Episode 134      21 min 10 sec
PTSD I: Describing and diagnosing post-traumatic stress disorder

In the first of a two-part programme, psychologists Professor Mark Creamer and Assoc Professor Meghan O'Donnell explain post-traumatic stress disorder, or PTSD, its diagnosis, and how it's been viewed historically. With host Jennifer Cook. 

"Human beings generally are very resilient and the vast majority are going to experience these events and recover without the development of long term problems." -- Professor Mark Creamer




           



Professor Mark Creamer
Professor Mark Creamer

Professor Mark Creamer has been ACPMH Director since 2001 and has been with the Centre since shortly after its inception in 1996. He has many years of clinical and research experience in the area of recovery from trauma and has assisted individuals, groups and communities following a large range of traumatic incidents. His research interests include the nature, assessment and treatment of posttraumatic stress. He has published widely in the area with over 100 refereed journal articles and served on the Board of Directors of the International Society for Traumatic Stress Studies from 2004 – 2010. Mark is internationally recognised for his work in the field. As Director, Mark takes overall responsibility for all aspects of ACPMH. He is the key link between ACPMH and the Board of Management, as well as between ACPMH and the University of Melbourne.

Associate Professor Meaghan O'Donnell
Associate Professor Meaghan O'Donnell

Associate Professor Meaghan O'Donnell joined ACPMH in 2003 after completing her postgraduate clinical psychology training at the University of Western Australia in 1996 and her PhD at the University of Melbourne in 2003 (under the supervision of Professor Mark Creamer). Meaghan has published widely in the area of posttraumatic mental health, holds a number of large research grants and is involved in both national and international research collaborations. She is an associate editor for the European Journal of Psychotraumatology and is on the Board of Directors of the International Society for Traumatic Stress Studies. Meaghan is involved in a number of research projects that encompass a range of areas including epidemiology, phenomenology, intervention, and biology of posttraumatic mental health, and the mental health issues in military and veteran populations.

Credits

Host: Jennifer Cook
Producers: Kelvin Param, Eric van Bemmel
Audio Engineer: Gavin Nebauer
Voiceover: Nerissa Hannink
Series Creators: Eric van Bemmel and Kelvin Param

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PTSD I: describing and diagnosing post-traumatic stress disorder

VOICEOVER
Welcome to Up Close, the research, opinion and analysis podcast from the University of Melbourne, Australia.

JENNIFER COOK
I'm Jennifer Cook.  Thanks for joining us.  What is your breaking point?  Just what kind of trauma or abuse would it take before your body and mind were pushed beyond their limits?  Thankfully, most of us will never know the answer.  But for the millions of people worldwide who suffer from posttraumatic stress disorder or PTSD, they have crossed that threshold to a place where they can no longer cope with the burden of their experience.   For many PTSD evokes images of shell-shocked World War I soldiers or the terrible experiences of those who fought in Vietnam which made it so difficult for them to reintegrate into peace time.
Then of course there are victims of violent crime, natural disasters and serious injury.  All different kinds and varying degrees of trauma.  But what happens when it becomes too much to bear?  In this episode of Up Close, the first of a two part series on PTSD, we'll ask what is this condition and how long has it been with us?  Are some people more likely to develop the condition than others?  And does it present differently across cultures?  With us in the studio are Mark Creamer, Professor of Psychology, Department of Psychiatry, University of Melbourne and Director of the Australian Centre for Posttraumatic Mental Health.  He's joined by Associate Professor Meaghan O'Donnell who is Director of Research at the Centre.  Thank you both for joining us.

MARK CREAMER
Thank you Jenny.

MEAGHAN O'DONNELL
Thanks Jen.

JENNIFER COOK
I'd like to begin by asking you Meaghan exactly what we mean when we talk about PTSD.  What is it and crucially, who gets to decide what PTSD is?

