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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Mindfulness therapy comes at a high price for some, say experts

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anxiety, attention, breath, depersonalisation, Depression, health professionals, meditation, mindful living, mindfulness, mindfulness meditation, mindfulness therapy, mindfulness-based cognitive therapy (MBCT), NHS, side-effects, stress, teachers, training, trauma memories, vulnerability

Mindfulness therapy comes at a high price for some, say experts

In a first floor room above a gridlocked London street, 20 strangers shuffle on to mats and cushions. There’s an advertising executive, a personnel manager, a student and a pensioner. A gong sounds softly and a session of sitting meditation begins. This is one of more than 1,000 mindfulness courses proliferating across the UK as more and more people struggling with anxiety, depression and stress turn towards a practice adapted from a 2,400-year-old Buddhist tradition.

Enthusiasm is booming for such mindfulness-based cognitive therapy (MBCT) courses, which an Oxford University study has found can reduce relapses into depression by 44%. It is, say the researchers, as effective as taking antidepressants. It involves sitting still, focusing on your breath, noticing when your attention drifts and bringing it back to your breath – and it is surprisingly challenging.

Lifestyle magazines brim with mindfulness features and the global advertising giant JWT listed mindful living as one of its 10 trends to shape the world in 2014 as consumers develop “a quasi-Zen desire to experience everything in a more present, conscious way”.

But psychiatrists have now sounded a warning that as well as bringing benefits, mindfulness meditation can have troubling side-effects. Evidence is also emerging of underqualified teachers presenting themselves as mindfulness experts, including through the NHS.

The concern comes not from critics of mindfulness but from supporters, such as Dr Florian Ruths, consultant psychiatrist at the Maudsley hospital in south London. He has launched an investigation into adverse reactions to MBCT, which have included rare cases of “depersonalisation”, where people feel like they are watching themselves in a film.

“There is a lot of enthusiasm for mindfulness-based therapies and they are very powerful interventions,” Ruths said. “But they can also have side-effects. Mindfulness is delivered to potentially vulnerable people with mental illness, including depression and anxiety, so it needs to be taught by people who know the basics about those illnesses, and when to refer people for specialist help.”

His inquiry follows the “dark night” project at Brown University in the US, which has catalogued how some Buddhist meditators have been assailed by traumatic memories. Problems recorded by Professor Willoughby Britton, the lead psychiatrist, include “cognitive, perceptual and sensory aberrations”, changes in their sense of self and impairment in social relationships. One Buddhist monk, Shinzen Young, has described the “dark night” phenomenon as an “irreversible insight into emptiness” and “enlightenment’s evil twin”.

Mindfulness experts say such extreme adverse reactions are rare and are most likely to follow prolonged periods of meditation, such as weeks on a silent retreat. But the studies represent a new strain of critical thinking about mindfulness meditation amid an avalanche of hype.

MBCT is commonly taught in groups in an eight-week programme and courses sell out fast. Ed Halliwell, who teaches in London and West Sussex, said some of his courses fill up within 48 hours of their being announced.

“You can sometimes get the impression from the enthusiasm that is being shown about it helping with depression and anxiety that mindfulness is a magic pill you can apply without effort,” he said. “You start watching your breath and all your problems are solved. It is not like that at all. You are working with the heart of your experiences, learning to turn towards them, and that is difficult and can be uncomfortable.”

Mindfulness is spreading fast into village halls, schools and hospitals and even the offices of banks and internet giants such as Google. The online meditation app Headspace now has 523,000 users in the UK, a threefold increase in 12 months. But mounting public interest means more teachers are urgently needed and concern is growing about the adequacy of training. Several sources have told the Guardian that some NHS trusts are asking health professionals to teach mindfulness after only having completed a basic eight-week beginners’ course.

“It is worrying,” said Rebecca Crane, director of the Centre for Mindfulness Research and Practice in Bangor, which has trained 2,500 teachers in the past five years. “People come along to our week-long teacher training retreat and then are put under pressure to get teaching very quickly.”

Exeter University has launched an inquiry into how 43 NHS trusts across the UK are meeting the ballooning demand for MBCT.

Marie Johansson, clinical lead at Oxford University’s mindfulness centre, stressed the need for proper training of at least a year until health professionals can teach meditation, partly because on rare occasions it can throw up “extremely distressing experiences”.

“Taking the course is quite challenging,” she said. “You need to be reasonably stable and well. Noticing what is going on in your mind and body may be completely new and you may discover that there are patterns of thinking and acting and behaving that no longer serve you well. There might be patterns that interfere with living a healthy life and seeing those patterns can bring up lots of reactions and it can be too much to deal with. Unless it is handled well, the person could close down, go away with an increase in self-criticism and feeling they have failed.”

Finding the right teacher is often difficult for people approaching mindfulness for the first time. Leading mindfulness teaching organisations, including the universities of Oxford, Bangor and Exeter, are now considering establishing a register of course leaders who meet good practice guidelines. They expect mindfulness teachers to train for at least a year and to remain under supervision. Some Buddhists have opposed the idea, arguing it is unreasonable to regulate a practice rooted in a religion.

Lokhadi, a mindfulness meditation teacher in London for the past nine years, has regular experience of some of the difficulties mindfulness meditation can throw up.

“While mindfulness meditation doesn’t change people’s experience, things can feel worse before they feel better,” she said. “As awareness increases, your sensitivity to experiences increases. If someone is feeling vulnerable or is not well supported, it can be quite daunting. It can bring up grief and all kinds of emotions, which need to be capably held by an experienced and suitably trained teacher.

“When choosing a course you need to have a sense of the training of the teacher, whether they are supervised and whether they themselves practise meditation. Most reputable teacher training courses require a minimum of two years’ meditation practice and ensure that teachers meet other important criteria.”