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Treating post-traumatic stress disorder

Treating post-traumatic stress disorder: confronting the horror

Article from The Conversation – By Mark Creamer, University of Melbourne

While human beings have always known about the mental health effects of trauma, it was only in 1980 that the term post-traumatic stress disorder, or PTSD, was coined. This acceptance spawned an explosion of research on the causes, vulnerabilities, and optimum treatments for PTSD.

We have since learnt a great deal about how to help people with this disabling and often chronic condition. Evidence-based treatment guidelines in Australia and the United Kingdom are consistent in their recommendation of “trauma-focused psychological treatment” as the first line approach for PTSD. Of these approaches, the strongest body of evidence supports an intervention known as “prolonged exposure”.

PTSD is a complex disorder, with multiple symptom groups. Avoidance of trauma reminders, persistent hyper-arousal (constantly looking out for potential danger), and negative mood are key features. The hallmark, however, is that of “re-experiencing the trauma” in the form of intrusive images, memories and nightmares.

It is this inability to move on – being constantly haunted by the past horror – that drives the other symptom clusters. Any successful treatment, therefore, must target these traumatic memories and prolonged exposure is designed specifically to do that.

There’s a common perception that the best way to recover from trauma is to forget about it; the evidence shows this isn’t the case.
Christopher Ebdon/Flickr, CC BY-NC-ND

Prolonged exposure is a common sense approach. We are all familiar with “getting back on the horse” – confronting what frightens us and not avoiding it. The most successful treatments for all anxiety disorders are built around this concept.

To treat someone who is very frightened of spiders, for example, we would help them to face their fear.

Starting with a small spider in a jar across the room, we would gradually get closer and gradually move to bigger spiders. At each step the anxiety would increase but, by staying with it and not running away, it gradually reduces or “habituates” so that we can move on to the next step.

Treating PTSD is essentially the same process. We help the person to gradually confront situations, places and activities they’ve avoided since the traumatic event because they cause great anxiety; we call this in vivo (or live) exposure. In PTSD, however, the main “feared object” is not outside the person, it is the memory of their traumatic experience.

People with PTSD – consciously or unconsciously – block out and avoid these painful memories. Prolonged exposure helps them to gradually confront the memories and “work through” the experience in a safe and controlled manner; we call this imaginal exposure. Each time they confront the memory without avoiding, and stay with it long enough for the distress to reduce, they make another step towards recovery.

The first component of prolonged exposure is to explain clearly what we are doing and why; after all, we are asking them to do what they fear most. We explain the rationale and process in detail, often using metaphors to illustrate the mechanisms involved.

We also teach them strategies to manage distress. These are not to be used during prolonged exposure, but it is important for people to feel confident about controlling their distress at other times.

We then ask the person to talk through the event. Just as we graded our exposure for the spider phobic, we try to do for the memory. On the first few runs through, the person might talk with their eyes open, in the past tense (“I walked into the park…”), and skip over the worst aspects.

Visualisations often start with past-tense accounts and skip over the worst parts.
Luc De Leeuw/Flickr, CC BY-NC-SA

On later exposures, however, it is important to confront all aspects of the experience, to ensure there are no “skeletons in the closet” that will cause problems later. So we use eyes closed, present tense (“I am walking into the park…”), focusing on all senses (sights, sounds, smells, tastes, touch), and – as treatment progresses – confronting the worst aspects of the experience in detail.

We monitor the patent’s distress regularly to ensure it is reducing before moving on to the next level.

Imaginal prolonged exposure is a powerful process for both therapist and client. It results both in reduced distress and in greater understanding of what happened and why. “Putting the pieces of the jigsaw puzzle together” is crucial to recovery and has long been recognised as an effective treatment.

Early variations on prolonged exposure (such as “abreaction”) used drugs to access the memories, while more recent approaches (such as desensitisation) placed a heavy emphasis on relaxation and arousal reduction during exposure. We now know that neither is recommended; people can access the memories, and can tolerate the distress, without these additions.

