The NHS reported last week that 12.6% of women in England aged 16 to 24 screened positive for post-traumatic stress disorder (PTSD) in a national study, compared with just 3.6% of their male peers. These findings were especially alarming as only 4.2% of women in this age bracket were identified as having PTSD in 2007. Although the assessments carried out in the two surveys differed somewhat, the new data seemingly implies a rising epidemic of PTSD among young women in England today.
The principal cause of PTSD is exposure to an extremely stressful, often life-threatening, event. Stressors that are unpredictable, uncontrollable and especially terrifying are those most likely to produce the disorder. Interpersonal violence, such as combat, rape, torture and domestic abuse, usually triggers PTSD more often than accidents, natural disasters, and events not involving deliberate intent to harm.
PTSD is a disorder of vivid memory. Sufferers do not merely remember their trauma; they re-experience it emotionally in the form of involuntary, distressing thoughts; nightmares about the trauma; and sudden sensory “flashbacks” of sights, sounds and odours that produce the illusion that it is happening once again.
Yet the mind does not operate like a video recorder, infallibly encoding our experiences, traumatic or otherwise. And recollection is not like a replay of one’s experience. Rather, autobiographical recall entails reassembly of encoded elements of the event distributed throughout the brain.
Terror during trauma focuses one’s attention, strengthening memory for the most salient features of the experience, and occasionally at the expense of less salient ones as the phenomenon of “weapon focus” illustrates. Victims of armed robbery often encode and thus can recall details about the weapon, but sometimes fail to encode information such as the clothing worn by the assailant. Likewise, traumatised refugees seeking asylum who provide vivid accounts of an assault sometimes misremember the precise date that it took place. The upshot is that intense emotion at the time of an experience tends to produce robust memories of it. Hence, PTSD sufferers remember their trauma all too well.
Understandably, people with PTSD tend to steer clear of reminders of their trauma as best as they can. Activities, places, people and thoughts associated with the experience are avoided as much as possible lest intrusive memories become triggered. Sufferers are hypervigilant for potential threats, startle easily and are often irritable. Their sleep is disturbed, and their ability to concentrate in everyday life becomes difficult. They often lose interest in previously enjoyed activities, become disconnected from other people, and feel as if their capacity to experience positive emotions has disappeared. Finally, they can develop problematic beliefs, such as losing the capacity to trust other people and believing the world is an unpredictably dangerous place.
Acute symptoms of PTSD are common in the days following a trauma. But these must persist for at least one month before PTSD becomes diagnosable. Short-term stress reactions can be normal responses to an abnormal stressor, but the persistence of symptoms long after the stressor has passed is the hallmark of PTSD. For example, the clinical psychologist Barbara Rothbaum and her associates assessed 95 survivors of rape or attempted rape. They found that 94% of them met symptomatic criteria for PTSD within the first two weeks following the assault. The rate dropped to 65% and then to 47% approximately one and three months, post-assault, respectively. About half recovered naturally, whereas the others failed to remit.
Although exposure to one or more traumatic events is by definition essential for PTSD to develop, most people exposed to such events never develop the disorder. One representative survey of American adults conducted by the epidemiologists Naomi Breslau and Ronald Kessler found that 89.6% of the general population had experienced at least one traumatic stressor such as a serious accident, natural disaster, rape or the unexpected death of a loved one, yet only 9.2% developed PTSD. Such findings indicate that trauma is common, but PTSD is relatively rare, hence implying that risk and resilience variables influence the psychological impact of traumatic events.
Yet for years the study of risk factors for PTSD was de facto taboo for many working in the field of traumatic stress studies. After the diagnosis first appeared in 1980 in the third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, or DSM-III, some warned that research on risk factors amounts to blaming victims for their plight. But identifying statistical predictors of PTSD among trauma survivors no more blames victims than identifying predictors of other psychological or medical conditions. Indeed, progress continues as researchers pinpoint risk and resilience variables. For example, having a personal or family history of anxiety or mood disorders increases risk of PTSD, whereas above-average cognitive ability and good social support decreases it.
The evidence suggests many trauma survivors may prefer to rely on family, friends and clergy rather than counsellors
The recent NHS study underscores the urgency of taking steps to prevent PTSD, and to treat it effectively when it does develop. Primary prevention entails decreasing the frequency of events likely to trigger the disorder. Secondary prevention targets people who have recently experienced trauma.
A once-popular approach called “psychological debriefing” involved trained counsellors conducting a single session with trauma-exposed individuals shortly after their horrific experience. For example, a group consisting of firefighters or employees of a recently robbed bank was typical, although it was also used for individual survivors. The purpose was to prevent the emergence of chronic, post-traumatic reactions by having survivors describe aloud their thoughts and feelings during the trauma, reliving it while processing their emotions in the session.
Although debriefed individuals expressed gratitude for the efforts of their counsellors, dissemination of the method was premature. Indeed, most randomised controlled trials (RCTs) indicated that debriefed and non-debriefed trauma survivors did not differ in terms of symptoms at follow-up, whereas in other RCTs debriefing actually impeded natural recovery from trauma; non-debriefed survivors were doing better psychologically at follow-up than the debriefed ones.
Taken together, this evidence suggests that many trauma survivors may prefer to rely on family, friends and clergy rather than professional counsellors. Having professional counsellors available is important, but compelling survivors to undergo psychological debriefing is not.
The story of the rise and fall of psychological debriefing makes an essential point. We must not rely on clinical intuition alone when treating survivors of trauma. They deserve better. Furthermore, the methods we devise must undergo rigorous evaluation in RCTs. This is precisely what leading clinical researchers have been doing. There are effective cognitive-behavioural therapies developed and tested by clinicians, such as Edna Foa and Patricia Resick in the US, Metin Başoğlu and Anke Ehlers in the UK, and Richard Bryant in Australia, among others.
An important element of these evidence-based therapies is the gradual, systematic exposure to traumatic memories until their capacity to trigger distress diminishes. Although most PTSD patients benefit from these treatments, others terminate treatment prematurely or fail to recover. We need to continue to explore and evaluate new interventions to help those who continue to suffer.
What is PTSD? You asked Google – here’s the answer | Richard J McNally
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