Post-traumatic stress disorder: remembering and recovering

Today we remember the Fallen. In the stillness of the eleventh hour today, in this year one hundred years on from the start of the First World War, many of us will have in our minds the extraordinary image of the ceramic poppies ‘planted’ in the Tower of London”s moat and the words of Binyon’s poem, For the Fallen, published in September 1914. We hear these lines of Binyon’s in our acts of remembrance:

boys outing in 1912

Boys enjoying an outing in 1912. How many would go to war and not come home?

They shall grow not old, as we that are left grow old:
Age shall not weary them, nor the years condemn.
At the going down of the sun and in the morning
We will remember them.

But I’m reminded too of the lines that follow, with the image to which I keep returning: a photo of my 15 year old grandfather amongst a group of smiling boys, enjoying an outing, in the summer of 1912. I look at those boys and want to know their names and tell their stories. They must all have gone to war. How many came back?

They mingle not with their laughing comrades again;
They sit no more at familiar tables of home…

Grandpa joined up with his best friend Hubert. He was wounded at Messines, came home and lived a long life. But Hubert lies in Flanders.

The eloquence of the war poets is in contrast with the silence of the ordinary Tommy who came back and couldn’t, wouldn’t, describe the horrors of his experience of war. Other traumas sustained during peoples lives were generally not talked about and looking back from our own, more enlightened times, the degree to which people were required just to ‘get on with it’, whatever life threw at them, seems staggering. When my grandparents lost their first two sons, late in pregnancy, Grandpa was left to deal with their bodies. They never spoke of it.

What is PTSD?

Many traumatic situations, aside from military conflict, can cause great psychological distress which may result in lasting mental health problems. Post-traumatic stress disorder (PTSD) is one of the most common of these and in the last 25 years there has been a lot of work to develop effective ways to prevent and treat it.

People with PTSD experience heightened arousal (such as sleep disturbances and being easily startled) and intense fear, reliving the trauma they’ve been through, and avoiding reminders of it.

Sandra’s story

Sandra and family

Sandra enjoying time with her family

“Unlike the unfortunate servicemen and women dealing with the aftermath of horrors experienced on the battlefields, I was diagnosed with PTSD after enduring the repeated cancellations of diagnostic surgery to determine whether or not I had a cancerous polyp. During a tortuous period of 13 weeks I experienced three devastating “in situ” cancellations. On two occasions I was actually gowned up and physically and emotionally prepared for surgery. Each time I was sent home with no future date for the surgery and the agonizing uncertainty of the nature of the polyp. Was it cancerous? Was it growing or spreading during this extended waiting time? Just 18 months earlier my husband had undergone surgery to remove an aggressive malignant melanoma and my biggest dread was wondering if I would have to tell my adult children that I too had cancer. Thankfully, after receiving wonderful and efficient treatment in the private sector, I received the fantastic news that the polyp was in fact benign.

However,  the repeated traumas of cancellation and 13 weeks of intense anxiety had caused me to begin experiencing the debilitating effects of PTSD. I found myself unable to sleep for any length of time and when I did sleep I experienced traumatic dreams related to my experiences. I felt increasingly emotional. I experienced vivid flashbacks and felt in a permanent state of heightened anxiety and distress. I was alarmed by my inability to focus or concentrate. I wanted to avoid social occasions and as such I was unable to return to work as a primary school teacher for six months. I experienced a complete change in my personality and became withdrawn and anxious. Prior to my diagnosis of PTSD I had rarely missed a single day of teaching in the previous two decades!”

Preventing PTSD

Could something have been done to reduce Sandra’s chances of developing PTSD as a result of her traumatic experience? A recent Cochrane review gathered the best available evidence on whether medicines are an effective way of preventing PTSD in adults. Unfortunately, whilst there are some indications that hydrocortisone may help prevent PTSD and reduce the severity of the symptoms, there is too little evidence to guide the use of medicines for PTSD. An earlier Cochrane review found no evidence that single session individual psychological debriefing is useful for preventing PTSD after traumatic incidents and the two trials with the longest follow-up reported adverse effects. The reviewers point out that the possibility of doing harm must be remembered and that what works as a treatment won’t necessarily be helpful as a preventive measure.