While there is a common perception that the best way to recover from trauma is to forget about it and focus on the future, the research and clinical evidence is clear: for trauma survivors with PTSD, that is not the case. Indeed, the evidence is now sufficiently strong that it would be negligent not to offer a trauma-focused psychological treatment to a patient with PTSD.

The Conversation

This article was originally published on The Conversation.
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Tidal wave or trickle: treating returning veterans trauma

Tidal wave or trickle: treating returning veterans trauma

(This article is reprinted from The Conversaton – please see my comment at the end)

By Ben Wadham, Flinders University

While many people are relieved Australia is concluding its operations in Afghanistan, the effects of our involvement have, in many ways, only just begun. Retired Major General John Cantwell, the author of the military trauma book Exit Wounds, and veterans groups argue Australia will see a tidal wave of psychological trauma among veterans in the coming years.

Australians have been consistently involved in combat, peacekeeping and humanitarian roles for about 20 years. Since 1999, 45,000 Australians have served on overseas operations with the Australian Defence Force (ADF) on around 134,000 individual deployments.

In the Middle East, we have lost 40 men and we’ve seen around 240 serious injuries across both genders. Deaths and injuries have mostly been combat-related, through improvised explosive devices, firefights (a large exchange of bullets), green on blue attacks (from rogue members of the Afghan security forces) as well as other accidents.

Psychological trauma, however is more prolific and much harder to identify.

The Middle East Area of Operations Health Study, released last week, surveyed 3,000 Australian Defence Force (ADF) members deployed in Afghanistan and Iraq from June 2010 to June 2012. The study reports that deployment to the Middle East has doubled the incidence of psychological distress and trauma, and post-traumatic stress disorders (PTSD), manifesting in alcoholism, drug abuse and suicide.

The report builds on a parliamentary inquiry report, released earlier this year, and highlights both the ongoing development of services and support for traumatised military personnel. It also leads us to ask: are we doing enough, and are we doing it well?


Historically, trauma has gone by numerous names, from shell shock, to battle exhaustion to war neurosis. In 1980, PTSD was formalised in the Diagnostic and Statistical Manual of Mental Disorders (DSM).

While there’s widespread agreement about the causes of PTSD, there is much disagreement about its prevalence. The latest report states 6% of personnel who have left the ADF and 2.7% of serving members report symptoms of PTSD. While the authors acknowledge they haven’t given the matter the in-depth analysis it requires, other data sources differ considerably.

The current paradigm tends to reassert negative perceptions of trauma, further entrenching the veteran’s sense of stigma. Flickr/isafmedia

According to the 2010 ADF Mental Health Prevalence and Wellbeing Study, nearly 2,491 of 51,000 staff deployed between 2002 and 2009 suffered from PTSD, amounting to about 8% of serving members. But this only covers personnel diagnosed with PTSD. Another one in five had suffered a mental disorder in the previous 12 months, and more than half struggled with anxiety, alcohol or affective disorders at some stage in their life.

If you listen to veterans’ groups – the groups of men and women who have often been in this situation themselves, and whom veterans feel safest confiding in – the rate of PTSD and combat stress is reportedly closer to 30% among those who have left.


Military personnel returning from service are supposed to undergo post-operational psychological screening (POPS), which includes a questionnaire and interview. The contact with a psychologist should occur within three to six months after returning form deployment.

But there are some problems with this process. The high rate of deployment – itself a contributing factor to PTSD because of the chance of repeated exposure to trauma – has created significant backlogs in providing this service to returning personnel. As well, the stigma of mental illness remains a consistent challenge for the identification and treatment of trauma, despite the ADF and associated agencies recognising this.


For those who are diagnosed, there are a host of psychological and pharmacological treatments available. But they’re only part of the recovery story.

An equally important, but often overlooked component, is the role of veterans groups in providing a sanctuary for those experiencing trauma through a sense of camaraderie among veterans. Rebuilding, through a sense of shared experience, lessens the stigma of psychological trauma. These groups also help to remove the stigma of trauma being merely a psychological pathology.

