Second try. No, can't attach so will just copy and paste here: Hope I don't get bashed by a mod:
Posttraumatic stress disorder as an epidemiologically prevalent psychological disorder
1. Introduction
In this assignment posttraumatic stress disorder as an epidemiologically prevalent psychological disorder will be discussed in terms of its clinical description, diagnostic processes, aetiology, and treatment. Reasons will be supplied as to why this disorder is epidemiologically prevalent, especially within the South African context.
2. Posttraumatic stress disorder
2.1 Clinical description
PTSD is an anxiety disorder that develops after experiencing a very dangerous, frightening, and uncontrollable event such as military combat exposure, a violent crime, a life-threatening accident such as a car wreck, criminal or sexual assault, a terrorist attack, or a natural disaster. Not everybody who is exposed to a stressor requires treatment. However, if left untreated, PTSD can affect individuals to the point that, over time, even their daily functions become seriously impaired. This places them at higher risk for self-medication and abuse with alcohol and drugs, domestic violence, under employment and unemployment, homelessness, incarceration, and suicide. Research studies have also demonstrated that PTSD is linked with co-occurring physical illnesses such as physician-diagnosed chronic pain, hypertension (high blood pressure), sleep disorders, and cardiovascular diseases (
http://www.veteranshealth.org/GWOT/ptsd.html.)
The diagnosis of PTSD requires, primarily, that a person has been exposed to a traumatic event that led to a response of intense fear, helplessness or horror. A traumatic event could refer to the personal experience or witnessing of, other otherwise being confronted with, actual or threatened death or serious injury, or threat to the physical integrity of self or others. The diagnosis of PTSD further requires that a person presents with a set of symptoms following exposure to a traumatic event (Burke, 2012).
According to Cohen (2006), there are three main kinds of symptoms that clinicians look for when diagnosing PTSD. These include re-experiencing symptoms, avoidant symptoms and symptoms of increased arousal.
Re-experiencing symptoms include ways in which the person persistently re-experiences the traumatic event. These symptoms may include the following:
- intrusive memories of the traumatic event
- recurrent, distressing dreams about the traumatic event
- acting or feeling as if the traumatic event is reoccurring.
Avoidant symptoms are ways in which the person tries to avoid anything associated with the traumatic event. These symptoms may also include a “numbing” effect, where the person’s general response to people and events is deadened:
- · avoiding thoughts or feelings, people or situations associated with the traumatic event
- · not being able to recall an important aspect of the traumatic event
- reduced interest or participation in significant activities
- feeling disconnected from others
- showing a limited range of emotion
- having a sense of a shortened future.
Symptoms of increased arousal may be similar to symptoms of anxiety or panic attacks. Increased arousal symptoms include the following:
- ·difficulty concentrating
- exaggerated watchfulness and wariness
- irritability or outbursts of anger
- difficulty falling or staying asleep
- being easily startled.
Identifying people with PTSD can be difficult and this disorder is often unrecognized. PTSD is unique among psychiatric disorders in that it is identified not only by symptoms, but also by the precursor of the illness (the traumatic event). Since talking about trauma may evoke painful emotions, people often refrain from discussing past traumatic events (Cohen, 2006)
When a person is unable or unwilling to discuss a traumatic event, accurate diagnosis is difficult. For example, domestic violence and sexual abuse are subjects that many persons feel uncomfortable in raising, even with professionals. Additionally, persons with PTSD often have other disorders, such as substance abuse or depression. These other disorders share some of the symptoms of PTSD and can also make diagnosis more difficult. Doctors and health professionals may also ignore the signs and symptoms of PTSD, focusing on, and treating, individual symptoms of PTSD (Cohen, 2006).
2.2 Aetiology
Barlow and Durand (2012) state that PTSD is one disorder for which we know the cause at least in terms of the precipitating event; someone personally experiences a trauma and develops a disorder. However, whether a person develops PTSD or not is a complex issue involving biological, psychological, and social factors. As with other disorders, we bring our generalized biological and psychological vulnerabilities with us; the greater the vulnerability, the more likely we are to develop PTSD. (Barlow & Durand, 2012) A family history of anxiety suggests a generalised biological vulnerability for PTSD. Intelligence, personality and other characteristics, some of them partially heritable, may predispose people to the experience of trauma by making it likely that they will be in risky situations where trauma is likely to occur. There seems to be a generalised psychological vulnerability described in the context of other disorders based on early experiences described in the context of other disorders based on early experiences with unpredictable or uncontrollable events. At high levels of trauma, these vulnerabilities do not matter as much, because the majority (67%) of prisoners of war studied by Foy et al., cited in Burke (2012), developed PTSD. However, at low levels of stress and trauma, vulnerabilities matter a great deal in determining whether the disorder will develop.
