Vietnam veteran Ted Fish had not heard of Post-Traumatic Stress Disorder until just four years ago, when he realised he'd actually been suffering it for the past 30 years. In this program we hear Ted's moving story. Also, some of the latest findings about PTSD which suggest that the disorder is not just about haunting memories from the past - but may have more immediate effects on memory functioning. Post-traumatic stress disorder - once known as shell shock - is sadly just as relevant as ever.
http://www.abc.net.au/radionat...1/3426554#transcript
Relevant links and references at the end of the transcript
Speaker 1: I would have liked to have been 100 miles away from him, every time he walked in the front door. I mean, he walked straight through our glass door one night. I said something to him in the lounge room, do you want your tea? No, I don't want it, f- you and off he went, straight through the door.
Speaker 2: The first world war it was called shell shock, in the second world war it was called battle fatigue and in the last three or four years post-traumatic stress disorder. It's simply a new name for an old problem.
Selwyn Smith: About 17 per cent of the military personnel who were coming back from Iraq and about 11 per cent from Afghanistan were noted to have a psychiatric diagnosis. Either major depression, generalised anxiety or in fact post-traumatic stress disorder, and I would think those figures are probably under representative of the true figures.
Lynne Malcolm: Psychiatrist, Dr Selwyn Smith, Clinical Director of the St John of God Psychiatric Hospital in Sydney. He's referring to a recent study published in the New England Journal of Medicine, yet another sobering reminder of the true cost of war.
And before that an excerpt from the 1993 ABC feature Walking on Egg Shells, on the experiences of the wives of Vietnam veterans.
Hello, welcome to All in the Mind, I'm Lynne Malcolm and today we explore a debilitating condition now known as post-traumatic stress disorder, and some of the less obvious effects it may have on our memory long after the stressful event.
The term post-traumatic stress disorder or PTSD was coined in the mid 70s and formally recognised in 1980, largely as a result of the anguish which was still being experienced by returned soldiers from Vietnam. And it's not a new condition. Reports of stress associated with battle appear as early as the 6th century BC, but sadly with recent tragedies like Beslan and Darfur still resounding strongly in our minds, the effects of trauma are as much of concern today as ever.
Sandy McFarlane is a Professor of Psychiatry at the University of Adelaide. His research in the field began 20 years ago, around the time of the Ash Wednesday bush fires.
Sandy McFarlane: Post-traumatic stress disorder is a condition that people develop after their exposure to horrific or life-threatening experiences or, equally, events where they may have been threatened with that such as rape or sexual abuse. The core aspects of it are firstly that the person in a sense becomes dominated by the past; their mind becomes frequently preoccupied and revisits the traumatic experience. I mean that can happen in a variety of ways such as nightmares or triggered memories.
The second part about it is that these people often have a range of quite severe and debilitating anxiety symptoms, they might be manifest as sleep disturbance or difficulties with their memory and concentration, they become very watchful of danger, they also develop an exaggerated startle response where they become much more reactive to environmental stimuli.
The third part of it is that obviously people have to adapt to living with those sort of symptoms and they'll do this by doing two things. The first thing is to try and avoid either the thoughts or reminders that they relate to the trauma. The second thing is they become quite withdrawn and emotionally numbed and shut off and often these people find it very difficult to project themselves into the future, they become trapped by what's happened and that makes it difficult for them to see their life in the future.
Lynne Malcolm: So what is the difference between this disorder and a natural response to a traumatic event?
Sandy McFarlane: That's a very important question and what it's about is in a sense the trajectory of people's symptoms. I mean it's entirely appropriate to be highly distressed after you've had some horrific event. Post-traumatic stress disorder isn't something that begins on the day after an event, it occurs really in the first month afterwards and it's about the progressive failure of the patterns of distress that I described to ameliorate. So it's not really something that we define in an acute setting, it's really about people's longer term reaction.
Lynne Malcolm: Sandy McFarlane. And as he says it's important to remember that stress is a natural and necessary reaction to trauma, but post-traumatic stress disorder goes beyond a health response. So what determines who is unlucky enough to develop this disorder?
Sandy McFarlane: The strongest predictor in fact is the severity of somebody's exposure. I mean what that tells us is if we've had a population of people who've been exposed to some major catastrophe like the Bali bombings, we will predict those people have a very high risk, so that is one of the reasons why we need to think about prevention.
However, some of the vulnerability factors are things like a family history of psychiatric disorder, if you've previously suffered from depression or you have had prior significant traumatic events in your life. For example if you've had an unpleasant upbringing where you've been emotionally neglected or physically or sexually abused.
Equally the support and the response of an individual's social group or network or organisation is an important issue. There are some other issues that we're interested in but those are the really predominant ones.
Ted Fish: My name's Ted Fish, I went to Vietnam in 1966/67, which was the first task force that went over.
