Let’s talk about posttraumatic stress disorder
There is a lot written about posttraumatic stress disorder (PTSD), and it is important to be able to distinguish the hype from the evidence. PTSD is the second most common mental health condition in Australia, and is one of the most common mental health conditions in military populations. Research focused on Australian Defence Force (ADF) personnel indicates that 12-month estimated rates of PTSD among currently serving members is 8%, rising to 17.7% among ex-serving. The rate in the Australian population is estimated at 5.7% over a 12-month period.
Despite what you may hear and read, we know a lot about what works and what doesn’t, and also what complicates treatment outcomes. What we need to get better at is knowing what works for whom, when and under what circumstances. This is especially the case given that in the military and veteran population, there is more likelihood of co-occurring mental and physical health conditions. Military-related trauma is often associated with problematic anger, substance misuse, sleep disturbance, depression, guilt and shame as well as chronic pain and other physical health conditions. This can lead to a reduced response to treatment for this population. Stigma also plays a part in reluctance to get treatment.
The onset of symptoms can be delayed or episodic. PTSD symptoms may start years after the incident, or they may come and go over time. They can be exacerbated by life events and time of life.
The symptoms most common to PTSD are:
- reliving the event/s, sometimes in the form of flashbacks
- avoiding anything that reminds a person of the event/s
- having more negative thoughts and feelings than before the event/s, including anger, fear, shame and guilt
- feeling on edge or keyed up.
These symptoms are common after a traumatic incident but they usually start to resolve within a few weeks. It is when they persist that problems arise. If symptoms don’t resolve themselves, and are leading to problems in your life, such as problematic anger and interpersonal difficulties, and you’re becoming emotionally numb and socially isolated, then you may meet criteria for a PTSD diagnosis.
PTSD can be debilitating and can impact a person’s ability to function as a parent and/or partner and can lead to unmet family needs and stress within the family. In fact, one of the most common reasons that people seek help can be the strain these symptoms put on their relationship.
The good news is that effective treatments for PTSD are available, and there are many research trials looking at how best to maximise treatments, including the use of adjunctive treatments such as exercise, yoga and assistance dogs. Phoenix Australia has developed guidelines, based on the current evidence, to help guide clinicians, veterans, children and adults. You can find these on the Phoenix Australia website.
Treatments include counselling, medication, or a combination of the two. The guidelines advise that it is generally best to start with counselling, rather than rely solely on medication. Recommended counselling approaches for adults that target the traumatic memories include trauma-focused cognitive behavioural therapy (TF-CBT), cognitive processing therapy (CPT), trauma-focused cognitive therapy (CT), prolonged exposure, and eye movement desensitisation and reprocessing (EMDR).
What we know about treatment is that it is not one-size-fits-all, that it takes time, it takes trust, and it requires using a range of interventions that we know work. For example, if insomnia is present and causing disruption, and there is a reluctance to focus on the trauma, we may start with cognitive behavioural therapy for insomnia.
As a clinician, it is often a difficult juggling act to know where to start as there are often a range of difficulties present, all vying for attention and intervention. As avoidance is a hallmark of PTSD and if you use avoidant coping strategies as your go-to, then it is likely that treatment may be delayed for years, and even decades. A common (unhelpfully avoidant) way of dealing with distressing symptoms is to try and drink them away, or use other mind-altering substances. This, of course, just makes the problem worse.
Anger is another area to be addressed. It is often a way for people to avoid engaging with people and dealing with difficult memories and situations. Problem anger is strongly associated with PTSD and other mental health conditions, such as alcohol abuse in veteran and military populations. It is increasingly seen as an important consideration in trauma-impacted populations, and as a mental health issue in its own right.
Adding to this complexity is the fact that veterans experiencing poor physical health and chronic pain are often also likely to have heightened levels of distress, anger and irritability, which diminishes their capacity to manage their emotions. Add other mental health symptoms such as depression and alcohol and other drugs, as well as sleep difficulties, and the complexities become apparent. There has, and continues to be, a lot of work in this area to better manage and treat complexities including case-co-ordination, rehabilitation programs, and close management of comorbid medical and psychiatric symptoms by treating clinicians.
It is important to remember that PTSD is a condition that can be treated, with full or at least partial remission of symptoms. It often results in a greater level of day-to-day functioning, which improves your ability to connect with those you love and who love you.
Another factor that is often under-emphasised is that therapy is a two-way-street. Treatment requires that you are an active participant and that you trust your clinician enough to engage with the therapeutic process. There are treatments that work that can make a significant difference to a person’s quality of life. Often, because there are many areas of intervention, a range of treatments will need to be used in parallel or consecutively, and treatment may take some time. Clinicians at Open Arms – Veterans & Families Counselling are well trained in dealing with military trauma and are a great place to start (openarms.gov.au).
Enhancements to interventions are also being studied and include use of virtual reality, imaginal exposure, neurofeedback, psychedelic-assisted psychotherapy, and brief and intensive trauma-informed therapies. Some are showing promise, and many have still to build a strong evidence base. A current research trial being undertaken by Phoenix Australia is the IMPACT trial. This trial is running in Victoria for ex-serving ADF personnel and first responders using video-conferencing technology. The therapy helps individuals build skills to manage the emotional impact of trauma by developing strategies and awareness regarding emotion regulation. If you are interested, talk to your health professional. Information is available on the Phoenix Australia website.
There is a lot to digest here, but one thing to remember is that there is no one-size-fits-all approach, and that treatment needs will change over time due to changing personal and life circumstances. Treatment can comprise a series of stages, with different interventions at varying ‘doses’ or intensities, depending on the need of the individual veteran. This may include couple and or family therapy. This approach means that you receive help that matches the level of need. It may be the case that that you are not ready to work on your trauma memories, but that does not mean that you can’t focus on other areas that are creating difficulty, such as sleep, anger or relationship difficulties. It also does not mean you will never be ready.
References:
Treatment-for-posttraumatic-stress-disorder.pdf (phoenixaustralia.org)
Open Arms – Veterans & Families Counselling