Preface

One of my most nurse clients once told me in therapy; "When you have an abscess you know the source of the pain, you can get at it and remove it at source. When you have a wound on the body you know the source of the pain and you can get at the source and remove it. This pain of mental illness is different. You know the pain is there and it is real but you do not know where the source is and cannot get at it." Yes the pain of emotional illness is real and it is there deep inside our clients. Psychiatrists and other mental health professionals grapple with the problem of emotional pain on a daily basis. Unfortunately our understanding of how mental health problems arise is not yet adequate. Our only diagnostic gold standard in psychiatry remains the psychiatric interview and this can unfortunately be very subjective. There are multiple theories of causation and there is no single proven magic therapeutic bullet that can help our clients. In this volume titled: *Post-traumatic Stress Disorder in a Global Context*, authors from around the world share their valuable insights, knowledge, experience, and research in the hope that mental health practitioners gain a better understanding of this special mental disorder, post-traumatic stress disorder (PTSD) that arises after individuals are exposed to severe, terrifying, and horrifying experiences that threaten their safety, life, or integrity.

The pain of what has evolved to be known as post-traumatic stress disorder is peculiar. A common factor in the origins of PTSD appears to be an injury to the inner integrity of its victims, which psychoanalysts refer to as narcissistic injury. Author Corrine Anna Bissouma from Ivory Coast refers to this narcissistic injury as a "wound in the mind" to make it easier for her community of former child soldiers to understand what she means in her communications with them and their caregivers. What makes PTSD peculiar is the fact that it is often caused by people who are close to us; those we rely on everyday in our households; the people that we place our inner most trust in; the people that we believe cannot betray us; the people who are significant to us and are the reason we possibly exist. As humans even though most people may not be close to us in terms of their not being our family members, we still expect that they should not violate our integrity and cause emotional pain in us for whatever reason.

In the course of time psychiatrists from as early as Sigmund Freud have identified two major origins of PTSD; i.e. those arising secondary to the experience of natural

#### X Preface

disasters, and the ones that result from traumatic experiences in our interactions with each other. Freud particularly traced the origins of neurosis to the sexual violations of young children by their own adult kin. The commonplace experience of traumatic experiences, whether natural or manmade, makes one wonder if traumatic stress is in fact not the initial common pathway through which all major psychiatric disorders including post-traumatic stress disorder arise. After all according to Sigmund Freud, neurosis arising from childhood experience of sexual abuse, and sexual and physical childhood abuse, continues to be cited as one of the leading causes of mental health problems such as depression, suicide behavior, and post-traumatic stress disorder.

Preface XI

**Emilio Ovuga, MD PhD** 

Uganda

Professor of Mental Health and Dean,

Gulu University Faculty of Medicine, Northern Uganda, Gulu,

significant other members of the individual's immediate community is essential; recognition and management of PTSD at the time of cancer diagnosis as a vital component of palliative care is recommended. The development of PTSD in stroke as a significant cause of sudden and unexpected disability and potential lifelong dependence on other individuals is understandable. Finally Dr Wang has presented a carefully chosen set of research results that clearly highlight the long-term effects of exposure to earthquake on individuals and offspring of victims many years after

exposure.

The authors of *post-traumatic Stress Disorder in a Global Context* present a wide array of information that practitioners will find useful in understanding PTSD in practice. Carefully chosen, each chapter blends in with the others without unnecessary repetition and redundant overlaps. The book is divided into four sections. Section I provides an overview of PTSD as is currently understood. Dr Prasad Amarendra provides an overview of clinical features and current management approaches while Banister and associates present the history, prevalence, etiology, treatment, and comorbid disorders in PTSD related to combat situations. Dr Richardson and associates describe the military related psychiatric management of PTSD. Section II describes etiologic theories and risk factors for PTSD. Dr Kevin provides an interesting animal model of how avoidant behavior in PTSD is actively acquired, and highlights strain and sex differences in the acquisition process. Dr Yukata brings research-based data indicating the need for clinicians to screen accident victims for PTSD, as the emotional reactions of accident victims to their experience and their heart rate predict the potential development of post-traumatic stress disorder after motor vehicle accidents. Dr Ask and Dr Christiansen describe sex differences in the manifestation of post-traumatic stress disorder among males and females while Dr Chou attributes the development of post-traumatic stress disorder to the complex interaction of individual's biologic, psychological, environmental, and social factors, and low resource availability that predispose the vulnerable individual with sub-threshold psychiatric disorder to the full manifestation of post-traumatic stress disorder. In section III Dr Bissouma describes the invaluable role of social and community support in the rehabilitation of former child soldiers in Ivory Coast. Dr Ovuga and Dr Larroque describe the precarious situation of children in northern Uganda who live in abject poverty and social adversity with significant levels of aggression in the daily lives of the children four years after active war in the region ceased. Dr Ovuga and Dr Larroque further provide possible evidence of post-traumatic stress disorder across the lifespan related to exposure to trauma not only in military but also civilian situations in northern Uganda and Southern Africa. Using clinical vignettes, Dr Ovuga and Dr Larroque describe the difficulties in the recognition of post-traumatic stress disorder in clinical practice. In Section IV research in special situations suggests that post-traumatic stress disorder can indeed present in malignant disease (Dr Tacon), after stroke (Dr. Norman) and after exposure to earthquake (Dr Wang). Awareness of any malignancy as a significant cause of traumatic stress for the sufferer, family and significant other members of the individual's immediate community is essential; recognition and management of PTSD at the time of cancer diagnosis as a vital component of palliative care is recommended. The development of PTSD in stroke as a significant cause of sudden and unexpected disability and potential lifelong dependence on other individuals is understandable. Finally Dr Wang has presented a carefully chosen set of research results that clearly highlight the long-term effects of exposure to earthquake on individuals and offspring of victims many years after exposure.

