Abstract
Psychiatry is a slow-moving juggernaut which is driven as much by politics and convention as it is by the application of knowledge and the conversion of knowledge into effective interventions. The role of prejudices and enthusiasms in psychiatry is, perhaps, most apparent in psychiatry's ambivalent relationship with the field of traumatic stress. The last two decades have been a period of dramatic growth in the study of traumatic stress. Marshall [1] has highlighted the exponential growth in the number of publications about this field in contrast to the growth of medical literature in general. Posttraumatic syndromes have been investigated from a variety of perspectives including epidemiology, neurobiology, phenomenology and treatment. This field has revitalised theoretical speculations about the nature of the relationship between psychiatric disorders and stressful life events [2]. The National Mental Health and Wellbeing Survey found, using ICD-10 criteria, that posttraumatic stress disorder (PTSD) was the most common anxiety disorder with a population prevalence of 3.3% [3]. The National Comorbidity Study, using DSM-III-R criteria, similarly found that PTSD was the most common anxiety disorder in women [4]. Kessler [5] has also identified that PTSD carries a similar burden of disease to depressive disorders in terms of disability, suicidal thinking and utilisation of general medical services. These figures highlight the importance of this area, which requires attention in the delivery of mental health care systems and in the development of aetiological theory in psychiatry.
The conversion of knowledge into practice
The challenge is to convert the accumulated knowledge into clinical practice. Little of the specific information which has been gleaned is incorporated into undergraduate curricula or postgraduate training. Similarly, health departments in Australia have done little to redesign services in the light of the information and knowledge, which has emerged. While there has been an appropriate preoccupation with deinstitutionalisation and the development of community services, it is remiss to ignore the importance of traumatic stress and its contribution to psychopathology. In particular, this field has the potential to act as a positive force in modifying many of the archaic attitudes which still infiltrate current psychiatric services from their earlier institutional base. In this regard, it is important to remember that community psychiatry has its origins in the treatment of traumatic syndromes in World War I [6]. The ideas of instituting acute treatment with the principles of proximity, immediacy and expectancy was based on the notion that the environment in which treatment occurs is a critical factor in determining its effectiveness [7]. Military psychiatry was also the stimulus for the development of social psychiatry. It was the area where the principles of preventive psychiatry were first developed, giving birth to a public health perspective on the management of psychiatric disorders. In both World Wars I and II, there was a powerful impetus for looking at the interaction between somatic presentations and psychiatric morbidity.
Medicine's interest in traumatic stress involves core concepts about environmental health and the assessment of risk associated with exposure to a variety of physical and environmental toxins. There was a reluctance to take account of the fact that warfare was also highly toxic from a psychological perspective. Rather, military leadership wished to see the issues in terms of individual weaknesses. This served two functions. It meant that the problem was one of individual vulnerability and therefore not a concern of the military. Second, accepting that the psychological terror of battle could be toxic to soldiers also means that this became an issue of leadership. Soldiers' breaking down was equally a matter of bad command and morale. At times of war, necessity has meant an acceptance of the destructive nature of traumatic stress. But without the same reality test in peace time, there has been a slow acceptance of these ideas.
Against this background, the introduction of current thinking from the field of trauma should not be seen as particularly novel or threatening. Many of our current concepts about bereavement, crisis intervention and brief interventions owe their origins to the trauma field. In fact, the National Institute of Mental Health was set up in the USA [6] in the aftermath of World War II which created optimism about the value of effective psychiatric interventions. Ironically, today, the trauma field is seen to be of little relevance to mainstream psychiatry focusing on the severely mentally ill. Yet, research highlights the very high levels of traumatisation among the severely mentally ill [8,9]. There are a series of studies that document the failure to identify the presence of PTSD in conventional psychiatric settings [10]. This is equally true of inpatient and outpatient clinics. Furthermore, a study by North and Smith [11] demonstrated that PTSD was the most common psychiatric diagnosis in the homeless. Patients with schizophrenia and bipolar disorder who have a history of abuse have high rates of suicide attempts, show more aggressive behaviour and have longer hospitalisations [12]. At this point in time, there is little or no attention to these observations in mental health delivery in Australia. This is perplexing and a matter of concern, but not surprising, given the difficulties psychiatry has had in dealing with the effects of traumatic stress over time.