MEAGHAN O'DONNELL
So I think I'll answer that question using the diagnostic criteria that the American Psychiatric Association set.  They set criteria for all mental health disorders called DSM.  We're up to the fourth version of that.  So according to DSM-IV, the experience of going through a traumatic event can lead to posttraumatic stress disorder.  The first thing you have to do to experience the disorder is to go through a traumatic event.  Now DSM-IV defines what a traumatic event is.  And a traumatic event is one in which someone experiences, either directly or indirectly, an event in which there is actual death or severe injury.  So what I mean by a direct experience is, so someone might experience a car accident in which they're severely injured.  An indirect experience is where someone witnesses an event where someone else dies or where someone else gets seriously injured.
Now there's also some interesting kind of debate about other aspects of a traumatic event.  So this perception of an event being traumatic.  So let's say someone is in a bank holdup and they have a gun pointed to their head and they think they're going to die.  And then they find out later that the gun was a plastic gun so there was actually no actual threat to them but their perception of threat is very important.  So in that situation someone could still develop posttraumatic stress disorder.

JENNIFER COOK
Could we talk a little bit more about DSM before we move onto PTSD?

MEAGHAN O'DONNELL
So DSM is the Diagnostic and Statistical Manual of Mental Disorders.

MARK CREAMER
It is just worth noting of course that there is another major diagnostic manual.  It's called the ICD, the International Classification of Diseases.  And this diagnosis also appears in that.  So the DSM is the American one.  The ICD is the World Health Organisation one but is used a lot in Europe, UK and indeed in Australia.

JENNIFER COOK
And so the significance of it is it defines what disorder is which in turn, when it comes to the issue of compensation, this is used as a blueprint.  Is that right?

MARK CREAMER
Absolutely.  That's exactly right.  So it's a very, very important document in all sorts of ways.  Of course you know compensation is one aspect of it.  The real reason that we have the DSM is to drive treatment.  Because if we can diagnose a disorder then we know what kind of treatment to apply.

MEAGHAN O'DONNELL
And it also speaks to research as well.  So when we do research in a disorder we need to know that everyone is identifying the disorder in the same way.  So DSM-IV or DSM or ICD are the categories in which we define a disorder in order to research it as well.

JENNIFER COOK
And it's quite a thorough and fascinating process isn't it?  It takes years - it's what 15 years between volumes, is that right?

MARK CREAMER
Something like that yes.

MEAGHAN O'DONNELL
That's right.  So a leading group of experts get together and look at the research that's happened in the interim between versions of the classification systems and then they identify whether the disorder criteria should change based on the research that's occurred in the interim.

JENNIFER COOK
We have, as you say, DSM-IV but DSM-V is about to come out.

MEAGHAN O'DONNELL
That's right.  And so there are some differences between the proposed criteria for DSM-V relative to DSM-IV.  And one of the specific changes is that in DSM-IV, the second aspect of what defines a traumatic event is the subjective experience a person has.  So in DSM-IV the subjective experience is a fear response.  We expect a person to experience fear, helplessness or horror at the time of the event.  Now DSM-V has taken that out.  So they say you have to have experienced a traumatic event.  But your emotional experience at the time isn't important.  It's not required for the definition.

JENNIFER COOK
Now Mark what kind of repercussions is that going to have?

MARK CREAMER
Well to be quite honest with you, I actually don't think it will have a lot of repercussions actually although there's been a lot of debate about it.  And I guess part of the reason that it was taken out is in recognition of the fact that people respond very differently.  And sometimes during a trauma people might actually go onto automatic for example, particularly a soldier in a combat zone who is trained to respond.  And so the requirement that they must experience fear or helplessness or horror at the time might not apply to some of these populations.

JENNIFER COOK
So they actually might cope very well at the time.

MARK CREAMER
That's right.  But some time later and sometimes it might be a long time later, the memories start to come flooding back and then the other symptoms of this diagnosis of PTSD start to appear.

JENNIFER COOK
And what are those symptoms?  How does it manifest?

MEAGHAN O'DONNELL
So the first set of symptoms are the intrusive symptoms and they're really the essence of PTSD.  And these are the distressing, involuntary memories of the event.  And so someone has thoughts or feelings or memories of the event, in some cases a direct replay of what actually happened, so they're flashback experiences.

