Professor Gordon Turnbull is a consultant psychiatrist specialising in the assessment of patients suffering from the psychological after-effects of trauma. He is the leading Trauma and Post-Traumatic Stress Disorder (PTSD) expert at Capio Nightingale Hospital, Consultant Advisor in Psychiatry to the Civil Aviation Authority (CAA) and Visiting Professor to University College Chester.
In the following article he offers some answers to common questions about PTSD and Combat Stress. This includes a guide to the nature of the condition and some of the commons symptoms which may indicate the presence off the condition.
Dr Turnbull has also written leaftlets on PTSD and stress reactions which can be downloaded by following thel ink to Capio Nightingale Hospitals on the right-hand side of the page.
What Is Trauma?
Trauma has been documented since early times
Homer's Iliad (c.850 BC) contains graphic accounts of the psychological trauma of war. Almost all great authors, such as Shakespeare, and historians down through the ages, have done the same. That is because trauma is part of the human condition.
As experienced by soldiers during World War One, trauma was understood as 'shell-shock' but in recent years the changes that trauma brings, both psychological and physical, have been increasingly understood.
A trauma is a dangerous experience that does not only expose people to threat to life or limb: it also pierces strong psychological defences to produce a state of fear, helplessness or horror.
What is PTSD?
PTSD develops in response to direct exposure to a trauma but it can also be the result of witnessing or even learning about a terrifying event.
The trauma is usually life-threatening, or at least capable of producing bodily harm and it typically involves either violence or disaster, assault, rape, torture, terrorism, car or plane crashes, earthquake, tornado, or flood.
Traumatic events have in common the ability to elicit intense and immediate fear, helplessness, horror and distress. They do not send advance notice that they are about to happen. This is one reason why they are so shocking. Suddenness, unpredictability, and danger have the power to traumatise.
Understandably, people feel grief-stricken, depressed, anxious, guilty and angry following trauma. PTSD is a specific condition in which trauma survivors are unable to get the trauma out of their minds. Three symptom clusters are associated with PTSD:
1. Re-experiencing symptoms
Distressing images, unwanted memories, nightmares or flashbacks of the trauma that cause distress and physical symptoms such as palpitations, shortness of breath and other panic symptoms. Because the memory imprint has not been processed by the brain in the usual way the flashbacks are very vivid and realistic and there is a frightening and uncanny sense of going through the trauma all over again.
This can seem very strange and people sometimes think that they are going out of their minds and is one of the main reasons why people keep their trauma reactions to themselves.
Ordinary things can trigger off flashbacks. For instance, if a car crash happened while it was raining, a rainy day might bring on a flashback.
2. Avoidance & Numbing
The avoidance of reminders of the event, including people, places or things associated with the trauma becomes a major preoccupation, leading to increasing emotional numbness and withdrawal and being generally unresponsive to things that used to be interesting.
Increased use of alcohol and tobacco and other substances (including painkillers) are often used to 'douse' the memories.
Less communication with other people makes relationships at home and at work difficult.
Reflected in physical symptoms such as insomnia, irritability, poor concentration, being 'on guard' most all the time (hyper-vigilance), headaches, muscle aches and pains, diarrhoea, nausea and increased startle responses. The hyper-arousal occurs at inappropriate times.
Why is it important that the symptoms of PTSD or Combat Trauma are acted upon and not ignored?
It is important to realise that PTSD is a long-term trauma reaction.
What that means is that it lasts for longer than three months. To begin with, an Acute Stress Reaction (ASR) develops. It is quite normal for an ASR to develop following exposure to a traumatic event. All that this means is that the brain has registered the memories of a personally dangerous situation and is reminding the individual exposed to what actually happened and how they reacted to it emotionally.
There is a very good reason for remembering a traumatic event, even over and over again, because it facilitates the imprinting in long-term memory of everything that might be useful to personal survival in the future and, if you like, 'milks' the experience for all that it is worth so that the most useful information is imprinted and never forgotten. Survival is the strongest human instinct and remembering everything that occurred during a survival experience is regarded as being vital for the future. This is especially the case for those individuals who are in the business of facing up to danger in the course of their everyday activities, such as military personnel, emergency service personnel and police officers.
So, instead of seeing an ACR as an inconvenience there is much to be said for seeing it instead as an opportunity to learn from a trauma to improve performance next time round especially if you know it's bound to happen again. ACRs don't always happen following exposure to trauma but they do in about 70% of cases.
The core feature of an ACR is flashback memories of the event.
You can't have an ACR without flashbacks. These are different from ordinary memories which have a date attached to them and are appreciated to have occurred in the past. A flashback feels as if it's happening in the present, such a vivid and faithful reproduction of what actually happened that it feels as if it's happening all over again.
Avoidance and 'Emotional Shut-Down'
Because a flashback is so vivid those who experience them try to avoid having them. This leads to the other features of an ACR - avoidance of reminders by avoiding people, places and situations that will provide definite reminders. Individuals may 'shut-down' emotionally, so that the usual channels of communication with others are closed, making normal relationships difficult and intimate relationships almost impossible.
This may also keep the personal 'radar' in 'red alert' so that vigilance will help to protect from re-exposure to danger. This makes it difficult to sleep, and irritability and other effects of high levels of adrenaline are inevitable.
It is important to recognise what is happening and to let the brain do its job in order to absorb the information which it regards as vitally important. So, keeping a regular routine, acknowledging that the reaction is normal in the circumstances, avoiding excessive alcohol are all very important at this stage.
What role can alcohol or drug use play in suppressing symptoms?
On a conscious level there is no doubt that psychologically traumatised individuals deliberately use substances that they know will reliably dampen down their re-experiencing of an unpleasant event.
However, on a biological level we now have to take into account that the chemical changes that are part of the acute stress reaction mean that the traumatised individual may (unconsciously) seek to find substances that may boost flagging sources of intrinsic chemicals that modulate their emotional turbulence and pain.
These substances, produced in the body naturally, are called endorphins and are , in effect, the body's own morphine. And what externally available substances boost the levels of flagging endorphins? None other than the ones that we associate with trauma reactions - nicotine, alcohol, and other drugs, for example opiates such as morphine and ecstasy.
It is very important to realise that the use of such substances is often the reason why an individual, or those around him or her, does not realise that they have been traumatised, often for quite a protracted period. By then, of course, the Acute Stress Reaction will have matured into the long-term version which is called Post-Traumatic Stress Disorder (PTSD).
Medical Discharge or not?
Service personnel can be medically discharged from the military because they have developed PTSD.
Because service personnel are generally people who like to believe that they are resilient and strong they will, predictably, not want to leave the service with what they perceive to be a contradiction of that. The only way around this is improved psycho-education on the part of the soldier and the Ministry of Defence. Fortunately the biological discoveries about the nature of the trauma reaction, and its reversibility, should be the key factor in achieving this.
And if symptoms develop after leaving the Armed Forces?
Things may be changing for the better in this respect, as the National Institute for Clinical Excellence (NICE) has recently published guidelines which should improve awareness of PTSD. Individuals who leave the Armed Services may already be aware that they have the characteristic features of PTSD but might think that because the flashbacks relate to combat experiences they will fade away and no action is necessary.
This is seldom the case, however. It is also possible that the PTSD may be of delayed-onset. This means that an individual may remain completely unaware that they have been psychologically traumatised, sometimes many years after the trauma occurred.