Have you ever seen someone get killed

Post Traumatic Stress Disorder (1995)
Diagnosis and therapy of a widespread disease

Oliver Schubbe

Berlin, February 1995: A student sees her little child run into a car. A taxi driver is robbed. A bank employee is threatened by five armed robbers. But nobody is physically injured. The horror seems to be over.

May 1995: The student does not pass her exam because it is very difficult for her to concentrate. She is constantly afraid for her child. Night after night, the taxi driver wakes up bathed in sweat. He now works as a waiter so that he no longer has to think about the attack. The bank clerk remembers a previous rape that she thought she'd forgotten. All three people feel inexplicably tense. You are unsure: something is wrong.

Post-traumatic stress disorder is a widespread disease like diabetes or alcoholism. This stressful illness is caused by traumatic situations that happen thousands of times a day in a big city: work and traffic accidents, robbery, physical abuse and rape. Some people have been dragging the disease around with them since World War II or when they were imprisoned by the Stasi. Others bring them with them from acute war and disaster areas.

A remarkable number of people have the strength to cope with many a traumatic experience without medical help. A good quarter of traumatized people, however, develop the full picture of post-traumatic stress disorder. Characteristic symptoms are: recalling the traumatic event accompanied by fears, avoiding triggers of such memories, anxiety dreams, sleep disorders, reduced participation in social life and a multitude of vegetative stress symptoms.

"Post-traumatic stress disorder" is a new term that is still relatively unknown to the general public. Da Costa first observed this disease in an American Civil War soldier in 1871 (1). Terms coined at the time such as "irretable heart", "effort syndrome" and Da Costa syndrome are still used in some textbooks (2). In 1889 Oppenheim introduced the term "trauma" to neuropsychiatry (3). Later, the countless victims of National Socialism, but above all the veterans of the Vietnam War, triggered scientific research and political endeavors that led to the inclusion of PTSD (post-traumatic stress disorder) in the DSM-III in 1980.

Principles for the consultation with a doctor

1. Normality: Traumatized people quickly think that their reaction and they themselves are no longer completely normal. The doctor's job is to normalize the symptoms and help understand them as common reactions to an extraordinary event. He emphasizes that the symptoms can be very painful, confusing, and so unknown that even important caregivers cannot understand them.
2. Self-determination: People whose sense of security and personal dignity has been seriously violated initially tend to remain in the role of victim. To overcome the trauma, they need to regain access to their strengths and coping strategies. Patients therefore need opportunities to take control of their own life again and learn to shape it. Decisions about the form and course of treatment should be discussed in partnership with the patient and made jointly.
3. Individuality: Post-traumatic reaction patterns are as different as fingerprints. It is therefore important to pay attention to the specifics of the symptoms from the start and to create an individual treatment plan. The post-traumatic symptoms are so diverse that the PTSD category sometimes does not fit at all, even though there are severe consequences of the trauma. In other cases it is true, but there are also a number of other disorders present: phobias, dissociative disorders (4), depression, eating disorders, antisocial behavior, and suicidality.

The collaboration between general practitioners, trauma doctors, psychiatrists and psychotherapists is of crucial importance for the success of the treatment. Since the patients themselves often do not know who to turn to, it remains the doctor's responsibility to identify the disorder in good time. Otherwise, half of all untreated courses become chronic. Only psychotherapy that starts earlier than three months after the trauma can completely prevent the chronification.

Trauma therapy

Every recognized form of psychotherapy contains the basic "tools" for treating post-traumatic disorders. The psychotherapist creates a stable working alliance, creates a supportive framework for dealing with stressful content and enables patients to make informed decisions about the form of treatment.

Only at the beginning of such psychotherapy can it make sense to relieve severe panic attacks or sleep disorders with the help of psychotropic drugs, relaxation exercises or biofeedback. According to the current state of research (5), however, this has no curative effect. The "special tools" - procedures, which help to process and integrate the traumatic experience in a very targeted manner, have a curative and quick effect. For this it is important to desensitize the memory with the help of new learning stimuli or repeated visualization in order to finally give it an appropriate place in the patient's self-image and worldview. Over the past few years, such trauma therapeutic methods have come to be known under several abbreviations: TIR (Traumatic Incident Reduction) is a regressive method that draws on analytical and cognitive theories and that is structured but nevertheless client-centered (6). TFT (Thought Field Therapy) names characteristic points of the traumatic experience (change in breath, adrenaline rush, etc.) in the sequence experienced in order to fully address the memory.