Models for implementation
There is a need to change models of current service delivery in the light of these facts. A variety of initiatives are called for. First, public health policies need to be developed to focus specifically on the mental health consequences of traumatic events. In a setting where excessive attention is paid to emergency inpatient and crisis services, the alternative approach of programmatic treatment interventions needs to be a greater priority. These would focus specifically on the people who contact crisis services in highly distressed states. These people commonly present with a variety of difficulties and should be offered therapeutic intervention that addresses more substantial goals than merely settling the current symptomatic exacerbation. Paterson [13] highlighted that a significant majority of people who contact crisis services have histories of severe traumatisation, yet this often goes unrecognised and no intervention is offered. Consequently, these people are excluded from care by public health system until such time as their behaviour becomes extremely dysfunctional. This goes contrary to all the notions of effective preventive intervention. There is a need to ensure that if treatment programs are established in the public sector, these meet the appropriate standards and are utilised to ensure demonstrable benefit. One of the ironies is that this work can be highly motivating to staff.
The development of skills in this area can assist workers in coping with the challenge of dealing with patients with severe psychotic disorders. The trauma model of psychopathology can do much to increase the sensitivity of workers to the traumatisation caused by chronic mental illness and social decline, which are often triggers. This humanising effect of services has been demonstrated in San Francisco after the 1989 earthquake [Tru: personal communication]. The staff in mental health clinics took an active role in dealing with the psychiatric morbidity which emerged after this disaster. This had an important impact on morale and future directions of that service which came to embrace victims of trauma using preventive and therapeutic interventions.
The neglect of child abuse victims
The need for an active intervention strategy is probably greatest for children. The annual growth in notifications of child abuse in Australia has been steady in recent years. The Australian Institute of Health and Welfare has documented a growing number of cases in the last decade. Between 1988/89 and 1994/95 the number of reported cases grew from 42 468 to 76 945 [14,15], indicating an 81% increase over the 6-year period. The total number of notifications in Australia in 1998/99 were 102 624 (excluding the Northern Territory) [16]. The number of substantiated notifications increased from 18 816 in 1988/89 to 30 615 in 1994/95, with most of this increase occurring between 1991/92 and 1992/93 (a 20% increase) [16]. In 1995–1996 the type of abuse included 28% physical abuse, 31% emotional abuse, 16% sexual abuse and 24% neglect [16]. All too often, the process of notification is followed by a detailed process of assessment, but with little effective intervention. There is a major lack of effective interventions for the traumatised children despite the major adverse consequences in adult life including increased rates of substance abuse and adverse health outcomes [17]. Streeck-Fisher and van der Kolk [18] discuss the impact of child abuse and neglect on psychological development. If the words are to be no more than platitudes, there needs to be a major increase in government funding for interventions in this area. To speak of prevention requires confronting the gross deficiencies of services in this area and this should be a matter of major concern to the government and public alike. For long enough, the issues of child abuse and neglect have been dealt with through a combination of denial and wishful thinking about the idealised nature of families. This neglect of the victims of abuse raises the interesting question as to where the traumatic stress field should sit in professional organisations to ensure it is addressed more effectively.
The impact of financial compensation
The scientific and clinical concerns in the field are often complicated by concerns about the effect of the legal and compensation systems. The stigmatised view that plaintiffs are self-serving and exaggerate the nature of their disability has an important impact on policy in this area. Similarly, an oversimplification of the issues of aetiology in these cases does not address legitimate concerns about defining appropriate liability. These arguments are often used to obscure the established relationship between a traumatic stressor and the resultant morbidity. Unless there is some modification by legislation, the egg shell will remain the guiding principle of the law, namely that the victim must be taken as he is found. This debate is not only about the application of knowledge about psychiatric illness in the legal domain, but also raises some important basic questions of political ethos. Governments at the present time are very preoccupied with the liability of the defendant, given that they employ many individuals in high-risk occupations such as the emergency services, the military and correctional services. In this respect, the Government can be seen to possess a conflict of interests. By protecting their own liability as an employer they must shift the blame to the defendant. By doing this, however, they are failing to uphold the primary role of the Government: to protect individual rights. As individuals, we require the government to place the needs of individuals above the collective use of power. People will only be employed in dangerous occupations and put themselves at risk for their fellow-citizens if they believe that they will be cared for, or that their families provided for, if they are killed in the line of duty.
At the same time, a legal system should not provide for a trivial degree of liability or allow long-standing disabilities to be wrongly attributed to a recent stressor. There has been a recent trend, by legal counsels, to try to apply the notion of PTSD to include a range of non-traumatic events in the hope of best serving their clients' interests. It is important that a level of severity of the qualifying trauma is sustained so as not to trivialise the notions of psychological suffering which would create an unsustainable system. The public interest will only be served by having a compensation system that provides benefits which an informed public will see as justified. Ultimately, if governments are held liable for the way in which they have traumatised populations, they will be less willing to fight unnecessary wars and to create systems of social injustice which leave the citizens at risk of crime. The legal system is one mechanism for holding governments accountable by the careful scrutiny of legal minds in conjunction with scientific information provided by expert witnesses. Equally, those who deny their social contract and seek to profit excessively from personal suffering, without making the necessary attempts to re-establish a functional life, should not be rewarded.
