Treating PTSD with Cognitive Processing Therapy
Introduction
PTSD is a type of a mental disorder, which can develop after overcoming a trauma, especially if a person feels that his life is threatened. Even if a person was not wounded, he still can develop PTSD, for example, if he was threatened by death or was a victim of violence. Such type of mental disorder often affects soldiers who cannot forget events of battles. However, there are also other people who develop PTSD, for example, victims of serious crimes, witnesses who survived accidents, natural disasters, or acts of terrorism. PTSD can constantly cause bad memoirs, which are bright and distinct and can disturb memory of an accident. Majority of people with PTSD have problems with sleep. They experience feelings of estrangement, fault, paranoia, and sometimes panic fear that they can be attacked again. People with PTSD are in a group of risk of committing suicide (Brewin, 2005).
In most cases, the experienced event remains in people's consciousness for some time, but it gradually disappears and allows a person to return to a normal life. Support of a family and friends is thus very important. At the same time, quite a big number of people experience post-traumatic symptoms, which over time transform into a post-traumatic stress disorder (PTSD).
Treatment of PTSD is directed at the reduction of signs of fear and prevention of future problems. General signs of PTSD include recurring bright and distinct memories of an accident, avoidance of places and similar situations where the incident occurred, inability to remember or discuss incident details, alienation, emotional catalepsy, desire to be along, unstable mental condition, problems with sleep and lack of attention. Mental disorder can be diagnosed 1 month later after a trauma, though in certain cases symptoms do not develop within many months or years after the trauma occurred. Majority of people experience symptoms of PTSD for about three months. Some people experience these symptoms from time to time (Brewin, 2005).
Chapter 1. What is PTSD?
1.1 Clinical Manifestations of PTSD
Post-traumatic stress disorder (PTSD, “the Vietnamese syndrome”, “the Afghan syndrome”, “the Chechen syndrome”) is a psychological condition, which results from psycho-traumatic situations going beyond usual human experience and menacing physical integrity of a subject or other people. It has prolonged influence, has a latent period, and can be manifested during the period from 6 months up to 10 years and more after a single or repeating psychological trauma. As claimed by Bisson "chronic post-traumatic stress disorder (PTSD) is a common disorder that people may develop after exceptionally threatening and distressing events. Psychological treatments from various theoretical perspectives have been found to be effective for chronic PTSD" (2007).
PTSD disorder is characterized by repeating and persuasive reproduction of a traumatic event in consciousness. Stress experienced by the patient is exceeded by what he felt at the time of actual injuring event, and is often extremely emotionally intensive experience causing thoughts of a suicide in a person with a purpose to escape emotional pain. Repeating nightmares and flashbacks are also a characteristic of PTSD.
The patient with PTSD avoids thoughts, feelings, or conversations connected with a trauma as well as actions, places, or people who provoke these memories. PTSD is characterized by psychogenic amnesia. where the patient cannot reproduce a traumatic event in memory in detail. The patient also experiences constant vigilance and is in a condition of continuous expectation of threat. The condition is often complicated by somatic frustrations and diseases generally of nervous, cardiovascular, digestive, and endocrine systems.
1.2 Symptoms of PTSD
Post-traumatic stress disorder (PTSD) is a severe and dangerous condition for a person who experiences it as well as for people surrounding that person. Reminiscences of a trauma constantly pursue the patient. Knowledge of various symptoms of PTSD will help people understand whether they have this illness or not. There exist methods of treatment of PTSD that proved to be effective, and there are no reasons for a patient to suffer alone. The symptoms of a post-traumatic stress disorder (PTSD) can be subdivided into three main categories:
1. Repeated experiences;
2. Refusal to perceive reality;
3. Hypererethism.
According to Bradley (2005), repeated experiences include realistic memories of a trauma, which include pictures and memories that recur again and again in the memory of a patient and cause strong depression and despondency. Patients also suffer from regularly repeating frequent nightmares about a trauma, which make them experience it again and again. This creates a constant feeling that a traumatic event did not finish. Patients also have feelings of depression and anxiety provoked by the objects or situations. which are somehow connected with a trauma or symbolize it. Refusal to perceive reality include such manifestations as avoidance of thoughts, feelings, and conversations connected with trauma, places, activities, and people reminding of a trauma, loss of interest in activities, which seemed attractive earlier, feeling of alienation and detachment from surrounding people, difficulty to feel and express positive emotions, for example, love or happiness, unwillingness to think and speak about the future.