Lynne Malcolm: Ted Fish hadn't heard of PTSD until four years ago when he hooked up with a Vietnam Veterans group. He'd been unaware that he'd suffered from it for over 30 years. He kindly agreed to speak with me in what he considers his safe haven, the beautiful historic mansion at the centre of the St John of God Hospital in Richmond on the outskirts of Sydney.
On his return from Vietnam, he walked into his family home just 48 hours after he'd been on shotgun duty in the middle of a war zone. So how did he cope when he got home?
Ted Fish: Completely switched off, anything to do with being in Vietnam. You didn't admit in any way shape or form that you had been there. And tried to just get on with life.
However, what I've found out since then is triggers that relate back to Vietnam, how we were treated when we came back to Australia as well, caused anger, depression and the disassociation of feelings. You couldn't express love or even though you accepted love you couldn't communicate that you had accepted that from people. It wasn't really till I came out here and we went through, I fully realised what I'd been like to live with.
Lynne Malcolm: What sorts of experiences did you have in Vietnam that triggered these terrible memories?
Ted Fish: Well the first one was the loss of a friend at the Battle of Long Tan. You felt so helpless that that happened, you become fatalistic while you're over there you either dig a hole and stay there for the 12 months or you go on with your life.
And when you come back and you think how did I cope with that 12 months, why did I do the things I did, it's hard to describe and I prefer not to go into the fine detail of it. But it was purely just a situation I was in which without me knowing it had me under very severe stress for long periods of time.
I had a lot of people relying on me, you don't think of it at the time, 21 years old, this is dead easy, it's only when you think of it later and think, if something had happened could I have done something, would I have been able to do it?
So that was causing the depression, the anger, the quick anger. The family couldn't understand why I'd suddenly go off or disappear into myself in depression over something so absolutely minor and miniscule.
Lynne Malcolm: Can you give me an example of some of the triggers for you?
Ted Fish: Normally crowds is one problem, if I go shopping or something like that and it's very crowded the stress really builds up in me, so any minor thing happens-I go. And I have on several occasions when I've been in a supermarket-on one occasion actually everything had been put through the scanner and I've walked out and left everything there.
Lynne Malcolm: Vietnam veteran, Ted Fish. After studying the effects of PTSD on the brain Professor Sandy McFarlane and his colleagues found that the disorder is a lot more than having trouble with anger. It may involve complex effects on the functioning of memory.
Sandy McFarlane: What people have come to think about post-traumatic stress disorder is that it is a disorder of memory. Now there are two ways that we might think about the question. The first one is that it might in fact be that people who develop post-traumatic stress disorder lay down the memory of the traumatic experience in a different way from the people who don't develop the condition.
Another hypothesis or alternative which we've been doing a lot of research on is actually that the exposure to traumatic events and the nature of the stress response that we all get might in fact disrupt the capacity for us to integrate and manage information, which is one of the critical functions of memory.
Lynne Malcolm: So that second hypothesis really points to the way people handle information now?
Sandy McFarlane: Absolutely, and the way I first became interested in this was after the Ash Wednesday bushfires. What I did was to look at several large populations-one of children, one of emergency fire fighters-and what we found was that you know these were all people who had very high exposures.
The symptom that best differentiated the people who had post-traumatic stress disorder from those who didn't wasn't the nightmares, wasn't the intense preoccupation; in fact it was the disturbed concentration. And what that made me begin to want to investigate was really what was going on in the brain about these people's difficulty in managing and organising information.
Now what we have done is to investigate that using a technique where we can measure the brain waves when people are doing specific tasks, and we can compare the way that people with post-traumatic stress disorder manage a very simple task compared with a group of people who haven't got post-traumatic stress, simply by measuring the electronic activity that we can pick up on the surface of the scalp.
And what we first found was that people with post-traumatic stress disorder in a sense were living in a world where they couldn't highlight what was relevant from what was irrelevant, so it's almost like they were living-to a degree-in sea of confusion. So it's a bit like being in a room where the lights are dimmed, when you drop something on the floor and have to find it in contrast to being in a brightly lit room. So you had to make more effort in a sense to drag the relevance out of the external world.
Now you can imagine, if you are in a state of mind where in a sense the world isn't sort of impinging on you in the same way, it can do two things. The first thing it can do is actually make you feel more anxious, because one of the reasons why we don't feel anxious about our immediate surroundings normally is because we can make sense of them, we can define what's relevant and what is irrelevant.
The second part of it is that you can imagine if you're living in a slightly dimmed environment you're much more likely to be preoccupied by very powerful memories or thoughts or preoccupations with inside of you.
Ted Fish: That other area in the anger was ah... I gave a financial institution three days of hell over a 5 cent piece.
Lynne Malcolm: Tell me more about that.
