Posttraumatic Stress Disorder (PTSD)

Question

Essay question: Critique the scientific literature on ONE of the following traumatic stressors – road accidents, sexual assault, or work-related death (fatalities). 1. What are the functional limitations that a person with PTSD resulting from the stressor may experience? 2. What are the main interventions referred to in the literature and how do they align to the Australian guidelines for the treatment of PTSD? Essay structure: Question 1: functional limitations – answers from all articles. Question 2: interventions & Australian guidelines – answers from all articles. Draw from the review the information on limitations and interventions, and then compare the interventions with the Australian Guidelines Note: 1. Copies of EIGHT of the abstracts of articles used to write the essay must be attached. 2. Please make sure that the references used are relevant to the topic and are genuine referred articles from a database (published in a journal or e-journal). 3. ALL 13 references must be relevant, up to date, and genuine referred articles (NOT information directly from websites!). 4. Referencing – please use APA 5th. 5. In-text referencing is required. 6. The word count is 2500 words maximum.

Answer

Post-Traumatic Stress Disorder is an anxiety-related condition that develops after one is exposed to a terrifying ordeal or event in which grave physical harm occurs or is threatened. Traumatic events that can trigger PTSD include human-caused or natural disasters, violent personal assaults, military combat or accidents. This paper critiques the existing scientific literature on road accidents, one of the most traumatic stressors in PTSD. The various functional limitations of a person with PTSD that result from road accident experiences are highlighted. The interventions discussed in the literature are assessed for alignment with the existing Australian guidelines for PTSD treatment.

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Holeva, Tarrier& Wells(2005) carried out a study to determine the prevalence of post-traumatic disorder (PTSD) and acute stress disorder (ASD) following road traffic accidents. The study focused on prospective and cross-sectional relationships between this prevalence and thought-control strategies. An assessment was made on 434 consecutive admissions to various accident and emergency clinics. This assessment lasted for four weeks following the RTA (road traffic accidents). Of these victims, 265 were reassessed for 6 additional months.

            Twenty-one percent of all the victims met the ASD symptom criteria during the initial assessment. Four to six months after the accidents, 23% of the victims met the PTSD criteria. These results agree closely with those done in other studies that recruited similar populations in an exactly similar manner (Holeva, Tarrier & Wells, 2005). In this study, those subjects who were considered to be suffering from ASD during the initial assessment were 20 times more likely to be classified among PTSD sufferers after follow-ups were done. The results of this research were as predicted, meaning that they conform to the models of trauma whereby persistent disorders are characterized by inhibition of emotional processing.

In a related study, Fuglsang & Moergeli (2005) assessed the morbidity rate of post-traumatic stress disorder and acute stress disorder. This research was in the form of a self-report survey whereby variance in levels of PTSD and ASD symptoms was assessed. Ninety patients were involved in the longitudinal self-report survey. The Acute Stress Disorder Scale and the Post-traumatic diagnostic scale were used to assess the PTSD condition as part of a 6-8-month follow-up. Twenty-five patients satisfied the requirement of the ASDS (28%). Fifty percent of the patients who were noted to have ASD later developed awfully high levels of PTSD symptoms. The 35% of the variance in the ASD level of symptoms was explained using a three-variable model. The acute level of traumatic symptom represents an explanation of a large part of the variance in symptoms of PTSD.

The results of Fuglsang & Moergeli’s (2005) study reflect the problems that have already been voiced with regard to PTSD diagnosis. A lack of precision was noted with regard to the prediction of the development of PTSD after a road accident. The level of acute traumatic symptoms explains the variance in the level of PTSD symptoms. However, many other variables play a significant role, as well.

Ongecha-Owuor & Kathuku (2005) sought to determine the prevalence rate of PTSD and various associated factors among survivors of motor vehicle accidents at Kenyatta National Hospital, Nairobi. The cross-sectional study involved 197 adult male and 67 female patients. Overall, the prevalence rate of PTSD turned out to be 13.3%. None of these cases had been diagnosed with PTSD previously. The rate of PTSD prevalence was higher than that of males.

