Sitting in my local with some friends last year, a story on the local evening news got our attention. A well-known local police officer, a ‘man’s man’ and all-round nice bloke, was facing charges for high-range drink-driving. His lawyer’s defence? ‘My client is suffering post traumatic stress disorder as a result of his work, and his maladaptive coping mechanism was to drink alcohol to escape the pain and distress he has been experiencing.’
The hotel quickly erupted with cynical abuse and criticism:
‘It’s just a weak excuse’
‘Tell him to toughen up and take responsibility for his own behaviour’
‘He knew what he was getting himself into when he became a copper’
Not a New Phenomenon
The reality is, however, post traumatic stress disorder (PTSD) is a very real phenomenon. It’s not a new ‘fad’ or a ‘cosmetic diagnosis’ invented by pharmaceutical companies to push the increased use of medication, or by barristers as an excuse to get people off serious charges in court.
Although you may have only heard of PTSD a relatively short time ago, it’s a phenomenon that we’ve been aware of and investigating since the late nineteenth century. Soldiers surviving the American Civil War who presented with cardiac symptoms but had a healthy heart were diagnosed with DaCosta’s Syndrome (Oglesby 1987).
Other diagnoses post-war included neurological explanations such as shell shock and war neurosis (Crocq & Crocq 2000). In civilian populations, one term that was coined was railway spine to describe survivors of train accidents who were incapacitated despite not being physically injured (Bynum 2001). Later descriptions of this phenomenon included rape trauma syndrome, survivor syndrome and post-Vietnam syndrome (Figley 1985).
A Formal Diagnosis
By the late 1970s, we were ready to formalise these diagnoses under one name rather than names specific to an event, and post traumatic stress disorder became an established diagnosis. In 1980, in the American Psychiatric Association’s 3rd Edition of the Diagnostic and Statistical Manual, the stressor criterion was defined by the exposure to ‘a recognisable stressor that would evoke significant symptoms of distress in almost anyone’ (American Psychiatric Association 1980).
An Australian Perspective
According to the National Survey of Mental Health and Wellbeing, anxiety disorders are the biggest mental health condition in this country, with 14.4% of us meeting the diagnostic criteria for having an anxiety disorder, of which PTSD is one. Of that 14.4%, almost half is made up of people meeting the diagnostic criteria for having a diagnosis of post traumatic stress disorder (Australian Bureau of Statistics 2008).
In real terms this means that as a nurse or midwife, you are more likely to be looking after a client with PTSD (6.4%) than you are someone with depression (6.2%) or with a substance use disorder (5.1%). And the reality is, it’s not uncommon for a person with PTSD to also be living with depression, a substance use disorder, or both (Kitchener, Jorm & Kelly 2010).
Understanding and Treating PTSD
PTSD is complex. Anyone can develop it. It’s beyond their control and has nothing to do with their strength (or lack) of character, determination or inherent capabilities. The Australian Centre for Posttraumatic Mental Health describe it as:
‘A set of reactions that can develop in people who have experienced or witnessed an event which threatened their life or safety, or that of others around them, and led to feelings of intense fear, hopelessness or horror.’
(Australian Centre for Posttraumatic Mental Health 2011)
The person with PTSD may find themselves re-living the event when they don’t want to, being wound up or highly strung and avoiding any reminders of the event. These symptoms can be significantly disabling for the person.
The first line of treatment for PTSD is not medication. Medication can be used as an adjunct therapy to help manage some of the symptoms, but essentially what we want to use are psychological therapies, and these take time. The cornerstone of treatment requires confronting the traumatic memory with a qualified clinician (ACPMH 2011).
Nursing and PTSD
Nurses and midwives often find themselves in a dual role, managing the physical condition of their client or patient, which is their primary role (for example, an MVA survivor in an orthopaedic ward) as well as the mental and emotional health of the person, and this may well involve PTSD symptoms. So what can you do to support and assist this client?