Ted Fish: I'd banked some coin and one of them was a foreign coin and the staff member rang me up and asked me what I wanted to do about this foreign coin and that just tripped me over the edge for three days. But I mean it was that stupid that in the bundle of two dollars of 5 cent pieces in the bag that they'd found a foreign coin which technically they shouldn't put in my account. I just took that as too much.
Lynne Malcolm: And did you experience nightmares or flashbacks?
Ted Fish: Yes and actually over the last few months the nightmares are starting to include my family in it, in that danger situation and that is really worrying.
Lynne Malcolm: So the nightmares, are they taking you back to Vietnam?
Ted Fish: Yes, yeah definitely and that's as I say where suddenly the family's brought into that situation as well. It really does get to you and I sleep in a waterbed sometimes (and we don't have a waterbed), from the perspiration and night sweats.
Lynne Malcolm: So it may not be as straightforward as we've previously thought, that there are haunting memories that just keep coming back to us?
Sandy McFarlane: No, and I think that's a very important issue. See one of the things that we often presume is that people can tell us what's wrong with them. For example with modern methods of investigation such as cardiac monitoring you can find out whether people have got palpitations and you can look at whether they report having palpitations and you actually find that there's not a strong as correlation as we would believe.
So often I think, particularly in psychiatry and psychology, we presume that patients can tell us about the core aspects of their illness. What they will tell us about is the things that are most apparent and most troubling to them and in post-traumatic stress disorder that's the traumatic memories.
But in fact behind that there might be much more pervasive and disruptive problems with the way their brain is managing their environment. But it requires an enormous amount of introspection to observe it.
I mean it's a bit like if the listeners were to think about-if I were to ask them question you know, what's your concentration like? You know, how on earth do you make a judgement about that? Because it really is a relative statement, it requires a great deal of reflection. I think that's one of the reasons why people obviously complain about the nightmares and the traumatic memories, because that is what really causes them the most immediate distress.
Lynne Malcolm: So this also implies there's actually physiological neural connections that have changed?
Sandy McFarlane: Absolutely. See one of the things that we have been very interested in post-traumatic stress disorder are the ways that the stress hormones, particularly noradrenaline and cortisol might impact on memory and there have been a number of studies in normal subjects for example which show that there's a U shape, an inverted U shaped curve. Now what we mean by that is that if you've low levels of cortisol or noradrenaline, you don't remember things so well. If you've got a moderate increase your capacity to remember a situation actually improves.
The interesting thing is that if you further increase the levels of cortisol and noradrenaline in fact you're less likely to remember a task. So what people tended to presume is that perhaps in post-traumatic stress disorder there's some abnormality of the stress response, like too much of a stress response.
Now the irony of it actually seems that these stress hormones actually might be beneficial, they actually might encourage you to forget and in fact if you don't mount a full stress response, you are then more vulnerable to laying down these traumatic memory structures.
Now the other issue is that there are a number of neural structures that are very sensitive to the effects of these stress hormones and they can actually influence the rate of turnover and the rate of connections between nerve cells. And what our research would suggest is that these neuro hormones are actually disrupting over the longer term the connections in different parts of the brain and that as the alarm reactions become more and more automatic in somebody with post-traumatic stress disorder, this then disrupts the way that our brains are working.
Lynne Malcolm: Which would explain the impact on people's everyday lives perhaps years after the traumatic event.
Sandy McFarlane: Absolutely, because one of the other important things that we've been able to do with the sort of research methodologies we have now, is to actually look at the neural networks that we use when we're having thoughts.
Now what we mean by neural networks is that the brain really is like a symphony orchestra; it's not just the first violins, it's actually many different areas of our brains being activated at any particular time. In fact any feeling or thought you have is just one particular, unique set of connections between multiple regions in your brain.
And what we're interested in is whether the patterns of activation in the brain in post-traumatic stress disorder are different from those people who don't have post-traumatic stress disorder. In fact what we find are very significant disruptions and one of the most interesting ones is the loss of activation of the area that's involved in expressive speech.
Lynne Malcolm: And that is quite evident in the symptoms of people who suffer the condition?
Sandy McFarlane: Well, interestingly, in some ways it's not something that people will necessarily complain of, nor is it part of the diagnostic criteria, but the more we become sensitive to these issues, one of the things that we find is that people with post-traumatic stress disorder will say things like, when they go to a party, for example, they find it much more difficult to engage in social conversation. Equally they find it more difficult to read aloud, and on sophisticated forms of neuropsychological testing we can actually pick this up.
One of the ironies of it is that people who have been really traumatised, and in fact have speechless terror, and you know we always presume that language is the vehicle for learning. Well it seems that perhaps this is one area of human evolution that in fact hasn't been as well captured by language as we would hope.