Future developments in the field
Any field which has been successful in establishing itself is in danger of creating a degree of rigidity in the thinking of its practitioners. It is important that inquiry and new ideas are not stifled by the rarification of current knowledge. The development of treatment guidelines and other types of consensus statements has many benefits. These include providing a framework for optimising outcomes in treatment and developing protocols for assessment. In addition it allows large data sets to be created from different research projects such as in the Cochrane collaboration. The danger is that the politics of a field can be as influential as current knowledge in determining such consensus statements. The paper in this series by McFarlane and Yehuda [19] on treatment, highlights some of the important questions that remain and must be open to examination if the field is going to continue to develop. The debate about complex PTSD similarly, requires a frame of mind open to the range of symptoms that should be examined in various clinical populations. For example, in this series and elsewhere van der Kolk [20] has argued about the limitations of our current notions about PTSD in describing the consequences of child or sexual abuse.
The importance of welcoming, surprising and unanticipated results is perhaps the best epitomised in this field in relation to the area of the early intervention. As Dheal [21] discusses, the early promise of critical incident stress debriefing did not hold up when systematically researched. On one hand, it is important not to be too critical of those who sought to change the attitudes of organisations dealing with the emergency service personnel. The nature of the stresses and the demands of the work in these organisations required critical analysis and the impact on employees demanded recognition. However, the advocacy of clinicians and practitioners unfortunately preceded adequate outcome research and hence when outcome research finally arrived, it failed to justify their original pronouncements. Their response was to claim that the research was inadequate rather than questioning the clinical practice [21].
It is important that in the context of this debate about early intervention, that the need to maintain a culture of sensitivity to the detrimental effect of trauma is not lost. However, we need to establish carefully researched protocols that focus on how to best treat the acute and adverse outcomes of trauma. This strategy requires a commitment, both on the part of organisations who employ these individuals, as well as from funding organisations who can support this type of research. The role of preventative intervention is an example of how the traumatic stress field extends into many areas of public health. It is possible to deal with high-risk groups and individuals by using a different model of health care intervention, namely by identifying and providing high-risk individuals with immediate care rather than waiting for them to present to a health practitioner.
The theoretical contribution of the study of traumatic stress
Psychiatry, from an historical perspective, has struggled to develop a model which integrates the relationship between environmental and biological factors. The contribution of genetic factors always seems to have a greater legitimacy, particularly at a time in history when the human genome has been sequenced and there is a wave of public concern about genetic engineering. Furthermore, the origins of psychiatry in medicine tie the discipline strongly to its biological roots. The field of traumatic stress has the potential to provide a unifying theoretical model that can bridge this divide. Therefore, the general reluctance to accept the importance of horrific and life-threatening adult experience as an important cause of psychopathology is somewhat perplexing [22]. Perhaps it is because humankind likes to be the controller of its own destiny and acknowledging the damaging effect of experience creates an unwanted sense of vulnerability.
In some regards, this intellectual struggle is very similar to the barriers which have existed as a part of the inevitable acceptance of Darwinian evolution as a central tenet of observational science. While there seems to be a broad acceptance of the relationship between the distant and the recent past, the same relationship between the present and the immediate past provokes considerable resistance. In part, characterising this intellectual struggle involves a sophisticated understanding of memory. Essentially, the core of traumatic syndromes is the capacity of current environmental triggers (real or symbolic), to provoke the intense recall of affectively charged traumatic memory structures, which come to drive current behaviour and perception. There has been a very slow accretion of this conceptual model into psychiatry.
At the end of the 19th century, there was the dramatic realisation of the capacity of trauma to sculpture a patient's symptoms. Freud, Charcot, Janet and Rivers, to name a few, understood the ability of traumatic stress to create a series of abnormal mental states [23]. Paradoxically, a twist of history led to the loss of this understanding. Ultimately, when Freud renounced the reality of childhood sexual abuse, he negated the lives and suffering of millions of people. Furthermore, this led to the rejection of the notion that adult experience could mould pathological mental states other than by a triggering an unresolved early developmental conflict. The irony was that this developmentally based view of psychopathology moved psychopathological concepts away from a purely genetically based origin. This view placed major emphasis on the developmental experience of children under the age of 5. It was as though people were immutable in terms of environmental experience passed that point. (It must be acknowledged that Freud, himself [24], saw traumatic neurosis as a distinct and separate entity. This observation was a consequence of the experience of World War I.)