Hypererethism is represented by sleep disorders, irascibility, bursts of anger, difficulties with concentration and study, constant feeling of readiness for something bad, sharp reaction to loud sounds, and sudden movements.
Minor symptoms include a recurring sense of guilt connected with the consequences or behavior during a traumatic event, continuous repetition of memories of a traumatic event, and incessant thoughts of trauma. Furthermore, all interests are reduced only to questions connected with trauma, splitting of personality, and the feeling of isolation from oneself.
1.3 PTSD and Military Personnel
Military stress is an etiological factor of psychosomatic pathology among participants of war. Participation in military actions is a stressor, which is traumatic for practically any person. Unlike other stressors, participation in war is the prolonged psychological traumatization.
According to Monson (2006), participation in war activities is always accompanied by a complex influence of a number of factors: 1) a realized feeling of threat for life, so-called “biological fear” of death, wound, pain, and invalidization; 2) incomparable stress arising among people, who directly participate in military actions; there is psycho emotional stress caused by deaths of comrades and by a need to kill opponents; 3) influence of specific factors of a fighting situation (deficiency of time, acceleration of the rates of actions, suddenness, uncertainty, novelty); 4) deprivations (lack of a full-time sleep, special water and food modes); 5) specific climate (for example, hot climate in the mountain and desert district in Afghanistan leads to hypoxia, heat, and increased perspiration).
There are two types of causes of a military PTSD. First of all, it is s psychological trauma, which has caused noticeable stressful changes of mental and physical conditions and obvious violations of behavior (aggression, panic escape, catalepsy, etc.). Other reasons of developing PTSD include inability of people who successfully participate in fights to re-adapt to a peace life. Repeated traumatization is a reason of the renewal of PTSD after a quiet latent period. Negative attitudes of surrounding people, medical personnel, and social workers can also become a reason. It happens because they have a peculiar psychological complex in the form of an extra mental protest against the opportunity emergence of the same illness.
Research on fighting stress showed that the process of fighting PTSD after a war is more complicated and takes longer than PTSD in a peace time because of cumulative stress and a memory of repeatedly endured horrors of war, physical and mental overstrain, grief over the loss of comrades, and empathy to the wounded. During military operations, constant disturbing vigilance and readiness for instant aggressive activities of the enemy are formed. Thus, the perception of a value of human life and responsibility for the aggression decreases. Long-term studies show that after fighting traumatic psychological stress participants of military operations should recreate in new to them conditions of peaceful life. They need to restructure their personal space, including the structure of their self-perception, self-assessment, and life orientations (Monson, 2006). According to Chard "the current wars in Iraq and Afghanistan are producing large numbers of veterans who have experienced a variety of combat stressors. The potential impact of combat exposure has been established, including significant rates of posttraumatic stress disorder (PTSD)" (2010).
Long stay of soldiers in a zone of fights becomes an important psychological injuring factor. It was found out that after 6 months of stay in a fighting environment, 20,3% of soldiers develop adaptive abilities of personality. Fighters become resistant, alert, and capable to successfully resist the opponent. Statistics shows that about 42.6% of soldiers have no noticeable emotional and behavioral changes. However, 36.1% have “a permanent social and psychological disadaptation”. A stay of more than a year in a fighting situation leads to “personal disadaptation” in 83.3% of soldiers. Probability of developing chronic consequences after fighting mental trauma directly depends on the severity of the transferred stress influence and duration of stay in battlefield conditions. Findings show the following percentages: the second year of war – 5.5%; the third year of war – 4.3%; the fourth year of war – 2.4%. The second group includes exogenous psychoses. Psychoses connected with a heavy loss and somatic exhaustion are frequent in this group. The second year of war – 6.9%, the third – 7.2%, the fourth year – 4.6%.
1.4 PTSD and Children
Children can also experience PTSD. They can show additional signs, for example, bad behavior, or they can act out the trauma, and it will emerge even more distinctly in their memory. Many children cannot tell a doctor about the trauma because of the inability to speak at the time of stress or due to a loss of speaking skills as a result of an incident. Reactions of fear and shame arising because of the distorted processing of traumatic experience block the desire of children to share the experienced violence. In certain cases, children lose trust to adults because of what happened to them, and thus communication with older people becomes a triggering factor for anxiety.
Children with PTSD can feel constant anxiety after they experience a traumatic event. Wars, tortures, rapes, natural disasters (for example, earthquakes and hurricanes), and also fires and road accidents belong to such events. There is a line between these types of traumas and other stressful events of life such as an illness or family problems. Usual skills of overcoming stress, which the majority of people have, as a rule, do not help to cope with traumatic experiences connected with PTSD.