Psychological therapies can help recovery

There’s better news when it comes to treatment, with evidence from a Cochrane review supporting the use of psychological therapies for adults with chronic PTSD.

Trauma-focused cognitive behavioural therapy (TFCBT), non-TFCBT, and eye movement desensitisation and reprocessing (EMDR) were all found to be effective, with the strongest evidence supporting TFCBT and EMDR. These appear to have comparable benefits immediately after treatment but TFCBT and EMDR were better than non-TFCBT one month and four months after treatment.

TFCBT combines cognitive and behavioural therapies, aimed at helping the person to both think and act differently, through exposure to memories of the event. EMDR helps the person to reprocess their memories of the event.

The evidence isn’t high quality. There were problems with the designs of the studies and we don’t know whether these therapies have harmful effects. The reviewers note that drop-out from treatment is a signficant problem. There’s plenty for future researchers to do in this area.

“EMDR gave me back my personality and way of life”

For Sandra at least, EMDR has helped her recovery, as she explains here.

“I consider myself very fortunate to have been diagnosed by a very knowledgeable psychiatrist who explained the possible benefits of EMDR therapy in overcoming the symptoms of PTSD. I found a very experienced EMDR practitioner and after an initial assessment we began to work on reprocessing my memories of the traumatic experiences.

EMDR collageEMDR involves using multisensory bilateral stimulation. It sounds complicated but in effect it required me to follow a light on a computer screen, whilst wearing headphones which made a sound in alternate ears in time with the light. In each hand I held a buzzer which operated in time with the other two inputs. My psychologist explained that while discussing and visualizing the traumatic events, the sensory input of the EMDR process enables the patient to reprocess the memories from the active memory into the long term memory and to be stored there without the emotional attachment.

I have found EMDR to be a very effective treatment for the extreme levels of disturbance I was experiencing. It has been a long process, no quick fixes, but so worthwhile and supportive. After over six months of weekly, then fortnightly, sessions of one hour I have finally reached a stage where I am now able to recall and talk about my experiences without becoming distressed and emotional. My sleep pattern is much improved, I am able to concentrate much better and I am no longer anxious and withdrawn. Best of all, I recently returned to work doing the job I love. From my own experience EMDR has been instrumental in giving me back my personality and my way of life.”

Our thanks to Sandra for sharing her story.

Links:

Featured image PTSD art 2 from: http://meatandmarrow.blogspot.co.uk. EMDR collage from:http://www.clintontherapist.citymax.com

Amos T, Stein DJ, Ipser JC. Pharmacological interventions for preventing post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews 2014, Issue 7. Art. No.: CD006239. DOI: 10.1002/14651858.CD006239.pub2.

Cochrane summary http://summaries.cochrane.org/CD006239/DEPRESSN_medications-to-prevent-post-traumatic-stress-disorder-ptsd-a-review-of-the-evidence

Rose SC, Bisson J, Churchill R, Wessely S. Psychological debriefing for preventing post traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD000560. DOI: 10.1002/14651858.CD000560.

Cochrane summary http://summaries.cochrane.org/CD000560/DEPRESSN_psychological-debriefing-for-preventing-post-traumatic-stress-disorder-ptsd

Bisson JI, Roberts NP, Andrew M, Cooper R, Lewis C. Psychological therapies for chronic post-traumatic stress disorder (PTSD) in adults. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD003388. DOI: 10.1002/14651858.CD003388.pub4.

Cochrane summary http://summaries.cochrane.org/CD003388/DEPRESSN_psychological-therapies-for-chronic-post-traumatic-stress-disorder-ptsd-in-adults


Sarah Chapman

About Sarah Chapman

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Sarah's work as a Knowledge Broker at Cochrane UK focuses on disseminating Cochrane evidence through social media, including Evidently Cochrane blogs, blogshots and the ‘Evidence for Everyday’ series for nurses, midwives, allied health professionals and patients. A former registered general nurse, Sarah has a particular interest making evidence accessible and useful to practitioners and to others making decisions about health. Before joining Cochrane, Sarah also worked on systematic reviews for the University of Oxford and the Royal College of Nursing Institute, and obtained degrees in History from the University of Oxford and in the history of women’s health and illness in early modern England (MPhil., University of Reading).

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