Deployment to the Middle East has doubled the incidence of psychological distress and trauma. Flickr/isafmedia

The ADF and its preferred providers have created a comprehensive approach to promoting good mental health. This includes recognising health issues, building peer support and engaging families, command and service providers. A key plank has been developing the coherency of services on departure to civilian life.

The ADF Mental Health and Wellbeing Plan (2012-2015), which was released in February, also shows the ADF is attempting to improve communications strategies, develop e-services, up-skill service providers, improve pathways to care and will continue to build peers support networks.

A common complaint among veterans, however, is the lack of service experience among counsellors. This has been a major challenge, as personnel struggle with trauma and their new life away from the structured and team-based context of service life. The sense that no-one, other than other military personnel with similar experiences, can understand generates a profound sense of loneliness.

What can we do better?

It is only in recent years that the ADF has demonstrated a strong understanding of the complexity of PTSD. Bureaucratic supports are in the process of catching up. Recent reports have begun to name the key issues and find appropriate strategies to support returning veterans, both in, and after service.

But broader, culturally sophisticated approaches would improve the outcomes of veterans with PTSD. Take gender, for instance. Men, particularly those in the military, are reluctant to acknowledge weakness, and military training further instills the imperative to remain in control. Women veterans, often struggle to identify as “veterans”, given its masculine connotations. This undermines their capacity to acknowledge their condition and seek help.

Research literature suggests that the current paradigm tends to reassert negative perceptions of trauma, further entrenching the veteran’s sense of stigma.

Whether we see a tidal wave or a trickle of PTSD, we must continue to work on new therapeutic approaches that develop a sense of trauma wisdom among the afflicted, and their support networks, as well as diminishing the stigma of diagnosis.

Ben Wadham does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.

The Conversation

This article was originally published at The Conversation.
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My Comment:

I think the following is around the wrong way: “The sense that no-one, other than other military personnel with similar experiences, can understand generates a profound sense of loneliness.”


Those with PTSD usually have depression as part of the condition. Depression and other issues are associated with social withdrawal. I think it is this that creates the loneliness that the client then explains by thinking that no one can understand them.


The social withdrawal is also due to the culture that you identify of not wanting to disclose weakness. Once diagnosed most are no longer at work and therefore no longer connected to the social support one would normally get, another source of loneliness. Avoidance of workmates is also part of the condition in that they act as a reminder of the trauma and possible trigger for flashbacks.


PTSD is a difficult condition to treat with a high rate of treatment failure and high drop out rates. This is associated with the condition itself. Part of the depression are feelings of helplessness and these are then acted out by not attending therapy. The patterns of avoidance can also be acted out by not attending therapy. In many alcohol abuse and anger issues create barriers to good support from friends and family. Those affected by these patterns may then potentially blame the therapy for not working. It may of course be that the therapy is not working due to insufficient skills in the therapist. Complex indeed.


There are now therapy groups for PTSD in outpatient and inpatient settings. With evidence that social support improves outcomes in PTSD it makes a lot of sense to provide group programmes for Veterans. It also makes sense for the ADF and their rehabilitation providers to co-ordinate these to ensure sufficient numbers. An interesting research project to see the impact of this.


I suspect the numbers diagnosed and seeking treatment for PTSD will increase over time and looking into the anxiety, depression and alcohol use may find these secondary to the trauma of service.


Rewriting Memories with Red Herrings

(The following article discusses the possibility of changing memories in PTSD)

By Sunanda Creagh, The Conversation and Michelle See-Tho, The Conversation

Certain types of long term memories can be “rewritten” without drugs or surgery, according to a new study that experts say offers hope for sufferers of post traumatic stress disorder.

The study, conducted by Jason C. K. Chan and Jessica A. LaPaglia from Iowa State University, showed that declarative memories — memories of events, facts or details that can be consciously recalled — are open to change and can be disrupted through exposure to false details or alternative narratives.