Other significant risk factors included experiencing motor vehicle accidents for the first time and having post-primary education. Other medical illnesses were also a risk factor in the prevalence of PTSD. The type of accident, immediate reaction, and role/status turned to be insignificant. Ongecha-Owuor & Kathuku (2005) suggested that a multidisciplinary approach should be adopted in the management of survivors of RTA at trauma and orthopedic clinics. Such a form of care is an absolute necessity if their psychological and physical needs are to be sufficiently met.

Mather & Tate (2005) admit that controversy still exists about the issue of PTSD and the role of TRA in as a PTSD risk factor. In a study of PTSD and road traffic accidents, Mather & Tate (2005) examined the course, frequency, and co-morbidity of PTSD among children sustaining TBI (traumatic brain injury) after road traffic accidents. The researchers interviewed 43 children together with their parents six weeks after the traffic accident, in an effort to assess PTSD and associated symptoms. Fourteen children had mild TBI while 29 had not TBI.

Symptoms of PTSD were noted in both the children with TBI and those without this condition. In the initial assessment, 74% of all the children were classified as PTSD symptomatology that is significant. General anxiety was a dominant symptom in both groups. At follow-up, the PTSD symptomatology decreased to 44%. No correlation between parental support and PTSD symptomatology was noted.

PTSD symptomatology remains a very common consequence of traffic accidents among children, although TBI is not a risk factor for this condition. Mather & Tate (2005) underscored the importance of systematic assessment and the implementation of ofmultifaceted intervention strategies for treating children with PTSD.

According to Matthews (2005), poor work outcomes among people with PTSD following road traffic accidents can be improved through clinical treatment programs. These programs should be implemented in the form of a referral to various occupational rehabilitation programs and early interventions. Mather & Tate’s (2005) studied participants who were working prior to suffering road accidents. The participants were in their post-accident phase, whereby the mean duration after the accidents was 8.6 months.

The results of the study indicated that survivors without PTSD had more work potential than those with PTSD. The most significant barriers to employability among survivors with PTSD include reduced time-management ability, high levels of depression and over-concern with physical injuries. However, respondents with PTSD said they were more intrinsically motivated compared to those without PTSD.

According to Meiser-Stedman & Yule (2005), acute stress disorder as a predictor of later PTSD among adolescents and children. However, the utility of dissociation as a predictor of PTSD has questionable utility. In their study, Meiser-Stedman & Yule interviewed 93 patients aged between 10 and 16 years, who had encountered road accidents and assaults.

Bryant & Mayou (2006), in the background to their study, indicate that little is known about behavioral and psychological consequences of road accidents for adolescents and children. In the one-year cohort study, children aged between 5 and 16 years were interviewed. The interview was complemented with medical notes and self-reports generated after three months. The physical outcome of the children after 3 months was excellent since only 15% and 25% respectively suffered from PTSD. After six months, the number suffering from PTSD had dropped to 18%. Following the research’s outcomes, Bryant & Mayou (2006), recommended that changes need to be put in place in order for distressing and disabling problems to be prevented, identified and treated.

Kenardy & Spence (2006) observe that children who have previously suffered from any form of accidental injury have an increased risk of getting PTSD. It is essential that the right strategies are put in place in order for those children at a high risk of developing PTSD symptomatology to be identified. Kenardy & Spence (2006) found the Child Trauma Screening Questionnaire to be a quick tool of cost-effectively aiding in the prevention of PTSD among children after road traffic accidents. This questionnaire functions most effectively if it is used between one and six months after the traumatic accident.

Harmsa (2006) highlights four main themes of recovery among PTSD sufferers: the privacy of suffering, finding a new fit, survivor pride and anticipatory coping. The themes are the result of three-year research of survivors of major road accident survivors. The aim of the research was to examine the way in which survivors of a road traffic accident at the Victorian rehabilitation understand their traumatic experiences.

The themes were uncovered within an ecological framework, where the focus was on the subjective and psychosocial factors that determine the rate of recovery. The subjectivity of the issues was presented in the form of perceptions of trauma, the recovery resources, and future coping mechanisms.

