Dispelling the nightmares of post-traumatic stress disorder

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avoidance, behaviour, cbt, distress, Ehlers and Clark, flashback, hyperarousal, interpretations, low mood, Memory, negative thoughts, nightmares, post traumatic stress disorder, psychological effects, psychotherapy, PTSD, reliving, reminders, symptoms, threat, trauma, trauma memories, traumatic event, treatment, triggers

Dispelling the nightmares of post-traumatic stress disorder

On Wednesday morning we woke to the news that a passenger ferry had sunk off the coast of South Korea, with at least four people confirmed dead and 280 unaccounted for. Meanwhile, though the search has continued for the missing Malaysia Airlines plane, relatives’ hopes of a safe landing have long since been extinguished.

Human tragedies like these are the stuff of daily news, but we rarely hear about the long-term psychological effects on survivors and the bereaved, who may experience the symptoms of post-traumatic stress disorder for years after their experience.

Although most people have heard of PTSD, few will have a clear idea of what it entails. The American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) defines a traumatic event as one in which a person “experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others”. PTSD is marked by four types of responses to the trauma. First, patients repeatedly relive the event, either in the form of nightmares or flashbacks. Second, they seek to avoid any reminder of the traumatic event. Third, they feel constantly on edge. Fourth, they are plagued with negative thoughts and low mood.

According to one estimate, almost 8% of people will develop PTSD during their lifetime. Clearly trauma (and PTSD) can strike anyone, but the risks of developing the condition are not equally distributed. Rates are higher in socially disadvantaged areas, for instance. Women may be twice as likely to develop PTSD as men. This is partly because women are at greater risk of the kinds of trauma that commonly produce PTSD (rape, for example). Nevertheless – and for unknown reasons – when exposed to the same type of trauma, women are more susceptible to PTSD than men.

What causes it? In one sense, the answer is obvious: a specific trauma. Yet this is only part of the story, because not everyone who is raped or badly beaten up develops PTSD. Of the contemporary psychological attempts to answer that question, the most influential is the one formulated by the clinical psychologists Anke Ehlers and David Clark at the University of Oxford.

They argue that PTSD develops when the person believes they are still seriously threatened by the trauma they have experienced. Why should someone assume they are still endangered by an event that happened months or even years previously? Ehlers and Clark identify two factors.

First is a negative interpretation of the trauma and the normal feelings that follow, for example believing that “nowhere is safe”, “I attract disaster”, or “I can’t cope with stress”. These interpretations can make the person feel in danger physically (the world seems unsafe), or psychologically (their self-confidence and sense of well-being feel irreparably damaged).

Second are problems with the memory of the trauma. Partly because of the way the person experiences the event, the memory somehow fails to acquire a properly developed context and meaning. As a result, it constantly intrudes. Ehlers and Clark liken the traumatic memory to “a cupboard in which many things have been thrown in quickly and in a disorganised fashion, so it is impossible to fully close the door and things fall out at unpredictable times”.

These factors change the way people behave. They may avoid situations that might spark a memory of the trauma, and will sometimes try to deaden their feelings with drink or drugs. Yet these strategies tend to entrench and exacerbate the problem.

PTSD can be treated with antidepressants or various kinds of psychotherapy, including prolonged exposure therapy and eye movement desensitisation and reprocessing. However, a recent meta-analysis of 112 studies conducted over the past 30 years found that cognitive behavioural therapy (CBT) was the single most successful type of treatment.

CBT typically comprises three main strands. First, it evaluates the individual’s excessively negative thoughts about the trauma and its aftermath – for example by helping them understand that they are not to blame or that their feelings are normal and natural. Second, the treatment works on the person’s memory of the trauma: the individual might be asked to write a detailed account of the event; relive it in their imagination; revisit the site of the trauma; or be shown how to cope with the kind of objects or situations that trigger the traumatic memory.

The final strand involves tackling the kind of behaviours that tend to fuel PTSD, for example by demonstrating that attempting to suppress a thought is futile (if you doubt it, try right now not to think of a white bear) or that avoiding a situation only strengthens one’s fear.

A course of CBT for PTSD normally involves meeting with a therapist once or twice a week over several months. Given how debilitating the problem can be, that can seem like a very long time to wait to get one’s life back on track. However, pioneering research published in last month’s issue of The American Journal of Psychiatry suggests that there may be an alternative. Instead of months, it may be possible to tackle the symptoms of PTSD in just seven days.

Anke Ehlers at the University of Oxford and her colleagues randomly assigned 121 patients with PTSD (about 60% female, 40% male) either to a seven-day course of intensive CBT; weekly sessions of CBT for three months; a type of psychotherapy known as emotion-focused supportive counselling; or to a 14-week waiting list. Participants in the first three groups all received the same amount of therapy (18 hours).

