Trauma Disorders

Question 1

What is the diagnostic criteria for PSTD in the DSM-5 and ICD-11?

Answer 1

A) Experienced an event that involved actual or threatened death, serious injury, or sexual violence (direct experience, witnessed, heard about an event experienced by a family member or close friend)
B) Re-experiencing the trauma in some way (e.g. flashbacks, nightmares, intrusive thoughts and images)
C) Avoidance of traumatic reminders (behavioural or cognitive)
D) Hypervigilance (poor sleep and concentration, startle response, scanning for danger)
E) DSM-5 ONLY: Negative changes in cognition and mood (reduced interest in usual activities, feelings of detachment from others, restricted range of feelings, exaggerated negative beliefs about oneself, persistent negative emotional state)
F) Symptoms last at least 4 weeks (DSM) or “several weeks” (ICD)
G) Symptoms cause significant distress or impairments in daily functioning.

Question 2

Do all people who experience traumatic events develop PTSD?

Answer 2

• NB: Temporary symptoms of the above are common and normal in trauma survivors, who often return to equilibrium naturally. Only a minority go on to develop PTSD, but this varies by country.
• 8% of USA adult population has had PTSD in their lifetime, but only 2.4% of SA population has- why?

Question 3

What percentages of the population in 24 countries across the world have experienced a criterion A trauma? (WHO survey)

Answer 3

• Overall, 70% had experienced a traumatic event.
• 30.5% experienced 4 or more events.
• War related trauma: 13%
• Gender-based violence: 23%
• Other physical assault in childhood or adulthood: 23%
• Accidents or illness: 34%
• Witnessed trauma or trauma to loved ones: 23%
• Unexpected death of loved one: 31%

Question 4

What is the prevalence of trauma exposure in south africa?

Answer 4

SASH national prevalence study of SA population found:
- 75% have experienced trauma
- 56% have had multiple traumas
- 38% have been victimised by violence
- Intimate partner violence 24% (up to 50% in other studies)
- Sexual assault 3.5% (but up to 25% in other studies)
- Child abuse 12% (but up to 42% in some studies)
- Physical assault: 25%
- In SA trauma exposure is the norm, not the exception.
- The stats might be skewed by cultural norms.

Question 5

What are the rates of PTSD in WHO GLobal survey?

Answer 5

• The vulnerability paradox: PTSD rates are lower in more socioeconomically vulnerable countries, even though trauma exposure rates are equal to or higher than those in well-resourced countries.
• Low-lower middle income countries: 3%
  -Upper-middle income countries: 3.6%
• High-income countries: 6.9%

Question 6

In terms of history of PTSD: what are the two competing narratives

Answer 6

• Judith Herman: Trauma has always had damaging effects, but these have often been denied by society (e.g. Freud’s theories of sexual abuse; World Wars; Vietnam war)
• In the 1970s: the rise of feminism and war veteran groups in the USA created political environment that was more open to recognising the damaging effects of violence and abuse.
• Thus PTSD entered the DSM system in 1980 (DSM-3).
• The other narrative is that of Allan Young: the cultural invention of PTSD.
• Historically documented traumatic stress syndromes did not have the same symptoms as PTSD (e.g. intrusive thoughts and avoidance symptoms not prominent.
• He argues that PTSD has not always existed- in recent decades it has become culturally available and culturally codified as an acceptable and recognisable way to express traumatic stress in Northern/Western contexts
• Development of a “PTSD industry”: PTSD Research Centres, scales to assess PTSD, and treatments developed specifically for PTSD serve to “glue” the diagnosis together
• He says that this idea of ptsd does not need to be rigid. we can just see it as something that we are using now. Thinking about it this way allows to be able to change the definition as necessary.

Question 7

What is railway spine and what are its symptoms?

