Posttraumatic Stress Disorder Ptsd

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Geoff was a policeman who had served on the streets for over ten years; in that time he had won two commendations for bravery. Geoff was a popular guy, who was respected, trusted, and liked. He had a reputation as being the life and soul of the party. While on escort duty one day in the back of a police van, the prisoner whom Geoff was in charge of became extremely violent. He managed to throw Geoff against the side of the van and smashed Geoff's head out of the window before being overcome by the other policemen. The incident lasted less than a minute in total. Following that day, Geoff underwent profound changes. He had nightmares about the event and kept thinking he saw the prisoner among crowds on the street. He felt very vulnerable and it became such that his colleagues could no longer trust him to back them up in a tight situation. At home, Geoff became withdrawn and irritable and his marriage started to suffer. Twelve years later, Geoff came for help. He had been thrown out of the police, his wife had left him, and he worked in an office job where he had taken care to get the office in the centre of the building where no one could "get to him". On describing that minute of his life twelve years earlier, Geoff broke down into tears saying "I always thought that whatever happened, I would be able to handle it; now I'm frightened of my own shadow."

Since its inclusion in the DSM-III (APA, 1980), post-traumatic stress disorder (PTSD) has been the subject of a great deal of empirical and theoretical work. A number of well thought-out psychological models of PTSD have been proposed, many within a cognitive framework (e.g., Brewin, Dalgleish, & Joseph, 1996; Ehlers & Clark, 2000; Foa & Rothbaum, 1998; Horowitz, 1979, 1997; Litz & Keane, 1989). In this section we review briefly existing empirical and cognitive theoretical work in PTSD before outlining in some detail how PTSD might be conceptualised within the SPAARS framework.

According to DSM-IV (APA, 1994), PTSD can follow traumatic events in which individuals experience a threat to their own life or the lives of others or a threat to their own or others' physical integrity. Although such attempts at objectively defining the aetiological events in PTSD are useful, we suggest that it is the impact of the event or events on an individual's current models of self, world, and other that is central. For some this might indeed be the life-threatening car crash or the tour of duty in Vietnam; for others, however, being shouted at by their previously calm and supportive boss at work might be sufficient.

The clinical features of PTSD following such events include: (1) re-experiencing symptoms such as intrusive memories, thoughts, or images, and nightmares; (2) avoidance reactions such as emotional numbing where the individual is unable to feel a range of emotions or is able to describe the trauma in a dispassionate way, amnesia for all or part of the event, behavioural avoidance where individuals go to great lengths to avoid stimuli that will remind them of the trauma, and cognitive avoidance such as the use of distraction techniques to get rid of unwanted thoughts; and (3) arousal symptoms such as an exaggerated startle response, irritability, and hyper-vigilance for trauma-related information. In addition to anxiety, PTSD is commonly accompanied by a wide range of other emotions such as sadness, anger, guilt, and shame. A distinctive feature is that in many cases the intrusive memories consist of images accompanied by high levels of fear or are re-enactments of the original trauma ("flashbacks"). Herman (1992) has referred to flashbacks as "frozen memories", a term that captures their repetitive, unchanging quality.

The American National Comorbidity Study of nearly 6000 representative adults gave an overall lifetime prevalence for PTSD of 7.8%, with the rates for women (10.4%) being twice the rate for men (5.0%) (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Rates of PTSD, following exposure to a traumatic event, average around 25-30% in the general population; although certain events such as rape seem to be associated with much higher rates (Green, 1994). Prevalence rates tend to decrease over time although up to 50% of individuals may develop chronic PTSD. Indeed, studies have shown PTSD up to 40 years on in Second World War veterans (e.g., Davidson, Kudler, Saunders, & Smith, 1990) and survivors of the Holocaust (e.g., Kuch & Cox, 1992). The course of PTSD can be intermittent (e.g., Zeiss & Dickman, 1989) and onset may be delayed by many years (e.g., Blank, 1993; McFarlane, 1988) although reliable estimates of the rates of delayed-onset PTSD are not yet available. In psychiatric terms, around 70-80% of PTSD sufferers usually receive an additional diagnosis (McFarlane, 1992). Epidemiological surveys indicate that rates of somatisation disorder, psychosis, anxiety disorder, and depression are substantially elevated in PTSD sufferers (e.g., Shore, Vollmer, & Tatum, 1989) and studies of combat veterans indicate that depression, GAD, and substance abuse are the most frequent co-diagnoses (e.g., Davidson & Foa, 1991).

A number of event variables have been found to be important in PTSD such as bereavement (e.g., Joseph, Yule, Williams, & Hodgkinson, 1994) and personal injury and life-threat (e.g., Fontana, Rosenheck, & Brett, 1992). In addition, a premorbid history of psychological or behavioural problems is predictive of PTSD following a subsequent trauma (e.g., Atkeson, Calhoun, Resick, & Ellis, 1982; Breslau, Davis, Andreski, & Peterson, 1991; Burgess & Holmstom, 1978; McFarlane, 1988). However, other research has not found prior clinical history to be associated with outcome (e.g., Solkoff, Gray, & Keill, 1986). The important role of prior experience of traumatic events in general has been confirmed in numerous studies (e.g., Breslau et al., 1991; Burgess & Holmstrom, 1974) and it may be that rates of prior traumatisation can account for the association between previous clinical history and the severity of PTSD (Bowman & Yehuda, 2005; King, King, Foy, Keane, & Fairbank, 1999).

Higher levels of social support have been found to be protective against the development of PTSD (e.g., Kilpatrick, Veronen, & Best, 1985; King et al., 1999). Follow-up studies have shown an association between better outcome and a more internal locus of control (e.g., Cederblad, Dahlin, Hagnell, & Hansson, 1995; Regehr, Cadell, & Jansen, 1999) and a more internal and controllable attributional style for positive events (e.g., Mikulincer & Solomon, 1988). Furthermore, internal and control-

lable attributions for disaster-related events seem to be associated with poorer outcome (e.g., Joseph et al., 1991, 1993).

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