore, increases unemployment by 150% and causes instability in 60% of marriage relationships (Galovski & Lyons, 2004). PTSD is also considered a cause of increasing the “risk for depression, anxiety, alcohol or substance use disorders, hypertension, bronchial asthma, peptic ulcer, diseases of the cardiovascular, digestive, musculoskeletal, endocrine, respiratory, and nervous systems, as well as infectious diseases” (Davidson, 2001). Those who were abused in childhood have a high percentage of having PTSD (Davidson, 2001) and consequently, a higher percentage of “smoking, contracting sexually transmitted diseases, developing severe obesity, ischemic heart disease, cancer, chronic obstructive pulmonary disease, fractures, and liver disease than the general population”(Davidson, 2001).

         Galovski and Lyons's (2004) review of 141 articles indicate that “secondary traumatization” is one of the impacts caused by “numbing/arousal symptoms” of PTSD on the relationship of veterans with their families. The trauma can also be passed to the next generation, when a child becomes traumatised by learning of their parent's trauma, or copies their symptoms to identify with them (Galovski & Lyons, 2004). Similarly, Ray and Vanstone's (2009) study with 10 “contemporary
peacekeepers” from 37 to 46 years old, made evident that “veteran's anger” and “emotional withdrawal from family support” not only impacts their family relationships, but prevents positive treatment outcomes, and, hence, are the first symptoms that should be addressed during PTSD treatment (Ray & Vanstone, 2009).

         A thorough assessment of PTSD includes the collection of the relevant data in order to assess presence and severity of the symptoms as well as diagnostic criteria, trauma exposure and comorbidity (Frueh, Grubaugh, Elhai & Ford, 2012). The clinician must also explore the client's history, “marital status and family situation, the client's strengths and resilience, and response to previous treatments” (Frueh, Grubaugh, Elhai & Ford, 2012). Furthermore, the clinician also need to make a differential diagnosis and prognosis, decide the best approach to be used, establish treatment goals and plan, and monitor the treatment and its outcomes (Frueh, Grubaugh, Elhai & Ford, 2012). This interview can take from 15 to 60 minutes, where the Mental Status Examination is applied, and suicide assessment may be necessary (Frueh, Grubaugh, Elhai, & Ford, 2012). During the PTSD assessment process, the mental health professional need carefully eliminate the possibility of “malingering” or other forms of “factitious-PTSD”, (Rosen & Taylor, 2007).

         The National Centre for Posttraumatic Stress Disorder, suggests the use of the multimethod approach for the assessment (Mueser, Rosenberg, & Rosenberg, 2009). According to the “multimethod approach”, the most common methods and measures that can be used to screen, diagnose and monitor treatment outcomes are “Diagnostic Interviewing, Self-report questionnaires and Psychophysiology measures”(Friedman, Keane & Resick, 2014). Furthermore, the clinician may need to use “multiscale personality inventories”, see the client's medical records and collect information related to client's behaviour from other people (Friedman, Keane & Resick, 2014).
Different measures can be used for different populations, considering different “cultural and linguistic background and different cultural trauma conceptualisations” (Australian Centre for Posttraumatic Mental Health, 2013).

         An adequate treatment of PTSD involves building a strong therapeutic alliance (more time will be required for clients who have suffered more prolonged exposure or severe traumas), ensuring the client's safety, making a careful “assessment, case formulation, considering PTSD chronicity, comorbidity, and cognitive and physical health, including hormone levels which are affected during the stress reaction” (Martin & Captain, 2013). In addition, the therapist should consider the client's background, treatment expectancy, treatment setting (including environments where the client is exposed to continuous stress and trauma such as detention centres, refugee camps, corrective centres, theatres of combat, women's refuges), individualised treatment planning, and monitoring (Australian Centre for Posttraumatic Mental Health, 2013). The clinician may also need to provide practical information, psycho-education and foster client's network support and encourage regular physical exercises (Australian Centre for Posttraumatic Mental Health, 2013). Most importantly, clinicians must be skilled, trained, and able to use their clinical judgement to chose the best approach to use as a “first or second line intervention” (Forbes, Creamer, Bisson & Cohen, 2010).