Essentially, a related conceptual question focuses on whether humans have a continuous vulnerability to adverse environmental effects or whether at some point the human brain becomes relatively immutable. In fact, evolutionary principles were as much an environmental theory as they were notions about predetermination. These evolutionary principles are concepts about how environmental factors change the direction of the species. Inevitably, biology can only be understood as a dynamic process occurring between the environment and the inherent biological characteristics of populations. Intrinsic to the core of this theory is the vulnerability of the biology of species to being changed by environmental factors. Major shifts or stress in the environment are likely to be the core of those factors which can lead to an important shift in biological structure. Our genetic vulnerability is not fixed, but rather a script which influences the nature of the responses we can make to the host of environmental experiences we may or may not have. It is at times of exposure to life-threatening events when these interactional forces are particularly brought to bear.
One of the interesting paradoxes of history is the misuse of Darwinian ideas in formulating psychopathology. This misuse of Darwinian ideas has had a profound affect in inhibiting the acceptance of the role of psychological trauma as an important agent in the aetiology of psychiatric illness. The simple interpretation of evolutionary ideas was to emphasise the importance of one's genetic inheritance, where our genes irrevocably determined our future. This conceptualisation encouraged the 19th century views of the aetiology based on ideas of moral degeneration, espoused by figures such as Morel [25]. This perspective allowed the conceptualisation of the psychiatrically unwell as the underclass and linked their mental illness with conditions such as alcoholism, syphilis and poverty. This was as much a political view about social class as it was a theory of illness. The emerging dominance of molecular biology leaves us vulnerable to focusing exclusively on identifying and modifying genetic structure. Rather, the interaction between these genes and the environment should be a matter of discourse as it may be far less risky to change the environment than to engineer our genes. Genes are a memory of adaptation and we should not forget that there might be benefits for the group at the cost to individuals.
Traumatic stress as a field, has the capacity to show the future direction of functional neurobiology. Exposure to these events are critical points in the switching on of a variety of adaptational processes such as the hypothalamic-pituitary-adrenal axis which appears to have a relatively unique pattern in PTSD [26]. For this reason, the longitudinal course of post-traumatic reactions is a matter of considerable theoretical interest [27]. Documenting the shifts in a variety of neurobiological systems with the passage of time is likely to tell us much about the general aetiology of psychiatric illness. The work of Post [28] in looking at the onset of affective disorders at times of stress has emphasised how a range of genetic induction processes can occur in the brain. These induction processes lead to the progressive automaticity of response and highlight how genetic vulnerabilities can be modified in response to environmental stress. Hence, ‘kindling’ is a particularly interesting model to explain the interaction between an individual's biology and environmental forces [29]. In passing, it is interesting to note Darwin's interest in emotion. He observed the affects of psychiatric patients and commented on the similarities between the affective states of animals and those of humans. In this regard, he built a further breach between the animal kingdom and Homo sapiens. The development of dynamic structural models is one of the challenges in understanding the neural processes involved in the traumatic stress response. The work of Rauch et al. [30] has played a central role in demonstrating the role of structures such as the amygdala and the relative inactivity of the Broca's area during the processing of traumatic memories. Chemtob (cited in Burgess et al. [31]) has highlighted the importance of the right hemisphere in both vigilance and the perception of threat, and how this plays a central role in the conceptual understanding of the way in which the human brain processes traumatic stress. When considered as an overview, this field highlights the impossibility of constructing a hierarchy of environmental versus genetic factors.
The fact that traumatic stress is a field that sits astride such complex theoretical issues with core relevance to psychiatry highlights the contributions it can make to the general understanding of psychopathology.
Conclusion
Traumatic events cause demonstrable and chronic long-term effects on psychological and physical health. Attempting to prevent these adverse effects is a critical public health issue. The avoidance of traumatic memories and the ambivalence of victims towards acknowledging their state of mind are major barriers in establishing systems of care and can lead to underestimating the consequences of these events. There are effective treatments that can be offered, but these require specialised training programs for clinicians. However, it appears that there are still a group of patients who remain disabled and distressed despite the optimal interventions.
The interaction between the memory of a traumatic experience and the existing meaning structures of an individual means that PTSD remains one of the corner stones to psychodynamic thinking in DSM-IV. The constellation of biological processes involved in the development of the symptoms of PTSD provides a model for the interaction with the environment in a range of disorders that have important genetic and neurological factors operating.