Family instability is one factor that may instil a sense that the world is a potentially dangerous place so it is not surprising that individuals from unstable families are at increased risk for developing PTSD if they experience trauma. Social factors play a major role in the development of PTSD. The results from a number of studies are consistent in showing that a strong and supportive group of people around the victim decreases the chances of developing PTSD after trauma. The broader and deeper the network of social support, the less chance of developing PTSD, as it affects our biological and psychological responses to stress. A number of studies show that support from loved ones reduces cortisol secretion and hypothalamic-pituitary-adrenocortical (HPA) axis activity (Barlow & Durand, 2012).
Heather Pollett (n.d.) objects to this type of view, saying that one of the issues facing victims of violence is that mental health treatment is currently based on the traditional bio-medical model. This model focuses mainly on biological and genetic factors of mental illness and does not adequately take into the account the social determinants of mental health such as poverty, housing and stigma. Nor does the bio-medical model fully consider the extent to which past experiences of violence influence the onset of mental illness in adulthood. All of these factors disproportionately affect women because of gender inequality.
2.3 Treatment
The evolving standard of care for the treatment of PTSD includes psychotherapy supplemented by psychopharmacology where appropriate and used to relieve posttraumatic symptoms as well as associated symptoms of depression, anxiety, obsessive-compulsive disorder (Courtois, 2004). Most clinicians agree that victims of PTSD should face the original trauma, process the intense emotions, and develop effective coping procedures in order to overcome the debilitating effects of the disorder. The most common strategy is to work with the victim to develop a narrative of the traumatic experience that is then reviewed extensively in therapy. Cognitive therapy to correct negative assumptions about the trauma, such as blaming oneself in some way, feeling guilty or both, is often part of treatment (Barlow & Durand, 2012).
One complication is that trauma victims often repress the emotional side of their memories of the event and sometimes, it seems, the memory itself. This happens automatically and unconsciously. Occasionally, with treatment, the memories flood back and the patient dramatically relives the episode. Although this may be frightening to both patient and therapist, it can be therapeutic if handled appropriately. Evidence is now accumulating that early, structured interventions delivered as soon after the trauma as possible to those who require help are useful in preventing the development of PTSD. On the other hand, there is evidence that subjecting trauma victims to a single debriefing session, in which they are forced to express their feelings whether they are distressed or not, can be harmful (Barlow & Durand, 2012).
Judith Herman is concerned that many current models of trauma counselling prioritize the re-telling of the trauma story. She feels that the trauma story needs to be told gradually so that the therapeutic relationship can develop into a protective support before intense emotions are evoked (SACAP, 2012).
Herman’s model comprises the following stages which are embraced by
· a healing relationship
· understanding traumatic transference / counter transference
· the contract
· counsellor support system (SACAP, 2012).
The early stage of treatment is devoted to the development of the treatment alliance, affect regulation, education, safety, and skill-building. The middle stage, generally undertaken when the client has enough life-stability and has learned adequate affect modulation and coping skills, is directed toward the processing of traumatic material in enough detail and to a degree of completion and resolution to allow the individual to function with less posttraumatic impairment. The third stage is targeted towards life consolidation and restructuring, in other words, a life that is less affected by the original trauma and its consequences. These three stages are described below, with the most emphasis on the first stage. Although the model is linear, it is not lockstep. Because posttraumatic decline and developmental deficits are difficult to reverse and because the development of trust requires time and effort, treatment usually proceeds in starts and stops (Courtois, 2004).
Because PTSD can have devastating effects on family members and those close to the patient, family and other group therapies may be indicated as adjuncts to individual treatment of the patient with PTSD (Grinage, 2003).
From the above it is clear that effective diagnosis and treatment of PTSD requires intensive, long-term treatment by an adequately qualified clinician. The question is whether the mental health care system is South Africa is able to provide the necessary services.
3. The epidemiology of PTSD in South Africa
Epidemiology examines epidemic (excess) and endemic (always present) diseases; it is based on the observation that most diseases do not occur randomly, but are related to environmental and personal characteristics that vary by place, time, and subgroup of the population (
http://www.answers.com/topic/epidemiology#Gale_Encyclopedia of_Public_Health_ds:). Edwards (2005b) states that in South Africa there is a high rate of the kinds of traumatic events that cause PTSD, such as criminal violence, motor vehicle accidents and industrial accidents. As a result, PTSD is a significant public health problem. Edwards fails to take into account endemic South Africa problems, such as domestic violence and poverty.