Answer 7

• Railway spine is the 1860s diagnosis for the post-traumatic symptoms of passengers involved in railroad accidents.
• Anxiety
• Nightmares
• Forgetfulness
• But also prominent physical or somatic symptoms (headaches, problems, numbness of arms, legs etc.)
• Autopsy’s showed no physical damage to people’s spines.

Question 8

What is Hysteria and what are its symptoms?

Answer 8

• Paralysis, seizures, blindness with no organic cause
• Emotional excitability
• More consistent with Conversion Disorder and the “feminine” personality disorders (borderline, histrionic) in the current DSM system.
• Associated with repressed rather than intrusive memories.

Question 8

What were the symptoms of Shell Shock and Combat Fatigue?

Answer 8

• Nightmares
• Restlessness
• Irritability
• But also prominent somatic symptoms (paralysis, seizures, muteness and blindness with no organic base)

Question 9

What are the benefits of having a PTSD diagnosis?

Answer 9

• Acknowledgement and normalisation
• Reduces victim blame and isolation
• Allows access to treatment and resources
• Facilitates development of targeted treatments
• Reduces social and financial costs of unrecognised and untreated trauma.

Question 10

What are the risks of the “medicalisation of suffering”?

Answer 10

• Locating pathology in the individuals disguises systemic and political oppression of specific groups (e.g. children, women, refugees. politically oppressed groups, workers). This implies that the person needs to go through their own process of healing. It ignores other levels of intervention.
• Derek Summerfield and others argue the following:
• The effects of trauma are symptoms of power imbalances in society, not of individual illness
• A trauma diagnosis constitutes an apolitical, decontextualised understanding of trauma and violence that marginalises survivors’ experiences of injustice and exploitation.
• A trauma diagnosis implies that the individual is responsible for recovery, thereby maintaining social inequalities (and stigma). it takes away the requirement to address social inequalities.

Question 11

What are the stats on the psychological impact of prolonged abuse?

Answer 11

Global prevalence of childhood physical abuse:
- 22.6% of children
- No children or cultural-geographic differences found
Global prevalence of childhood sexual abuse
- 12.7% of children (there is probably under-reporting)
- More common in girls than boys, but Africa had highest rate of sexual abuse of boys compared with other continents (could be a reporting difference)
Global prevalence of childhood emotional abuse:
- 36.3% of children
- No gender or cultural-geographic differences found.
Global prevalence of intimate partner violence
- 30% of women aged over 15 years
- These stats show that being in an abusive situation is common.

Question 12

What is the psychological impact of prolonged abuse?

Answer 12

• Abuse often occurs in critical development windows, is predictable but inescapable, involves relational trauma, and occurs in broader context of disturbed family relationships.
• 46% of general psychiatric hospital patients reported histories of child sexual abuse in research interviews but in only 14% of cases had this history been documented in case files. (this might be because people are scared to disclose in community settings, maybe they haven’t processed what happened to them,
• Patients with childhood abuse histories have higher rates of re-admission and are more expensive to treat than patients with no abuse histories- repeated diagnostic and treatment failures? Part of the problem is that PTSD doesn’t fully encompass the unique challenges of abuse. So there aren’t any effective treatments.
• Some survivors of prolonged abuse develop a wide range of other symptoms not captured by the PTSD diagnosis- alternative diagnostic formulations have been suggested.

Question 13

What are the symptoms of complex PTSD according to Judith Herman?

Answer 13

• Disturbed sense of identity- feelings of fragmentation and detachment
• Difficulties with regulating emotions-substance abuse, self-hard, dissociation, somatisation
• Difficulties with relationships- revictimisation, unstable relationships (too trusting vs mistrusting)

Question 14

What is the relationship between C-PTSD and Borderline Personality Disorder

Answer 14

• 80 to 90% BPD patients have histories of childhood abuse or neglect.
• More consistently negative identity, emotions, relational experiences vs inconsistency/fluctuation of BPD; less self-harm, less impulsivity, more relational avoidance.