The cognitively oriented EMDR (Eye Movement Desensitization and Reprocessing) has been scientifically best studied of these trauma therapy methods. EMDR is a structured, relaxing, and highly supportive method. Bilateral alternating stimuli (induced eye movements, tapping the hands, snapping the hands) restart the processing and integration of the traumatic experience and bring it to an end. While the client visualizes a memory and visualizes the associated self-message and body feeling, the therapist offers the alternating sensory stimuli (7). Processing is accelerated to such an extent that a significant and lasting improvement in symptoms can be observed after just three sessions (8). We are currently researching which elements of these methods are effective (9). Most of the severely suffering patients are neither aware of the help available, nor do their doctors recognize the unspecific psychological and psychosomatic complaints as untreated long-term consequences of trauma. As early as 1991, Dreßling and Berger (10) therefore demanded further training for rescue personnel and resident doctors for the German health system. Psychotherapists should only be used on site in special cases, but instead offer specialist advice and supervision to doctors working in primary care. Last but not least, newspapers and television are called upon to provide factual information on stress disorders in connection with disaster reports.

Medical Interview Guide (11)

1. Non-criminal events
So far, have you seen any events in which you were afraid of perishing or of being seriously injured?
Have you ever experienced situations in which you were seriously injured or physically impaired? Have you ever seen someone face serious injuries or death by force?
In particular, have you ever
- had a serious traffic accident or accident at work or the like?
- experienced a natural disaster - a strong hurricane, a flood disaster, earthquake or similar?

2nd murder
Losing a member of your family can be a major burden. Has anyone in your family or close circle of friends ever been killed, killed themselves, or been killed by a drunk driver?

3. rape
Many people, especially women, experience unwanted sexual advances. These experiences are often not shared with family and friends or the police. The person making the rapprochement is not always a stranger, but can also be a friend, partner, family member or colleague:
Has anyone previously used threats or violence to force you to have sex?
Has anyone previously forced you to have oral or anal intercourse?
Has anyone previously inserted objects into your vagina or anus using threats or violence?

4. Sexual harassment
In addition to the situations mentioned: Has anyone previously touched your breasts or their genitals under threats or violence, or allowed themselves to be touched in these areas?
Besides the situations discussed above, are there any other situations in which you have not been exposed to direct sexual contact, but in which you have been pressured to do so?

5. Physical violence
Another form of stressful events is physical violence. Aside from what you have described so far, has anyone - including family or friends - threatened you with a weapon, knife or other object? It doesn't matter how long ago the event was or if they viewed it. Has someone - including family or friends - attacked you physically without a weapon in order to kill or injure you?

Remarks:

  1. Andreasen, N. (1985): Post-traumatic stress disorder. In: Kaplan, H.I .; Sadock, B.J. (Ed.), Textbook of Psychiatry / IV, Vol. 1, 4th edition. Williams & Wilkins, Baltimore, 918-924.
  2. Harrison, T. (1980): Principles of Internal Medicine, 9th Edition. McGraw Hill, Auckland.
  3. Oppenheim, H. (1899): The traumatic neuroses: according to the observations collected in the psychiatric clinic of the Charité in the last 5 years. Hirschwald, Berlin.
  4. With the questionnaire on dissociative disorders (FDS), the validated German version of the tried and tested DES is finally available. Available from the Institute for Trauma Education and Therapy.
  5. Meichenbaum, D. (1994): A Clinical Handbook / Practical Therapist Manual for Assessing and Treating Adults with Post-Traumatic Stress Disorder. Institute Press, Waterloo, 295ff.
  6. Valentine, P. (in press): Traumatic Incident Reduction: A review of a new intervention. Journal of Family Psychotherapy.
  7. Shapiro, F. (1995): Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols and Procedures. Guilford Publications.
  8. Wilson, S.A .; Tinker, R.H .; Becker, L.A. (1994): Eye Movement Desensitization and Reprocessing (EMDR) - A Treatment Method for Traumatic Diseases. German version published by: Dr. Arne Hofmann, Am Gaßgang 5a, 61440 Oberursel, Fax / Tel. 06171/78803.
  9. Research from Florida State University's Psychosocial Stress Research Program, Prof. C. Figley
  10. Dreßling, H .; Berger, M. (1991): Post-Traumatic Stress Diseases. To the development of the current concept of disease. The neurologist 62, 13-26.
  11. Guide based on Resnick, H.S .; Falsetti, S.A., et al. (1994): Assessment of rape and other civilian trauma-related PTSD. In T.W. Miller (Ed.), Stressful life events, 2nd edition. International Universities Press.