Lynne Malcolm: If PTSD affects memory, what implication does that have for treatment?
Sandy MacFarlane: Focussing on the traumatic memory alone probably is not sufficient. What we need to think about is are there ways that we can actually improve people's memory function? We might be able to do that from a pharmacological point of view and we've been doing some interesting trials using drugs that improve memory functioning and find that that does lessen the symptoms of post-traumatic stress disorder.
I think what it also means from a psychological point of view is that maybe what we need to spend sometime doing with people who've got post-traumatic stress disorder is helping them develop strategies for being able to filter their environment and focus more effectively.
The broader treatments, though, in post-traumatic stress disorder traditionally have focussed on trying to get people to develop their narrative for the traumatic event and to bring into that narrative all the aspects of the memory-which is often stuck in very physical and sensory modalities-and to bring together a much more coherent and complete description of what they've been through.
Lynne Malcolm: So people who've experienced trauma may not have the words to provide a coherent narrative of the event, but Dr Selwyn Smith argues that many of his patients at St John of God hospital in Sydney face the additional burden of not understanding what's happening to them now, let alone many years ago.
Selwyn Smith: The first focus is to explain to the patient what they're experiencing. Most patients in my experience do not know or understand what they are going through. And if you spend time, like any disorder, and explain the symptomologies and how it has developed, that is in itself very therapeutic if you acknowledge the problem, very important in terms of moving forward.
The group itself is very therapeutic. It's a milieu of support in which, suddenly, an individual realises that they are not alone and they can share these traumatic experiences. Very helpful. The next phase of the program is to develop within them better coping strategies; how do you deal with anxiety, how do you deal with depression in a cognitive or learning mode, working out better ways rather than negative ways that they've coped.
We educate the family as to what their partners are experiencing. Medication may also be of assistance in providing symptomatic relief not only with regard to the anxiety, helping them sleep and improving their depression. So it's really a multifaceted approach.
Lynne Malcolm: So what was the most helpful thing about the program that you did here?
Ted Fish: There's no magic cure, there's no magic bullet doing that course, but learning how to try and manage, I still don't succeed all the time but again, as another friend of mine says, he goes to his shed a lot less often. So you do a lot more work on managing, understanding what the triggers are, knowing your feelings and then trying to manage them.
Lynne Malcolm: Some individuals today are lucky enough to benefit from the knowledge we now have about PTSD and don't have to wait as long as the Vietnam veterans did to have society's support.
But many of the horrific events we're witnessing today such as September 11 involve large groups of people. What are the implications in situations of mass trauma where there's potential for a high incidence of PTSD?
Sandy McFarlane: One way of thinking about that situation is like any public health situation: There's been a known exposure to a toxin and in this setting it's a psychological toxin. What we need to do is to screen people, and those at high risk, we need to follow them.
I think the second issue is that traumatic events have a much greater relevance to understanding the way that societies work and one of the issues is that I think it's very important that we don't on one hand over-dramatise, because fear can have very disruptive effects to social groups. I mean it's what terrorists aim to do.
And the other side of it is that we do need to realistically appraise people's suffering and not underestimate it. And I think often the suffering of people after these events is far greater than people would anticipate and the public at large will think, well, have six months, everybody should be over with it. And so often the services and needs of these people are neglected in the longer term.
Lynne Malcolm: From your work in this area, how does it make you feel about the current background of war that we're dealing with in today's society?
Sandy McFarlane: Umm, very troubled, because terrorism-in fact torturers often use knowledge out of research to strategise. Having dealt with traumatised people I think I'd make an extremely good terrorist But what it also tells me is that we totally overestimate our ability to prevent these acts.
Lynne Malcolm: Professor Sandy McFarlane from the University of Adelaide. Now back to Vietnam veteran Ted Fish, whose life has changed significantly since he acknowledged his post-traumatic stress disorder. He and his family have worked hard at their relationships and Ted is the first to admit how lucky he is that he's marriage of 35 years has lasted through all the pain.
Ted Fish: Well there's a lot more communication and understanding. I don't feel any different in my love to her or my daughter but I am communicating that, which has helped her a helluva lot and my daughter as well.
And probably one thing I'm very thankful of with my daughter-because of this shield I had up, that I didn't express my love to her-she's allowed me to express myself completely with my three grandchildren and there's no jealousy, it's beautiful. So we are getting to understand and show our love and forgiveness and understanding about what happened.
Lynne Malcolm: Thank you very much Ted. That's all in the program today. Our producer is James Carleton with Jenny Parsonage on sound engineering and you can visit our website at abc.net.au/rn and follow the prompts to All in the Mind where you'll find audio of the program along with links and transcripts.
Join All in the Mind next week for more on PTSD including the moving story of a forensic policewoman and her struggle to come to terms with what she witnessed in the line of duty.
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