The researchers designed an experiment in which participants were asked to watch an episode of the TV show 24 about a fictional terrorist attack.

Soon after the video ended, the participants were asked to recount the plot details. They were then asked to listen to an audio recording of a person explaining the video storyline, but with elements of misinformation woven throughout — for example, the suggestion that the villain used a stun gun on an airline attendant, when in the video it had been a hypodermic needle.

After being exposed to misinformation about plot details, the study subjects fared much worse at remembering the real details but only if the ’re-learning’ occurred quite soon after the memory was first recalled.

“Here we show that existing declarative memories can be selectively impaired by using a noninvasive retrieval–relearning technique,” the authors said in their paper, which was published in the journal PNAS.

“These results demonstrate that human declarative memory can be selectively rewritten during reconsolidation.”

Post Traumatic Stress Disorder

Kristyn Bates, Research Assistant Professor of Experimental and Regenerative Neuroscience at the University of Western Australia said the new study was very interesting.

“The first thing that came to mind was that the data presented in this study could really help inform as to the best treatments for people who have conditions such as post-traumatic stress disorder, where unwanted memories can have such a devastating impact on a person’s life, through to better learning techniques for students studying for exams,” said Dr Bates, who was not involved in the study.

“Because declarative memory involves diffuse neuronal networks, it has been difficult to study in humans, unlike motor and fear-based memories which have localised, distinct neurological substrates. The authors have conducted a very well designed study where they have attempted to uncover whether declarative or long-term memories can be manipulated in humans without the use of drugs, which may have adverse side effects on other aspects of cognitive function.”

The authors of the study demonstrated that the incorrect details had to be specific, rather than vague, in order to be consolidated into the original memory, she said.

“This may explain why the numerous distractions and stimuli we encounter each day don’t destabilise our declarative memories. The memory-disruption effect was even present for items that participants had previously correctly recalled.”

Dr Bates said that further research was needed but the new findings may help to explain why certain forms of therapy are more effective for post traumatic stress disorder sufferers than others and may have important implications for crime investigation and interviewing of eye-witnesses.

“It is well known that eye-witness accounts can be manipulated. This study implies that the methods of questioning may be important for gathering reliable evidence. Importantly, this is a non-pharmacological, non-invasive technique, thus reducing the possibility of unwanted side effects on other memories and other aspects of cognition.”

Jee Hyun Kim, DECRA Fellow in Behavioural Neuroscience at The Florey Institute of Neuroscience and Mental Health, also welcomed the new findings.

“This study provides evidence how a stable ‘consolidated’ memory can be altered by what the person experiences following its recall,” said Dr Kim, who was not involved in the study.

“We already know that, especially in forensic context, existing memories can be manipulated and/or falsely remembered. This [study] explains how confabulation can be spontaneous as well as provoked. Confabulation is believed to depend on both subconscious and conscious processes. So far, reconsolidation studies provided subconscious ways in how a memory can be changed. [The new study] shows the conscious way.”

Dr Kim said that if brain imaging studies could be done while subjects recalled misinformed memories and original memories, “perhaps we can decode what confabulated memory looks like in the brain.”

“This could be used to differentiate true versus confabulated testimonies from eye witnesses in the court, or in diseases where confabulation is rampant such as Alzheimer’s, or alcoholism.”

The Conversation

This article was originally published at The Conversation.
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PTSD and Sleep

The article below appeared in The conversation. This represents another development in psychotherapy for PTSD as many clients present with nightmares and/or sleep disturbance.

Acting out the nightmares of post-traumatic stress disorder

By Andrea Phelps, University of Melbourne

You can run a marathon, fly over foreign lands, fight to the death with a two-headed dragon … all while you lie peacefully in your bed. This is the beauty of rapid eye movement (REM) sleep, where most of our dreaming occurs – our minds are active but our bodies are paralysed.

And just as well. When our body is paralysed it keeps us, and those around us, safe while we dream.

Unfortunately this protective mechanism seems to break down in the nightmares of some people who develop post-traumatic stress disorder (PTSD), causing them to enact aspects of their dreams while they’re sleep.