Winston (2006) concurs with Bryant & Mayou’s (2006) observation that one of the fiercest challenges faced in handling children and parents with PTSD is the lack of enough information on the psychological responses that take place after the traumatic encounters. Therefore, it becomes very difficult for adverse responses to be identified early enough.

One month after the road traffic accident, individuals may display avoidance, re-experiencing, hyper-arousal symptoms and dissociation. Dissociation may take the form of feelings of emotional numbing and unreality. Pediatric care providers should expect to see some acute stress syndrome symptoms in parents and children immediately after traffic-related injury (Winston, 2006). Some brief education is needed in the form of the explanation that these symptoms are merely normal functional limitations that are likely to subside within a short time.

Winston (2006) observes that today, pediatric traffic crashes are very common in Australia; although the level of diagnosis of PTSD still remains very low. For this reason, it seems as if probing recent crash exposures is an important part of the routine for maintenance of a child’s health. For instance, pediatricians need to call the family some days after the traffic injury in order to enquire about the family function and the child’s behavioral symptoms. This measure should be taken with the emphasis being put on the close physician-patient relationship, whereby an accurate assessment is made on the seriousness of the symptoms and the intensity of functional limitation in the injured child (Winston, 2006). The impact of the crash on the family should also be put into consideration. Whereas it is important to discuss such issues with parents, in the Australian guidelines, it is unacceptable to force parents to talk about the ordeal.

Cognitive-behavioral therapy, according to Blanchard& Hickling (2006), is better for dealing with chronic PTSD than supportive psychotherapy. On the other hand, the supportive psychotherapy approach was noted to be more effective than the Wait List control condition that contained two detailed assessments. The same results were produced when categorical diagnostic data were used (Winston, 2006). This finding has very significant implications in the way PTSD issues are handled in the Australian healthcare system. Although all three approaches are used in the management of PTSD, preference is not given to each of them depending on the aspect of effectiveness.

Yutaka (2008) did a study of injured patients in order to assess both the onset of psychiatric illness after motor vehicle accidents in Japan in comparison with Western data and predictors of PTSD. The predictors of psychiatry were also assessed in this study, whereby evaluation was done immediately after the traumatic event. It was found out that PTSD and psychopathology after traffic accidents in Japan is very common and that the incidence of these events is within the range that has been reported in western counties.

Such findings are very necessary for this era of evidence-based treatment, especially for a country like Australia where guidelines for the treatment of PTSD and ASD have been developed. The guidelines, which were developed by (ACPMH) Australian Centre for Posttraumatic Mental Health, were not meant to be a replacement of expert clinical advice. According to Winston (2006), failure to identify adverse responses among PTSD patients immediately after road traffic accidents are a major hindrance to medical interventions in Australia.

Instead of reflecting on the changes that continue to take place in terms of evidence-based research, the guidelines seem to be a reflection of the consensus that has been emerging on hour best to manage PTSD and ASD. A significant gap exists between routine clinical care and evidence-based PTSD treatment.

The PTSD-related complications highlighted by Holeva, Tarrier & Wells, (2005), Fuglsang & Moergeli (2005), and Mather & Tate (2005), have a direct significance on the healthcare interventions being carried out in Australia today. Holeva, Tarrier & Wells (2005) highlight the critical role of follow-ups after the initial tests are done following road traffic accidents.

The Australian guidelines can be summarized into two main categories: psychological and pharmacological interventions. From a psychological perspective, adults with PTSD need to be provided with trauma-focused interventions. The various elements of cognitive-behavior therapy to be considered include Eye Movement Desensitization, reprocessing and Vivo exposure. Non-trauma-focused interventions, including relaxation and supportive counseling, are not supposed to be provided to PTSD adults at the expense of trauma-focused interventions.

Schnyder & Wittmann’s (2008) research supports the pharmacological interventions provided for in the Australian guidelines for the treatment of PTSD and ASD. The symptoms observed by Schnyder & Wittmann (2008) in their research six months after the road accident are the ones that are used to derive the pharmacological insights for PTSD patients.