         Treatments may combine psychological and medical interventions, where the most indicated are the trauma-focus interventions, in order to reduce PTSD symptoms, anxiety and depression (Australian Centre for Posttraumatic Mental Health, 2013). Medication should not be used as a frontline treatment, but only after one month of symptoms appearance, and when psychological treatment is unsuccessful, or when it is necessary to treat comorbidity symptoms (Australian Centre for Posttraumatic Mental Health, 2013). If medication for adults with PTSD is needed, “selective serotonin re-uptake inhibitor (SSRI) antidepressants” are the most prescribed (Australian Centre for Posttraumatic Mental Health, 2013). It is important to highlight that debriefing is not advised soon after the trauma to prevent client's re-traumatisation (Australian Centre for Posttraumatic Mental Health, 2013).

          “Trauma-focused Cognitive-Behavioural Therapy (TFCBT), Eye Movement Desensitisation and Reprocessing (EMDR), Psychodynamic Psychotherapy, Supportive Counselling/Therapy, Narrative Exposure Therapy (NET), Hypnotherapy, and Psychological Debriefing are the common approaches used to treat PTSD” (Australian Centre for Posttraumatic Mental Health, 2013). However, Bisson, Roberts, Andrew, Cooper and Lewis's (2013) review of 70 studies including 4761 people about Psychological Therapies for PTSD, concluded that “Individual Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) and Eye Movement Desensitisation and Reprocessing (EMDR)” are the more empirical validated, dominant, and effective treatments recommended for PTSD in adults.

           TF-CBT uses techniques from Cognitive Therapy and Behavioural Therapy intending to change people's thoughts and behaviours in order to better deal with the traumatic incidents by the exposure of those memories (Bisson, Roberts, Andrew, Cooper & Lewis, 2013). EMDR is the progressive recall of trauma memories while making eye movements when the person reprocesses and replaces the trauma memories for more adaptive ones, decreasing stress levels (Bisson, Roberts, Andrew, Cooper, & Lewis, 2013). For children and adolescents,“developmentally appropriate Trauma-Focussed Cognitive Behavioural Therapy” is the most recommended treatment, including parent's involvement, children's homework, the use of “validated protocols”, attractive colourful materials and media (Australian Centre for Posttraumatic Mental Health, 2013). Further investigation about effectiveness of psychodynamic psychotherapy, supportive counselling/therapy, narrative exposure therapy (NET), hypnotherapy, and psychological debriefs are needed (Australian Centre for Posttraumatic Mental Health, 2013).

          As attachment and control are basic human needs, establishing a trustful therapeutic relationship and ensuring constant safety are the first steps to build a strong therapeutic alliance and facilitate change (Connie & Rossouw, 2013). Clients with PTSD can be more resistant to treatment as their reactions are in the “survive mode”(Conte, 2009). Those with insecure or disorganised attachment may carry a degree of developmental trauma, which enhances PTSD symptoms (Hartley, 2009). Hence, the human encounter must be genuine, individualised and non-judgemental so that the client can have a restorative emotional experience (Hartley, 2009). Clinicians also need to demonstrate empathy, acceptance, unconditional positive regard, recognise their counter transferences, and ability to withstand the feelings contained in the client's lived experience concerning the catastrophic event they suffered (Hartley, 2009). In addition, an ability to apply effective treatment methods, basic and advanced skills such as active listening, attending behaviour, questioning, immediacy, reflecting, paraphrasing, and summarising are required (Sommers-Flanagan & Sommers-Flanagan, 2012). Moreover, “Self-awareness, multicultural knowledge, and culturally specific techniques, which are multicultural competences” should also be considered (Sommers-Flanagan & Sommers-Flanagan, 2012). Furthermore, the clinician's supervision, and self-care are crucial to prevent secondary traumatisation (Stender, 2013).
 
         In conclusion, PTSD is a common and very distressing clinical condition that occurs after a traumatic event, impacting people's lives, and their families, in many areas (McHugh & Treisman, 2007). Type, presentation and duration of symptoms vary and must be differentiated from other disorders (McHugh & Treisman, 2007). Assessment measures and treatment approaches should be culturally appropriate (Australian Centre for Posttraumatic Mental Health, 2013). A trustful and genuine therapeutic relationship, in a safe environment, are the key elements to assist clients with PTSD to rebuild their lives (Blackwell, 2005). Further studies for a better comprehension of the correlation of PTSD symptoms and refugee's and immigrants' holistic experience is needed.

Mrs Glaucia Barbosa,
PACFA Reg. Provisional 25212 
MCouns, MQCA(Clinical)  
ABN: 19 476 932 954

References

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