This phenomenon has long been recognised, with vivid descriptions found in literature over hundreds of years. Take Shakespeare’s Henry IV, in which Lady Percy says to Hotspur:

In thy faint slumbers I by thee have watch’d
And heard thee murmur tales of iron wars;
Speak terms of manage to thy bounding steed;
Cry “Courage! to the field!” And thou hast talk’d
Of sallies and retires, of trenches, tents,
… Of prisoners’ ransom and of soldiers slain,
And all the currents of a heady fight.

Why is it a problem?

Acting out your dreams can be particularly concerning when they involve replays of actual traumatic experiences, or equally frightening related events. It can mean, for example, that the person acts out dreams of being attacked, engaging in combat, or fleeing from a bushfire. Typically, arms and legs thrash about, the person may yell and scream, and in some cases, unintentionally assault their sleeping partner.

Not surprisingly, PTSD sufferers often wake from sleep with the covers torn off, or may even find themselves on the floor. Some remember in precise detail what they’ve dreamt; while others wake with no memory of a dream, but have intense emotions of fear, horror or anger, as though the trauma has just occurred.

Such severe sleep disturbances are very distressing to both the people suffering PTSD and their partners, who often resort to sleeping in separate beds, afraid of being harmed during a violent dream.


Although post-traumatic dreams have been recognised for centuries, we know surprisingly little about them. Psychophysiological studies, recording electroencephalogram (EEG) and electromyography (EMG) activity associated with post-traumatic dreams, have proven difficult because these dreams don’t tend to occur in a sleep laboratory environment. This may be because of the perceived safety of that environment, with the presence of sleep technicians, allowing the person with PTSD to let their guard down, relax their usual hyper-vigilance and get a good night’s sleep.

At the most basic level, there is debate about whether the post-traumatic dreams of PTSD should be considered dreams at all, given their recurrent nature.

Freud, for example, could not reconcile the recurrent nightmares of returning World War I soldiers with his theory of dreams as wish fulfilment. He argued these nightmares were better understood as the psychological phenomenon of “repetition compulsion” – the attempt to psychologically master overwhelming experiences by returning to them again and again.

Similarly, the contemporary theory that dreams serve an adaptive function in the processing of emotional experience cannot explain the repetitive dreams of PTSD, leading to the conclusion that they are better understood as intrusive symptoms of PTSD rather than dreams. This would certainly explain the associated bodily movement – intrusive symptoms of PTSD can include trauma-related thoughts, emotions, and physiological and behavioural responses.

But the conclusions of dream theorists have not been put to an empirical test. An alternative explanation is that post-traumatic dreams share many of the features of normal dreams, with the accompanying body movement explained by other factors such as a REM abnormality (overriding the normal body paralysis during REM) or the dreams occurring in non-REM sleep (when the body is not paralysed).


Imagery rehearsal (IR) is an emerging treatment for the post-traumatic nightmares of PTSD. This involves helping the person to plan a change in the storyline of their nightmare in order to increase their sense of mastery or control, and then mentally rehearsing the new dream before going to sleep.

A pilot study undertaken by the Australian Centre for Posttraumatic Mental Health (ACPMH) at the University of Melbourne, in collaboration with Austin Health, found that IR was effective in ridding a majority of Vietnam veteran participants of their recurrent nightmares of 30-plus years. ACPMH is now is now trialing imagery rehearsal therapy with returning US Iraq and Afghanistan veterans through Philadelphia VA Medical Centre and University of Pennsylvania.

So we know that IR works for people without PTSD who have recurrent nightmares and, as the research builds, there is growing confidence it also helps those with PTSD.

But at this stage, the first-line treatment for people with nightmares as part of their PTSD remains trauma-focused therapy, which targets the overall condition. IR would normally only be considered in cases where nightmares persist following this established evidence-based treatment for PTSD.

Andrea Phelps does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.

The Conversation

This article was originally published at The Conversation.
Read the original article.