Making a real difference to those with post-traumatic stress disorder

Rates of post-traumatic stress disorder have been on the rise globally over the past two decades, indicating fundamental changes in trauma exposure and surrounding circumstantial risk factors.¹ We are currently seeing the realities of this shift playing out through our global pandemic, with early research indicating PTSD rates as high as 30.2 per cent in post-acute COVID-19 patients,² and 16.8 per cent in our front-line healthcare professionals.³

Trauma is an undeniably common human experience, often creating a range of devastating impacts that can be experienced across generations. An estimated 70.4 per cent of people worldwide will experience trauma within their lifetime.⁴ In New Zealand, research shows approximately 65 per cent of Māori and 61 per cent of non-Māori have experienced trauma.^5,6

Studies indicate 1.3 to 3 per cent of New Zealanders will be diagnosed with PTSD at some point in their lives.^7,8 This rate significantly increases when looking at specific populations. One study found 37 per cent of female prison inmates in New Zealand met criteria for PTSD,⁹ while 30 per cent of a sample of serving and retired New Zealand military personnel reported post-traumatic stress (PTS), with 10 per cent meeting criteria for PTSD.¹⁰

PTSD is not an inevitable effect of trauma, though many people will experience PTS following deeply shocking and distressing events. In the early days and weeks following trauma exposure, it is normal to experience nightmares, flashbacks of the event, heightened emotional states, and mood and behavioural changes. The challenge comes when these symptoms continue long term (six months or more), signalling a shift from PTS to PTSD.

PTSD is helpfully viewed as a psychological reaction to a significantly traumatic event, whether experienced directly or vicariously. Traumatic events may include witnessing or experiencing violence, sexual abuse, serious incidents, natural disasters or loss of a loved one.

PTSD is characterised by a range of often debilitating symptoms, which can be grouped into four distinct clusters:

Intrusive re-experiencing – flashbacks, nightmares and recurrent memories.

Hyperarousal – intense physiological responses to trauma recall, heightened startle response, hypervigilance and irritability.

Avoidance of trauma stimuli – avoiding internal and external reminders.

Mood and cognitive alterations – anxiety, depressed mood, poor concentration, overestimation of danger, and anhedonia.

People experiencing PTSD may display marked changes in behaviour as a direct result of the increased sense of danger associated with the trauma itself, and the frequent re-experiencing of it through flashbacks and nightmares. People commonly report feeling trapped inside a continual cycle of anxiety, avoidance and isolation, with an ongoing sense of fear that life has irrevocably changed forever.

Nightmares and chronic stress often result in insomnia. Substance misuse/abuse is also common, providing people with a reliable method of escape from the memories themselves and the day-to-day distress that can pervade life (refer to “Drug misuse” in How to treat, New Zealand Doctor, 29 September).

People’s ability to engage in society and with loved ones and whānau can be limited by a sense of detachment from others, attempts to avoid triggers, and the general stress intolerance and heightened sensory sensitivity that are common symptoms of chronic states of stress.

Overall, the associated symptoms and continuing distress can leave people cut off from adequate support and at higher risk of depression and suicide. A recent Swedish study identified 1.6 per cent of suicides in the general population could be attributable to PTSD, and up to 53.7 per cent in people formally diagnosed with the condition.¹¹

The term complex PTSD (C-PTSD) has been coined in recent years to recognise the more enduring and compounding effects of multiple trauma exposures, often including events experienced during childhood. People with C-PTSD may experience higher levels of distress and dissociative states, interpersonal difficulty, somatic symptoms and fixed negative beliefs relating to self, others, the world and the future.

Treatment guidelines for C-PTSD do not differ from those for PTSD. However, people often require longer durations of support with focus on enhancing sense of interpersonal safety, reconnection back to self and intensive psychological support to shift fixed negative core beliefs that dominate.

Protective factors following trauma that may reduce the incidence of PTSD include psychological flexibility, a positive sense of self, external support from whānau, meaningful help and an environment that promotes a sense of safety. These should be viewed as integral facets of treatment.

Vulnerability factors include multiple trauma exposures, lack of support, lack of identity and a wider sense of vulnerability within one’s environment. Māori experience these factors at higher rates as part of the ongoing, traumatising and disconnecting effects of colonisation.

It is important to be aware Māori may experience a reduced sense of safety in seeking help from mainstream services. This highlights the need for delivery of culturally responsive care, and strengthens the call for provision of more kaupapa Māori services within our communities.

In terms of treatment, the widely recognised Phoenix Australia (Australia’s National Centre of Excellence in Posttraumatic Mental Health) suggests provision of information, emotional support and practical assistance following trauma exposure.¹²

For identified PTSD, a range of evidence-based psychological interventions delivered within a stepped-care approach are recommended as first-line treatment. These include trauma-focused cognitive behavioural therapy, eye-movement desensitisation and reprocessing, cognitive processing therapy, prolonged exposure therapy and cognitive therapy.

Selective serotonin reuptake inhibitors, such as sertraline, paroxetine or fluoxetine, may be indicated where there are long wait times, unwillingness or inability to engage in psychological treatment, comorbid conditions that indicate medication (eg, severe depression) or where psychological treatment has not produced sufficient benefit.

Pharmacological treatment alone is not adequate for PTSD. A lack of psychological treatment and support increases the risk of trauma survivors experiencing continued symptomatology, ongoing deterioration, comorbidity and a greater sense of hopelessness.

The major challenges of PTSD come from the ongoing re-experiencing of trauma, alongside the damaging, distortive impacts on the survivor’s core belief system (their pervading sense of self, others, the world and the future).

Avoiding thinking about the trauma, while trying not to feel the associated emotional distress, reduces a person’s ability to process the memory of the trauma. This becomes a huge stumbling block to recovery.

When people become willing to expose themselves to the trauma and trauma triggers, the memory begins to process, and the level of distress and sense of current danger often reduces. As the memory becomes more easily located in time, the person becomes able to remember it, rather than re-experience it. This process can also support a shift in perspective and beliefs related to the trauma.

These essential changes rely on psychological processes and are enhanced through supportive relationships where an abundance of understanding and validation are provided.

Enhancing spiritual and cultural connection may also be needed by some people, particularly Māori. Trauma creates a disconnection from self, others and the world in general. Reconnection to these fundamental elements can increase resilience and hope.

Be aware that screening for PTSD often does not occur unless trauma has first been identified.

Trauma-informed care calls for healthcare professionals to universally screen for trauma in order to identify its prevalence and significance in people’s lives, assist in identifying PTSD and ensure adequate support and treatment (for further information, see “Trauma-informed care” in How to treat, New Zealand Doctor, 17 March).

Trauma screening is often limited to a few short questions and can be proficiently and respectfully included within assessments with adequate preparation and practice. Screening for PTSD is aided by tools such as the Impact of Event Scale–Revised, which identifies core PTSD symptoms.

It is essential to screen for trauma and PTSD in anyone presenting with mental health challenges, particularly those experiencing common comorbid disorders, such as substance abuse and borderline personality disorder. Lack of identification of PTSD in these patients often leads to treatment failures, higher levels of hopelessness, disengagement from services and greater levels of risk. People who come through our criminal justice system should also be screened for PTSD, given the high rates of trauma present.

Ensuring adequate support and treatment is essential to give people experiencing PTSD the best chance at improving their future trajectories.

Anna Elders is the clinical lead for Just a Thought, a mental health nurse practitioner and cognitive behavioural therapist for Tāmaki Health, and an honorary teaching Fellow at the University of Auckland