JENNIFER COOK
So it's not a matter of just sitting there pondering it.  Suddenly they feel thrown back into it and all those feelings cascade.

MEAGHAN O'DONNELL
That's right.  And so that's in the more extreme cases of flashbacks.  In other situations they might have an intrusive memory of a smell.  Or say, for motor vehicle accidents, they hear the screech of the tyres and the bang of the accident.  So something in their environment triggers off these intrusive memories.

MARK CREAMER
But the point you make is an interesting one Jen and it is quite different to the idea of just thinking about it all the time and ruminating about it, which a lot of people do after major events.  They think about what happened and why did it happen.  They try to work it out and go over and over it in their head.  And that is associated often with things like depression, posttraumatic depression.  But what Meaghan is talking about here is something quite different.  This is where these very vivid emotional memories are invading consciousness.  They're jumping into the person's mind when they don't want them to.

JENNIFER COOK
So how does a person handle those experiences?  How do they process them?

MEAGHAN O'DONNELL
Well they're often very distressing.  And so because they are so distressing and they're often associated with really high levels of arousal.  So they get hot and sweaty and their heart races and it's very, very distressing.  So for people who develop PTSD they develop avoidant strategies.  So they decide that if I avoid anything that reminds me of the traumatic event then I won't get these horrible intrusive memories.  And this is another feature of PTSD where we see these high levels of avoidance of people or places or activities that remind a person of the traumatic event.  And so of course this has complications because, say if someone was assaulted in their workplace.  They might not be able to go back to work because they want to avoid the situation in which the assault occurred.  So there are lots and lots of consequences of having these avoidant experiences.
And then the third set of criteria or cluster of symptoms that we would see in PTSD are the hyper arousal.  So these are the high levels of body reactivity.  High levels of startle, so people get shocked very easily.  You know if somebody drops something behind them and they react really strongly.  We get hyper vigilance so they're constantly scanning their environment to make sure they're safe.  And these kind of arousal responses are also very distressing.  So we have these three clusters.  We have intrusive phenomena, avoidant phenomena and then arousal phenomena.  And also in terms of a diagnosis, for someone to meet the diagnosis, we'd expect these symptoms to be at a level where they're impairing the person.  Impacting on their social, occupational and general experience of life.

JENNIFER COOK
You're listening to Up Close coming to you from the University of Melbourne, Australia.  I'm Jennifer Cook and we're talking with Mark Creamer and Meaghan O'Donnell about posttraumatic stress disorder.
Now Mark I'm just hoping you can give our listeners a context, a bit of a historical context on PTSD.  Most of us can conjure up an image of a shell-shocked World War I vet.  But just how accurate is that?  You say there are references and literature going back thousands of years.

MARK CREAMER
Absolutely.  Absolutely.  The diagnosis that we've just been talking about first appeared in the literature in 1980.  So only 30 years ago and since then we've seen a huge amount of interest in the area.  So it's now become almost common knowledge and it's the stuff of TV dramas and so on.  And we could be forgiven for thinking that we've only just discovered it.  But the point you make is absolutely right.  That we can go back to literature of the ancient Greeks, so more than 2,000 years ago and see very good descriptions of what we understand is posttraumatic stress disorder.  And indeed really literature throughout the ages, through Shakespeare and writers of his time also gave us lots of descriptions.  So it's a very important point to make.  That this is not something we've just made up.  It's not something we've just invented.  It's something that human beings have known about really since time immemorial.

JENNIFER COOK
Since we've suffered trauma.

MARK CREAMER
Since we've suffered trauma, that's right.  But of course it wasn't until, particularly the First World War and to a certain extent the American Civil War but especially the First World War that it started to become the focus of more serious academic medical attention, with what later became described as shell-shock in the First World War.

JENNIFER COOK
Which raises this question I'd like to put to you both.  Just how has society regarded sufferers of PTSD?  Have they been understood or misunderstood?  And how has that impacted upon those individuals?