X Preface

disasters, and the ones that result from traumatic experiences in our interactions with each other. Freud particularly traced the origins of neurosis to the sexual violations of young children by their own adult kin. The commonplace experience of traumatic experiences, whether natural or manmade, makes one wonder if traumatic stress is in fact not the initial common pathway through which all major psychiatric disorders including post-traumatic stress disorder arise. After all according to Sigmund Freud, neurosis arising from childhood experience of sexual abuse, and sexual and physical childhood abuse, continues to be cited as one of the leading causes of mental health problems such as depression, suicide behavior, and post-traumatic stress disorder.

The authors of *post-traumatic Stress Disorder in a Global Context* present a wide array of information that practitioners will find useful in understanding PTSD in practice. Carefully chosen, each chapter blends in with the others without unnecessary repetition and redundant overlaps. The book is divided into four sections. Section I provides an overview of PTSD as is currently understood. Dr Prasad Amarendra provides an overview of clinical features and current management approaches while Banister and associates present the history, prevalence, etiology, treatment, and comorbid disorders in PTSD related to combat situations. Dr Richardson and associates describe the military related psychiatric management of PTSD. Section II describes etiologic theories and risk factors for PTSD. Dr Kevin provides an interesting animal model of how avoidant behavior in PTSD is actively acquired, and highlights strain and sex differences in the acquisition process. Dr Yukata brings research-based data indicating the need for clinicians to screen accident victims for PTSD, as the emotional reactions of accident victims to their experience and their heart rate predict the potential development of post-traumatic stress disorder after motor vehicle accidents. Dr Ask and Dr Christiansen describe sex differences in the manifestation of post-traumatic stress disorder among males and females while Dr Chou attributes the development of post-traumatic stress disorder to the complex interaction of individual's biologic, psychological, environmental, and social factors, and low resource availability that predispose the vulnerable individual with sub-threshold psychiatric disorder to the full manifestation of post-traumatic stress disorder. In section III Dr Bissouma describes the invaluable role of social and community support in the rehabilitation of former child soldiers in Ivory Coast. Dr Ovuga and Dr Larroque describe the precarious situation of children in northern Uganda who live in abject poverty and social adversity with significant levels of aggression in the daily lives of the children four years after active war in the region ceased. Dr Ovuga and Dr Larroque further provide possible evidence of post-traumatic stress disorder across the lifespan related to exposure to trauma not only in military but also civilian situations in northern Uganda and Southern Africa. Using clinical vignettes, Dr Ovuga and Dr Larroque describe the difficulties in the recognition of post-traumatic stress disorder in clinical practice. In Section IV research in special situations suggests that post-traumatic stress disorder can indeed present in malignant disease (Dr Tacon), after stroke (Dr. Norman) and after exposure to earthquake (Dr Wang). Awareness of any malignancy as a significant cause of traumatic stress for the sufferer, family and

#### **Emilio Ovuga, MD PhD**

Professor of Mental Health and Dean, Gulu University Faculty of Medicine, Northern Uganda, Gulu, Uganda

**Part 1** 

**Overview of Clinical Aspects**

**Part 1** 

**Overview of Clinical Aspects**

**1** 

*India* 

Amarendra Narayan Prasad *Ministry of Defence (Indian Army),* 

**Post Traumatic Stress Disorder – An Overview** 

Posttraumatic stress disorder (PTSD) is a severe anxiety disorder that can develop after exposure to any event that result in psychological trauma. This event may involve the threat of death to oneself or to someone else, or to one's own or someone else's physical, sexual, or psychological integrity, overwhelming the individual's ability to cope. As an effect of psychological trauma, PTSD is less frequent but more enduring than the more commonly seen acute stress response. Post-traumatic Stress Disorder (PTSD) is a persistent and sometimes crippling condition and develops in a significant proportion of individuals exposed to trauma, and untreated, can continue for years. Its symptoms can affect every life

Posttraumatic stress disorder (PTSD) was first introduced into the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980, making it one of the more recently accepted psychiatric disorders. PTSD is one of the few DSM diagnoses to have a recognizable etiologic agent, in that it must develop in direct response to a severe (sudden, terrifying, or shocking) life event (American Psychiatric Association 2000). Since the introduction of PTSD into DSM-III (American Psychiatric Association 1980), the disorder has been documented in children exposed to traumas such as domestic violence, natural disasters, medical trauma (such as hospitalization or medical procedures performed on children), war, terrorism, and

According to the American Psychological Association, posttraumatic stress disorder (PTSD) is defined as "an anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. Traumatic events that may trigger PTSD include violent personal assaults, natural or human-caused disasters, such as terrorist attacks, motor vehicle accidents, rape, physical and sexual abuse, and other crimes,

PTSD is a problem in which the human brain continues to react with nervousness after the horrific trauma even though the original trauma is over. Brain can react by staying in "overdrive" and being hyperalert in preparation for the next possible trauma. Sometimes the brain continues to "remember" the trauma by having "flashbacks" about the event or

Reports of battle-associated stress reactions appeared as early as the 6th century BC. One of the first descriptions of PTSD was made by the Greek historian Herodotus. In 490 BC

domain – physiological, psychological, occupational, and social.

nightmares even though the trauma was in the past.

**1. Introduction** 

community violence.

or military combat [1]."

**2. Historical background** 