There are three key areas where the nurse can help the client with PTSD during a hospital stay:
- Sleep disturbances: The first choice here is usually a benzodiazepine, however, if the client is already taking a benzodiazepine for anxiety symptoms, this may not be very effective. Another option is to use a low dose antipsychotic (Robert et al. 2005). This can be arranged by speaking to the registrar or consultant on the treating team, or better still, contacting your Psychiatric Liaison Team and requesting a review.
- Anxiety: Some of the anxiety symptoms that accompany PTSD include breathlessness, tachycardia, sweating, nausea and feeling on edge (ACPMH 2011). Making use of the other teams available in your hospital or service, such as psychologists and social workers, can significantly help to reduce these symptoms.
- Drug and/or alcohol withdrawal: It is not uncommon for the person with PTSD to self-medicate with a substance (MHFA 2010). Begin by asking your client or patient about recent use. Assure them you’re not judging them, but that you simply want to offer them the best possible care. Contact the Drug and Alcohol nurse or doctor in your service and request a review to avoid serious complications such as an acute alcohol withdrawal.
You may not be involved in the long-term treatment of the person with post traumatic stress disorder, but these simple interventions that you can offer will have a significant positive impact on them. And the old adage of ‘knowledge is power’ is crucial here. The more we research post traumatic stress disorder, the better our understanding will become, as well as the interventions we can offer, which will ultimately improve the life of the person and those around them.
Geoff Ahern is a Clinical Nurse Specialist in Dual Diagnosis (Mental Health and Drug and Alcohol) with a background working in Critical Care and Trauma. He has presented at Ausmed’s Mental Health: PTSD and Acute Stress Disorder in Adults Seminars for Nurses and Midwives.
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- American Psychiatric Association (APA) 1980, Diagnostic and statistical manual of mental disorders, 3rd edn, American Psychiatric Association, Washington, MD, USA.
- Australian Bureau of Statistics 2008, National survey of mental health and wellbeing, cat. no. 4326.0, ABS, Canberra.
- Australian Centre for Posttraumatic Mental Health 2011, Posttraumatic stress disorder (PTSD), Australian Centre for Posttraumatic Mental Health, viewed 21 November 2016, http://phoenixaustralia.org/
- Bynum, B 2001, ‘Railway spine’, The Lancet, vol. 358, no. 9278, p. 339.
- Crocq, M & Crocq, L 2000, ‘From shell shock and war neurosis to post traumatic stress disorder: a history of psychotraumatology’, Dialogues in Clinical Neuroscience, vol. 2, no. 1, pp. 47-55.
- Figley, C (ed.) 1985, Trauma and its wake: the study and treatment of post traumatic stress disorder, Taylor and Francis Group, Bristol.
- Kitchener, B, Jorm, A & Kelly, C 2010, Mental health first aid manual, University of Melbourne, Victoria, Australia.
- Oglesby, P 1987, ‘Da Costa’s syndrome or neurocirculatory asthenia’, British Heart Journal, vol. 58, pp. 306-15.
- Robert, S, Hamner, MB, Kose, S, Ulmer, HG, Deitsch, SE & Lorberbaum, J 2005, ‘Quetiapine improves sleep disturbances in combat veterans with PTSD: Sleep data from a prospective, open-label study’, Journal of Clinical Psychopharmacology, vol. 25, no. 4, pp. 387-8.
Geoff is a clinical nurse specialist in dual diagnosis (mental health and drug and alcohol) with a background working in critical care and trauma. His interest in trauma begun when working with survivors of the Kosovo Crisis at Holsworthy Army Barracks in Sydney in the '90s. He has since worked with a number of special needs groups in the area of trauma including troubled youth in Outback NSW, asylum seeker groups in Sydney, and clients with substance use disorders associated with trauma. Geoff also works with school groups to actively address bullying in the education system helping teachers, parents and support staff to understand the link between bullying and many of the contemporary mental health problems evident in our community, in particular anxiety and PTSD.