MARK CREAMER
Well I think that it does have a fairly chequered history.  I think it's been seen very pejoratively for a long while and I think that there's been a big school of thought that says well maybe this happens, but it only happens to people who are weak and vulnerable and inadequate to begin with.  Well we know now that that's not the case.  Or secondly it doesn't really exist, this is just people malingering and at one point it was called compensation neurosis.  You know with a clear expectation that this is all about getting compensation or being able to get out of duties or whatever.  It's important to remember in the First World War the British Army shot well over 300 - executed 300 of its own soldiers for cowardice.  And in a recent review they've now acknowledged that these people actually had a psychiatrist disorder like PTSD and a couple of years they issued a formal apology to the families under the heading of Shot at Dawn.
So you know thankfully we've come a long way since then but it's an indication of just how poorly understood and poorly acknowledged and recognised these disorders were.

JENNIFER COOK
And just the impact of a value judgement that cost their lives.

MARK CREAMER
Absolutely.

MEAGHAN O'DONNELL
Yes absolutely.  You know when we talk about this kind of diagnostic criteria and statistical manuals, the fact that it was introduced meant that research could happen around it.  And because of that it meant that we understand much better.  So we understand vulnerability and we understand, to some extent, other aspects that are associated with it.  So we can inform the debate about whether, you know, is it malingering or the other kind of potentially negative things associated with this disorder.

MARK CREAMER
Yes.  I mean we've come a long way, but let's not forget that we're still some way to go.  I think particularly in some of the high risk organisations like the military and the emergency services, there still is often a bit of a culture that's we're tough, we're strong, we don't experience these kinds of things.  So we have come a long way but we've still got a long way to go.

JENNIFER COOK
Now in the context of manifesting across cultures.  What does it tell us about people and cultural norms?

MEAGHAN O'DONNELL
Well certainly we see evidence of posttraumatic stress disorder across cultures.  So when we've done big epidemiological studies across English and non[-English]-speaking cultures, we do see evidence of this disorder.   But I do think also within that people's responses to trauma can be manifested in different ways.  So we do see in Asian cultures a lot of somatic symptoms associated with experience of trauma.  So I think, especially in terms of research, we need to get much better at looking at the similarities in how people experience trauma and their responses to trauma.  But also the differences because I think there are differences.

JENNIFER COOK
Could you go in a bit deeper for me about the response in Asian cultures?

MEAGHAN O'DONNELL
I'm not an expert in this but certainly it can be experienced in the more somatic kind of symptoms.  So experiencing the stress in terms of body sensations.

JENNIFER COOK
I see.

MEAGHAN O'DONNELL
And describing their experience in terms of body sensations.  You know, I think in western cultures we talk about our emotional experiences.  But some cultures experience emotional symptoms through the physical manifestations of those responses.

MARK CREAMER
And of course the analogies there with the World War I shell-shock survivors is very interesting because there, there were a lot of physical manifestations.  And we look at now very old film of these guys they had problems walking.  They had problems with often - sort of mutism, being unable to talk or deafness or whatever that seem to have been driven by these horrible experiences.  Organically based, not physically based.  So again a very physical presentation of these problems.  Perhaps because there isn't or wasn't a language to express it in any other way.  Whereas now we do have.

JENNIFER COOK
So beside cultures, are there traits or groups of traits in individuals that can predict vulnerability or are there genetic markers that can predispose individuals to PTSD?

MARK CREAMER
The question about why some people develop this problem and not others is a very complicated one.  And basically we need to think about factors in three broad domains.  So the first is what was the person like before the trauma occurred?  What actually happened to them at the time?  And what has happened to them since?  And it's a complex combination of those.  So in terms of the pre-existing vulnerability, you're right that there is increasing research suggesting that certain genetic profiles may make some people more vulnerable than others.  Now we're never going to get to the point where genetics explains PTSD 100 per cent.  But it does incur, potentially, a vulnerability.  And then we have early childhood experiences.  We have prior experiences of trauma.  We have prior psychiatric history.
All of these things are going to make someone more vulnerable but not in themselves are the explanations.  We then have to look at how severe the trauma itself was and then what's happened since.  And there the really important things are social support.  We just know that those people who are able to access and use their support networks are going to recover better.  We also know that other stressful life events are very important.  So those people, who are exposed to more and more difficulty, more and more trauma, more and more stress, are going to find it more difficult to recover from the original incident.  And so the picture is a complex one and it all has to be kind of brought in together to explain it in any individual.