The symptoms of PTSD have a pronounced and complex character. They include excessive fear, feeling of helplessness and horror, which can be expressed by children in their unusual behavior and disorganization. Children suffering from PTSD, show the symptoms in many respects similar to the symptoms of soldiers taking part in military operations and experiencing horrors of war. Children can have nightmares, fears, and panic attacks for many years. They can regress to previous stages of development and their behavior cannot correspond to age (for example, they can be afraid of strangers). Children with PTSD avoid situations that remind them of a traumatic event, or they can come back to this event. Often such children become pessimists, feel vulnerable, and can have problems at school.
Some characteristic symptoms are expressed differently among children and adults. For example, instead of repeating bright images that revive a traumatic event in the memory, the trauma is more often endured in nightmares. Nightmares reflect a traumatic event, but over time become nonspecific. Similar to it, the memories arising in the day time can be expressed in a game. Reaction to a trauma among preschool children can be expressed in repeating drawings and games, the central theme of which is connected with a trauma, regressive behavior, antisocial, aggressive, or destructive behavior.
Emergence of PTSD can be caused by both: a single stressful event and multiple mental traumas in the early childhood. In certain cases, parents of children who experienced an extraordinary stress are also exposed to traumatization and are inclined to denial or replacement of the fact of a trauma. Therefore, they are not a reliable source of information.
Acts of violence performed by people from a group of primary support of a child are especially dangerous, e.g. women associate themselves with the image of a mother, medical staff, teachers, and tutors. Early mental traumas are not usually revealed with their replacement and dissociation, however, the consequences of a physical, psychological, and sexual traumas can be extremely serious and lead to the development of early PTSD in children.
1.5 PTSD Statistics
For the first time, PTSD was described in the USA based on longitudinal studies of mental condition of American soldiers, who returned from the war in Vietnam. In 1980, the concept “post-traumatic stress disorder” (PTSD) was accepted as a distinct and reasonable diagnostic category. Post-traumatic stress disorder can be defined as a condition, developed by a person, who experienced psychological and emotional stress, which could be traumatic practically for any person.
The war in Afghanistan is very similar to the war in Vietnam in terms of the impact it had on people’s mental health. According to the National Research of Vietnam Veterans in 1988, about 30.6% of Americans participating in the war developed a full-scale PTSD; 22.5% developed partial PTSD. About 55.8% of people having PTSD also experienced psychological frustrations related to the probability of being jobless (in comparison with others), divorces (70%), parental problems (35%), extreme forms of isolation from people (47,3%), expressed hostility (40%), violence (36.8%), and arrest or imprisonment (50%) (Foa, 2009).
In modern terminology, PTSD is a chronic mental disorder caused by a psychologically stressful event occurring out of the range of normal human experience. About 8% of all population is subject to it, and women are twice as likely to develop PTSD in comparison to men. According to medical statistics, a big number of women who were victims of sexual violence or its attempt have a similar disorder in the anamnesis. Any event, which caused strong stress, whether it was a physical abuse or casually seen murder, earthquake or a fire, can be a reason of PTSD. Both participants and involuntary witnesses of any military operations suffer from it. Different types of therapy directed mainly at noradrenergic, serotoninergic, and dopaminergic receptor complexes are most widely applied in treatment of PTSD. Preclinical research convincingly confirms the key role of noradrenergic system in concentration on bright and menacing events. Some researchers believe that this system is especially important in the development of a group of symptoms of overexcitement associated with PTSD. During PTSD the binding of paroxetine by thrombocytes is broken. It depends on the expressiveness of the symptoms of PTSD and is an objective marker of the therapeutic forecast in treatment by selective inhibitors of the return capture of serotonin.
PTSD is not a frequent phenomenon. About 1% of population suffers from PTSD, and separate symptoms of PTSD can appear in 15% of the population after heavy traumas such as a physical attack or military operations. PTSD becomes chronic in a considerable number of people. In general population, the disorder is often combined with other mental illnesses, including affective frustrations and abuse of alcohol or other drugs.
If to consider only war participants, PTSD, which is a syndrome delayed in time from a stay in a traumatic situation of specific reactions with stratification of secondary stresses, is noted in 18.6% of almost healthy veterans of war in Afghanistan; in 41.7% of chronically sick; in 56.2% of disabled people. The obtained representative data on the prevalence of PTSD among soldiers-internationalists testify that the signs of PTSD (various degree of expressiveness) occur in 62.3% of the surveyed.