Early intervention is one of the measures that are emphasized in the Australian guidelines, in which case, psychological debriefing on a daily basis is discouraged. Immediately after a traumatic event, practitioners should carry out a ‘psychological first aid’. This first aid normally takes the form of monitoring of the victim’s mental state, encouraging the use of social support, provision of emotional support, and self-care strategies.

However, Schnyder & Wittmann (2008) indicate that PTSD and ASD do not occur frequently following road accident injuries, the way it had previously been reported in the literature. This is contrary to the advice offered by the Australian Guidelines, whereby early intervention is emphasized.

            In conclusion, posttraumatic Stress disorder (PTSD) following road traffic accidents continues to be a major health challenge for both adults and children. In the Australian healthcare setting, efforts to deal with the PTSD challenge have led to the creation of guidelines on how the condition should be managed. Two main issues are highlighted in these guidelines: (a) the best time for psychological and pharmacological interventions, and (b) the best approach for helping PTSD sufferers. An important cautionary measure highlighted at the outset is the fact that these guidelines should not take the place routine evidence-based clinical procedures.

Recent literature on PTSD interventions contradicts the guidelines with regard to the timing of interventions. Earlier on, medical literature, on which the guidelines were based, hinted on the need to embark on the need for early psychological and pharmacological interventions. However, Schnyder & Wittmann’s (2008) findings indicate otherwise. More research is needed on the nature of the PTSD interventions needed and the right timing for them to be carried out.

References

Blanchard, E. & Hickling, E. (2006) A controlled evaluation of cognitive-behavioral therapy for posttraumatic stress in motor vehicle accident survivors, Behaviour Research and Therapy, 41(1),  79-96

Bryant, B. & Mayou, R.  (2004) Psychological consequences of road traffic accidents for children and their mothers, Psychological Medicine 34(2), 335-346

Fuglsang, A, Moergeli, H. (2004) Does acute stress disorder predict post-traumatic stress disorder in traffic accident victims? Analysis of a self-report inventory, Nordic Journal of Psychiatry, 58(3), 223 – 229

Harmsa, L. (2004) After the accident: Survivors’ perceptions of recovery following road trauma, Australian Social Work, 57(2), 161 – 174

Holeva, V. Tarrier, N. & Wells, A. (2005) Prevalence and predictors of acute stress disorder and PTSD following road traffic accidents: Thought control strategies and social support, Behavior Therapy, 32(1), 65-83

Kenardy, J.  & Spence, S.  (2006) Screening for Posttraumatic Stress Disorder in Children after Accidental Injury, Pediatrics, 118(3), 1002-1009

Matthews, L.  (2005) Work potential of road accident survivors with post-traumatic stress disorder, Behaviour Research and Therapy, 43(4), 475-483

Mather, F.   Tate, R. (2003) Post-traumatic stress disorder in children following road traffic accidents: a comparison of those with and without mild traumatic brain injury, Brain Injury, 17(12), 1077 – 1087

Meiser-Stedman, R.  & Yule, W. (2005) Acute Stress Disorder and Posttraumatic Stress Disorder in Children and Adolescents Involved in Assaults or Motor Vehicle Accidents, American Journal of Psychiatry, 162, 1381-1383.

Ongecha-Owuor, F. &  Kathuku, D. (2005) Post-traumatic stress disorder among motor vehicle accident survivors attending the orthopedic and trauma clinic at Kenyatta National Hospital, Nairobi, East African Medical Journal, 81(7), 362-366

Schnyder, U. & Wittmann, L. (2008) Posttraumatic Stress Disorder following Accidental Injury: Rule or Exception in Switzerland?, Psychother Psychosom 77, 111-118

Stallard, P. Salter, E. & Velleman, R. (2007) Posttraumatic stress disorder following road traffic accidents, European Child & Adolescent Psychiatry, 13(3), 172-178

Winston, F. (2006) Acute Stress Disorder Symptoms in Children and Their Parents after Pediatric Traffic Injury, Pediatrics, 109(6), 90- 98.

Yutaka, M.( 2008), Incidence and prediction of psychiatric morbidity after a motor vehicle accident in Japan: The Tachikawa Cohort of Motor Vehicle Accident Study, Critical Care Medicine, 36(1), 74-80.