MEAGHAN O'DONNELL
And Mark makes a really good point about the trauma itself is very important.  So there are aspects about the traumatic event that can make it more traumatic for someone.  So we know that people are much more likely to develop posttraumatic stress disorder after interpersonal violence.  For various reasons interpersonal violence is much more traumatic than say natural disasters or car accidents.  You're more likely to see higher levels of PTSD after rape than you would say after a motor vehicle accident.  And we think it's because of this kind of interpersonal characteristic of the trauma that makes it particularly traumatic.

MARK CREAMER
And perhaps because it shatters really fundamental assumptions we hold about other people and about the goodness of the world and so on that don't get shattered in the same way from an accident or a natural disaster.

JENNIFER COOK
So if someone experiences a traumatic event are they going to develop PTSD?  Is it inevitable?

MEAGHAN O'DONNELL
That's a very good question Jen.  Look we don't expect everyone to develop PTSD after a traumatic event.  It's interesting you know.  The thing about PTSD is a lot of the symptoms we see are actually normal symptoms that you'd experience after a traumatic event.  So we'd expect people to be sad after a traumatic event and anxious and stressed and fearful.  But what happens over time is those symptoms dissipate.  And so gradually the memories of the event lessen, the symptoms dissipate and people recover.  And we'd expect, depending on what kind of trauma they've been through, but say after severe injury, we expect 90 per cent of people to go on and recover and not develop PTSD.  However, a certain proportion do develop PTSD.  We expect about 50 per cent of people to develop PTSD after rape and maybe 10 per cent to develop PTSD after a motor vehicle accident.

MARK CREAMER
And can I just make the point very strongly that human beings generally are very resilient and the vast majority are going to experience these events and recover without the development of long term problems.  We need to make that point strongly otherwise I think there's too much emphasis on the mental health aspects of it.

JENNIFER COOK
And Mark, there are also other issues and things that can come up.  It's not just PTSD that people will have to deal with.

MARK CREAMER
Absolutely.  And I think it's a very important point to make.  Because since PTSD has been recognised there's a danger that that's all we look for - this is the trauma mental health response.  The reality is actually that other disorders like depression, like other anxiety disorders and of course substance use, alcohol abuse and all that kind of stuff.  These are also very common in the aftermath of trauma.  So as mental health providers, we need to be very careful not to look narrowly only for PTSD but to look across the spectrum of mental health problems that might develop as a result of trauma.

JENNIFER COOK
We've been speaking with Professor Mark Creamer and Associate Professor Meaghan O'Donnell from the Australian Centre for Posttraumatic Mental Health about the issue of posttraumatic stress disorder.  Tune into the final of our two part series where we discuss how to treat PTSD and ask what makes us vulnerable and if there are ways in which we can protect ourselves against the debilitating effects of this disorder.
Thank you so much for your time today both of you.

MEAGHAN O'DONNELL
Thank you.

MARK CREAMER
It's a great pleasure.

JENNIFER COOK
Relevant links, a full transcript and more info on this episode can be found at our website at upclose.unimelb.edu.au.  Up Close is a production of the University of Melbourne, Australia.  This episode was recorded on March 10, 2011 and our producers were Eric van Bemmel and Kelvin Param.  Audio engineering by Gavin Nebauer.  Up Close is created by Kelvin Param and Eric van Bemmel.  I'm Jennifer Cook.  Until next time goodbye.

VOICEOVER
You've been listening to Up Close.  For more information visit upclose.unimelb.edu.au.  Copyright 2011, The University of Melbourne.


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