The results were striking. The intensive CBT proved almost as successful as the standard three-month course, with respective recovery rates from PTSD of 73% and 77%, and the intensive version produced its effects more quickly. For the supportive counselling group, recovery was 43% (another finding that undermines the idea that all types of psychotherapy are equally effective). Among the waiting list group, just 7% had recovered. Both courses of CBT also led to large reductions in levels of anxiety and depression.

Most importantly, the benefits lasted: 40 weeks after entering the study, about two-thirds of the CBT patients were still free from the symptoms of PTSD. The therapy isn’t easy – it confronts highly distressing events and feelings, after all – but it works.

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A third of first-time mothers suffer depressive symptoms, research finds

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baby, Children, Depression, depressive symptoms, diagnosis, early years, first-time mothers, four years postpartum, GPs, health professionals, health visitors, irritable, low mood, maternal health, mental health issues, midwives, mothers, new mothers, parents, Postnatal Depression, postpartum, pregnancy, risk, signs, tearful, training, worrying

A third of first-time mothers suffer depressive symptoms, research finds

One in three first-time mothers suffers symptoms of depression linked to their baby’s birth while pregnant and/or during the first four years of the child’s life, according to research.

And more women are depressed when their child turns four than at any time before that, according to the study, which challenges the notion that mothers’ birth-related mental struggles usually happen at or after the baby’s arrival.

The findings have led to calls for all women giving birth in the UK to have their mental health monitored until their child turns five to ensure that more of those experiencing difficulties are identified.

The results are based on research in Australia, but experts believe that about the same number of women in the UK experience bouts of mental ill-health associated with becoming a mother.

In all 1,507 women from six hospitals in Melbourne, Australia, told researchers from the Murdoch children’s research institute and royal children’s hospital in Parkville, Victoria, about their experience of episodes of poor mental health at regular intervals until their child turned four.

The authors found that almost one in three first-time mothers reported “depressive symptoms on at least one occasion from early pregnancy to four years postpartum [and that] the prevalence of depressive symptoms was highest at four years postpartum”. The women’s depressive symptoms are often short-lived episodes and do not mean that the women were diagnosed with postnatal depression. Studies in both the UK and internationally have estimated that between 10% and 15% of new mothers suffer from that clinical condition.

The researchers also found that four years after the child’s birth 14.5% display depressive symptoms, of whom 40% had not previously reported feeling very low. At that time, women with only one child were much more likely (22.9%) than those with two or more offspring (11.3%) to be depressed.

Dr Jim Bolton, a member of the Royal College of Psychiatrists and a consultant psychiatrist at a London hospital, said that one in three women giving birth in the UK were likely to become depressed at some point during those first four years. “If a similar study was done here, I wouldn’t be surprised if the results were similar. Usually the sorts of mothers who are at greater risk of depression are younger mothers who feel they can’t cope and mothers living in situations of adversity or deprivation or partner violence,” he said.

“These findings are about depressive symptoms, which can be very short-lived, not a formal diagnosis of illness or postnatal depression. This study isn’t saying that one in three women gets that,” stressed Bolton, who treats mental health problems in pregnancy and after birth among new mothers in his hospital’s women’s health unit.

The authors recommend that the UK overhauls its monitoring of maternal mental health, which focuses on pregnancy and the early years after birth, because more than half the women who experience depression after becoming a parent are not identified by GPs, midwives or health visitors.

More women could have postnatal depression than the usual estimate of 10%-15% partly because women may mistake the signs of it – which include being more irritable than usual or unusually tearful, inability to enjoy being a parent or worrying unduly about the baby’s health – as being things undergone by all new mothers.

Health professionals do not always spot it or ask the right questions to identify it, though are far more aware of it than ever, Bolton added.

One leading psychiatrist said that the one in three women who had depressive symptoms was between two and five times higher than the estimated number of people in the general population who would experience serious low mood in their lifetime, but was higher than the number of women who experienced the most severe forms of depression. Between 5%-10% of people generally suffer major/serious depression during their lifetime.The study, published in BJOG: An international journal of obstetrics and gynaecology, is the first to follow a sizeable number of new mothers for as long as four years after birth. Elizabeth Duff, senior policy adviser at the parenting charity the NCT, said: “This study has included mothers for four years after birth, so suggests that perinatal mental health needs to be monitored for a longer period. Given the devastating effects of postnatal depression, health professionals should give equal consideration to the mental and physical health of parents with young children.”

A Department of Health spokeswoman said it welcomed any new research that would lead to women receiving better help with maternal depression.

“We want to do everything we can to make sure women and families get as much support as possible throughout pregnancy and beyond. That’s why, earlier this month, we announced that expert training in mental health will be rolled out for doctors and midwives to identify and help women who are at risk of depression or other mental health issues,” she said.

Numbers of midwives and health visitors have been growing under the coalition, while specialist mental health doctors and midwives will help improve earlier diagnosis of such problems, she added. However, the Royal College of Midwives said that even more midwives were needed to ensure mothers received the best possible care of their psychological welfare.