According to Grinage (2003), the epidemiology of PTSD is directly linked to the epidemiology of trauma. The likelihood of developing PTSD varies with severity, duration, and proximity of the experienced trauma. Approximately 25 - 30 % of victims of traumatic events develop symptoms of PTSD; however, response to trauma varies with the severity and the subjective experience associated with the trauma. In men, exposure to military combat and witnessing someone being badly injured or killed are the types of trauma most commonly associated with a diagnosis of PTSD. The most common traumatic events associated with PTSD in women are rape and sexual molestation. Grinage fails to factor in the importance of adverse conditions during the childhood, which create the conditions for complex trauma.
The full extent (epidemiology) of the problem is not known. Stein et al. (2008) say that there is a lack of epidemiological data on psychiatric disorders in South Africa. According to their research, a household survey conducted between 2002 and 2004, the most prevalent lifetime DSM-IV disorders were alcohol abuse, major depression and agoraphobia, while the most prevalent class of disorder was estimated to be anxiety disorders, substance abuse disorders and mood disorders. Mood and anxiety disorders were significantly associated with female gender, whereas substance use orders were significantly associated with male gender. Lifetime prevalence estimates varied significantly with age interview for several disorders, including panic disorder, generalised anxiety disorder and drug dependence.
Considering the fact that these figures are based on research done using a lay-administered diagnostic interview that generated diagnoses according to the criteria of the ICD-10 and DSM-IV criteria, the prevalent disorders could point in the direction of undiagnosed PTSD in the participants. This assumption is corroborated by figures in Table 1 (Grinage, 2003), which shows the comorbidities for PTSD:
Comorbidity
Men (%)
Women (%)
Major depressive disorder
47.9
48.5
Alcohol abuse or dependence
51.9
27.9
Drug abuse or dependence
34.5
26.9
Simple phobias
31.4
29.0
Social phobia
27.6
28.4
Dysthymia
21.4
23.3
Table 1: Comorbidities in Patients with Post-traumatic Stress Disorder
The public health consequences of these figures are not known. Comorbidities of PTSD and exacerbate not only PTSD symptoms, but could also complicate both the diagnosis and treatment. The emotional and behavioural problems associated with PTSD can have serious consequences for work and relationships. In severe cases, individuals may not be able to maintain their occupations. The disorder takes a severe toll on relationships especially with intimates and in the family (Edwards, 2005a). According to Stein et al. (2010), there is a particularly strong association between sexual and interpersonal violence and suicide ideation and/or attempt.
The epidemiological evidence shows that traumatising associated with PTSD is a common occurrence in South Africa (Edwards, 2005a). There is incontrovertible evidence that traumatic stress syndromes are very real, and that large numbers of South African adults and children are affected on a chronic basis, only a small percentage of whom receive any form of counselling or professional help. They show that the sequelae of traumatising events constitute a significant public health problem in South Africa and that attention needs to be given to providing clinical services to those affected (Edwards, 2005a).
References
Barlow, D. &. Durand, V.M. (2010).
Abnormal Psychology: An Integrative Approach. Wadsworth Cengage Learning .
Bendall, C. (2010). The Domestic Violence Epidemic in South Afric: Legal and Practical Remedies.
Women's Studies, 39(2), 100-118.
Burke. A. et al. (2012).
Abnormal Psychology. Cape Town, South Africa : Oxford University Press.
Cohen, H. (2006).
Symptoms and Diagnosis of PTSD. Retrieved November 7, 2012, from Psych Central: [DLMURL]http://psychcentral.com/lib/2006/symptoms-and-diagnosis-of-ptsd/[/DLMURL]
Courtois, C. (2004). Complex Trauma, Complex Reaction: Assessment and Treatment.
Psychotherapy: Theory, Research, Practice, Training, 41(4), 412-425.
Edwards, D. (2005). Post-traumatic stress disorder as a public health concern in South Africa.
Journal of Psychology in South Africa, 15(2), 125-134.
Gale Encyclopedia of Public Health. (n.d.). Retrieved November 7, 2012, from Answers.com:
Dead Link Removed Encyclopedia of Public Health
SACAP (2012).
Student Learning Guide: Abnormal Psychology. Cape Town, South Africa: SACAP.
Stein, D. et al. (2008). Lifetime prevalence of psychiatric disorders in South Africa.
The British Journal of Psychiatry, 192, 112-117.
Stein, D. et al. (2010, May 13). Cross-National Analysis of the Associations between Traumatic Events and Suicidal Behaviour: Findings from the WHO World Mental Health Surveys.
PLoS ONE, 5(5).
