An awareness of long-term psychological complications of life-threatening events can be critical, says Dr Leon Piterman
Boris cut a lonely, despondent figure when I first met him.
He was 45 years old, but looked more like 65. He was overweight with a large middle-aged spread, ruddy complexion, slow purposeful gait and relished the opportunity to sink into the patient’s chair. He had been sent to see me by his employer to assess the possibility of a return to work after a six-month absence. I knew this would be a long, if not very long, consultation – or maybe several consultations.
Boris had been the afternoon/evening manager in a print works that operated near our clinic.
He was born in Bulgaria but had lived in Australia since the age of 20. He was married to a woman 12 years his junior and had two sons, aged eight and six. He had been physically active, playing football until the age of 40, and had been proud of his fitness and virility.
This all changed one evening six months ago, when Boris was involved in an accident at work. He was fixing a light switch on the wall in the factory when a forklift reversed, stalled and trapped him against the wall. He felt crushed and was sure he was going to die.
It only took several minutes to restart the forklift, but it seemed like hours. Boris was alert during this time although the pain in his chest, back and pelvis was excruciating. An ambulance was called and Boris was rushed to the local teaching hospital. He was examined, had X-rays and scans and kept in for 24 hours in the short- stay unit.
He was informed that there were no fractures, just bruising, which would settle in time, and sent home with an outpatient orthopaedic appointment two weeks later. This turned out to be short consultation after a painful car trip and long stint in the waiting room. He was told that there no serious damage, given a certificate for two weeks off work, and told to see his GP.
Boris did not recover. His pain persisted and so did his nightmares. He dreamed he was being crushed or drowned. He frequently awoke in a cold sweat. These dreams and flashbacks became the norm. His wife was woken repeatedly and he was relegated to the spare room.
He was given sleeping tablets and another month off work but found himself becoming increasingly depressed and anxious. Car noises and sirens were intolerable. He visited his workplace on several occasions but the sight of the forklifts terrified him. He began drinking spirits on a daily basis and his relationship with his wife deteriorated. He even suspected she might be having an affair.
After a five-month absence from work he was seen by a psychiatrist who diagnosed post traumatic stress disorder (PTSD), started him on an SSRI and referred him for psychological treatment.
PTSD is a term now widely used in our lexicon as we continue to witness a wide variety of traumatic events on a daily basis.
The earliest systematic description of this disorder was “shell shock”, a term coined in 1917 in the midst of the First World War to describe what we now know as PTSD. This afflicted one in seven troops and a total of 80,000 British troops were treated for the condition, many of them not front-line troops.
PTSD has affected 250,000 US troops who have fought in Iraq and Afghanistan and more than 3000 Australian troops involved in these conflicts have been similarly afflicted.
While many of our world war and Vietnam veterans suffered in silence, turned to alcohol, drugs and violent behaviour, or simply became chronically anxious or depressed, the recognition of this syndrome has meant that early intervention, using a range of established and novel treatments, is improving outcomes.
Of course, PTSD is not confined the those serving in theatres of war. It can affect anyone exposed directly or even vicariously to trauma which is perceived to be life threatening. This includes traffic and work-related accidents, as in Boris’s case, natural disasters, criminal and terrorist acts, child abuse and domestic violence.
Those afflicted may not be the direct victims of the trauma but may have witnessed its horrific outcomes. This particularly affects emergency-services personnel and health workers, but may also affect bystanders, as has just happened tragically in the Melbourne CBD.
It is estimated that the lifetime prevalence rate of PTSD in Australia is 7.2% with a 12-month rate of 4.4%. One shudders to think what it might be in Syria!
PTSD has a range of clinical manifestations. These include: recurrent intrusive memories, nightmares, poor sleep, flashbacks, negative thoughts and feelings of self blame, physiological reactions such as sweats, palpitations, chest pains on exposure to cues, exaggerated startle response (for example to loud noise), avoidance behaviour, aggressive behaviour, loss of interest and poor concentration.
Some of these symptoms are also manifestations of depression and anxiety.
Treatment of PTSD includes both psychological as well as pharmacological approaches. Early intervention generally provides better outcomes.
Psychological treatments include cognitive behavioural therapy; prolonged exposure therapy, which involves talking about and reliving painful memories; and eye-movement desensitisation processing, i.e., while thinking about painful memories focus on other activities such as eye movements and hand-tapping.
Drug treatment includes the use of SSRIs which are also used to treat depression and anxiety.
Not everyone exposed to trauma will develop PTSD. For example, of the two million US troops who served in Afghanistan and Iraq, around 10% developed PTSD. This raises interesting research questions regarding individual susceptibility. A better understanding of the neurobiology of PTSD is emerging which may help identify those most at risk, as well as developing targeted therapies.
A better understanding of the neurobiology of PTSD is emerging, which may help identify those most at risk as well as developing targeted therapies.
Boris was able to return to part-time work after a six-month absence, and to full-time work after nine months.
I have continued to speculate if his outlook would have been very different if he had been treated with more understanding in the ED and in the orthopaedic outpatient clinic.
Being told: “You have normal X-rays so there is nothing seriously wrong” may not heal body nor soul. A more sympathetic assessment, coupled with awareness of the possible long-term psychological complications of a life-threatening event, may have helped prevent the damage caused by PTSD in Boris’s case.
I have recently been involved in convening a conference on PTSD. For details, please check:
www.traumaandmentalhealthconference.org
Professor Leon Piterman is Professor of General Practice at Monash University and has been in clinical practice for almost 40 years
Do you have similar professional experiences you would like to share? Please email: grant@medicalrepublic.com.au