Question 15

How does the ICD-11 define Complex PTSD?

Answer 15

• PTSD plus disturbances in identity, emotions, and relationships

Question 16

What happens when trauma isn’t “post”?

Answer 16

• PTSD and Complex PTSD assume the trauma is in the past (distant or recent)
• In SA, many people live in situations of chronic violence across home, school, work, transport routes, and neighbourhood.
• There is an absence of safe spaces
• Constant feeling of threat, realistic ongoing danger
• Violence as a condition rather than an event.
• Absence of protection, failure of systems of law and order.

Question 17

What are the features of Continuous Traumatic Stress (CTS) response?

Answer 17

• It is not a disorder
• Threat is contextual rather than relational
• Threat is pervasive across multiple sites
• Preoccupation with current and future danger rather than a past event.
• Avoidance and high levels of arousal may be protective rather than maladaptive “false alarms” as in PTSD.
• Need to discriminate between perceived and actual threats
• Absence of protection, failure of systems of law and order.

Question 18

What are the possible effects on youth of exposure to a combination of domestic and community violence?

Answer 18

• Defeat response: sense of futility, apathy, disengagement
• Emotional dissociation, lack of empathy
• Terminal thinking
• Learning problems
• Appetitive (rather than purely instrumental or reactive aggression
• Substance abuse.

Question 19

What is collective trauma?

Answer 19

• Cataclysmic events that have a shared psychological effect on groups of people defined by shared characteristics or social positionings within a society, or on an entire society.
• The events are represented in the collective memory of the group/society and have impacts at a group/societal level.
• Examples for the past ten years: Marikana, murder of George Floyd, Covid pandemic, war in Ukraine, Palestinian genocide.

Question 20

What is historical trauma?

Answer 20

• It is a specific category of collective trauma
• A construct to describe lon-term, enduring impact of previous experiences of colonisation, cultural suppression and historical oppression of a specific group by another specific group.
• It has long-term, trans-generational impacts:
  1. On the collective identity formation of the group. This representation of events in collective memory or consciousness of the group can have both positive (e.g. sense of belonging, pride and resilience) and negative aspects (e.g. internalisation of oppressor’s denigrated views of one’s own group)
  2. Within families.
• Denial and silencing of the “indescribable” and “undiscussable”. Children may become carriers or enactors of parents’ unacknowledged or unexpressed feelings of loss, shame, pain, fear, rage, hatred etc.
• Despite the possible similarities, each human catastrophe has its own history, social and political dynamics, and corresponding patterns of individual and collective response rooted in culture and context.

Question 21

What are the cultural variations in expressions of traumatic stress?

Answer 21

• Symptoms of PTSD have been found across many cultures, though their salience/importance varies:
  a) Post-trauma flashbacks are commonly reported, even in societies with no previous exposure to the PTSD construct
  b) avoidance/numbing symptoms are often absent outside western cultures
  c) Post-trauma nightmares very prominent in some cultures (e.g. indigenous people of the US who serve in us army; cambodian refugees)
• In many countries outside of the US, UK and Europe, trauma survivors present with prominent: somatisation, dissociative symptoms, cultural bereavement.
• Well-documented culture-bound trauma syndromes or idioms of distress: somatic blindess (cambodian refugees); ataques de nervois (latin america); “ghosts” of the Japanese Tsunami
• The danger of uncritically importing the ptsd industry to other contexts at the expense of contextually meaningful formulations of traumatic stress- this has important implications for intervention.
• Need qualitative, emic approaches to supplement quantitative etic approaches in trauma research, particularly outside of western/northern context.

Question 22

So what can we conclude about PTSD?

Answer 22

• The PTSD diagnosis has benefits for both trauma survivors and clinicians, but it is a limited formulation of traumatic stress that does not acknowledge:
• changes in traumatic stress response across time
• Variations in traumatic stress responses across types of trauma exposure
• Variations in traumatic stress responses across cultures.