The diagnosis of war

PTSD (1980) and of war at home, Complex PTSD (2018)


Main theme: Psychiatry at war

 

There is a war going on in Europe. Russia has invaded Ukraine. We haven't seen anything like it since 1945. We hear about crimes of war every day, even listening to the daily news is heavy. Thousands of people, civilians and soldiers on both sides get an acute mental trauma illness, beside their physical injuries. But there is something else.


Someone ought to write about the pure evilness that made Putin and his men attack their neighbor just because they could and wanted "Ukraine back". What makes young men able to kill innocent unarmed civilians? The phenomenon is recognized since before - in the IS, criminal networks, China, Ruanda and so on.


My article will focus on the late suffering of war seen as PTSD, and the new diagnosis Complex PTSD after domestic violence, when parents are perpetrators.



Introduction


When the Twin Towers in New York were attacked on 11:th of September 2001, a new era was started. President Bush proclaimed war against terrorism. People ran for their lives when the skyscrapers were hit by the Boeing-planes.


Summing it up afterwards one found that many had got PTSD. But several young people were worse ill than the others, especially those who were traumatized before the attack, who previously had experienced a developmental trauma.


Let’s have a look at the history of these two trauma diagnosis.


Trauma history in short


Trauma is as old as mankind. Already Homer described PTSD-symptoms in the Iliad after the Trojan War.


Sigmund Freud wrote about Hysteria 1896. He had met patients with different mystic symptoms of conversion i.e., fainting, weakness in an arm etc. The French professor Charcot in Paris showed these patients in real, all women, for his astonished colleagues. He had found his patients in the Red District in Paris, all were prostitutes. All of them had also experienced sexual abuse in their childhood.


Freud found patients with hysteria in Vienna. He wrote that this might be explained by sexual abuse. But he got cold feet, especially as many of his female patient’s fathers were his colleagues. Therefore, he started all over from the beginning again. He wrote a new version of the book stating that this must be the children’s fantasies. Freud’s daughter Anna Freud, also a famous psychiatrist, later concluded that “It was lucky that my father wrote the new version, or he would have been killed for it in old fashioned Victorian Vienna”.


After World War 1, about 27% of the invalids of war suffered from psychiatric problems. They did not get better with the treatment that was given and became chronically ill.


Other important trauma authors are Bruno Bettelheim and Viktor Frankl and the Norwegian author Arne Sund, who wrote “Psykiatri og stress under kriser, katastrofer og krig” (1976).


PTSD (post-traumatic stress disorder) was introduced in DSM III in 1980. The Vietnam veterans had returned home after losing the war in the seventies. Many soldiers developed psychiatric symptoms. While drinking and using drugs they lived out their traumas in society. They became losers in many ways.


John Lennon was shot in his home by Mark D Chapman in 1980 in New York. Mark Chapman, who was psychotic, was one of these veterans.


Complex PTSD was incorporated in ICD 11, in the English version, in the year of 2018. It took almost 40 years after PTSD was introduced in 1980.


We will have to wait another two to three years for the Swedish version of ICD 11 until we can use it on our patients.


PTSD


PTSD in DSM 5 is a disorder with a significant cause, apart from almost all of the other psychiatric diagnosis. The patient must, by definition, have been exposed for something in real life, not only film or other media. There are four main symptoms:

  1. Re-experience

  2. Avoidance

  3. Persistent perceptions of current threat

  4. A dissociative subtype

About 8-10% of those who seek mental health service in the US are diagnosed with PTSD. Still PTSD is considered underdiagnosed, it has been suggested that another 15% meet the criteria. I believe PTSD is even more underdiagnosed in Sweden.


The dissociative subtype means they report that they feel disconnected from their body - it does not feel real. This leads to that they don’t protect themselves which might lead to retraumatization. The traditional PTSD emphasizes hyper- arousal symptoms that are protective, the dissociative group does not.


PTSD criteria (in short)

  • Re-experiencing (flashbacks, nightmares)

  • Avoidance

  • Persistent perceptions of current threat

Traumatic events are not only remembered, instead they are relived, as if they are still occurring.

Symptoms: memory problems, feeling worthless, irritable and angry, easily frightened.


Dissociation


Basil van der Kolk writes in his book The Body keeps the Score: “Dissociation is the essence of trauma. The overwhelming experience is split off and fragmented, so that the emotions, sounds, images, thoughts and physical sensations related to the trauma take on a life of their own. The sensory fragments of memory intrude into the present, where they are literally relived. (...) many people are not aware of the connection between their crazy feelings and reactions and the traumatic events that are being replayed. (...) Flashbacks and reliving are in some ways worse than the trauma itself. A traumatic event has a beginning and an end, Flashbacks (return) and come any time.”


Dissociation is a big risk for suicide-attempts, and suicide. Only some of the people with PTSD have dissociation, but almost every one of the C-PTSD has it.


All drawings and photos (except patient drawings): Svante Bäck.
All drawings and photos (except patient drawings): Svante Bäck.

Trauma overview


Look at this picture below. There are a few different types of trauma. The PTSD diagnosis are found in the left and middle part. The part to the right with children suffering from childhood abuse is different. In the year 2018 it finally got its own diagnosis, Complex PTSD.


PTSD and Complex PTSD. Image by Svante Bäck.
PTSD and Complex PTSD. Image by Svante Bäck.

Complex PTSD and DESNOS


This diagnosis suits for different situations, but I will focus on the child abuse theme. And how we meet it in young adults and adults.


If we look more in detail on this picture, we find that the active trauma period belongs to BUP, Police and Social services. After a symptom free period of several years the symptoms start again. Generally, no one connects them with the child abuse. They are easily seen as something new and not traumatic. We know that psychiatrists often don’t ask about the childhood.


Image by Svante Bäck.
Image by Svante Bäck.

The American psychiatrist professor Basil van der Kolk was one of the key persons defining PTSD in 1980. In 1995 he also tried to get a trauma diagnosis for child abuse, DESNOS (Disorder of Extreme Stress Not Other Specified). He failed. One reason for this was that there were many ongoing trials considering false memories of sexual abuse. If the therapist is unprofessional, the patient can start telling fantasies that will please the therapist’s expectations. We have our own Swedish world-famous “Quick affair”, where a man in forensic treatment “remembered” seven yet unsolved murders and was sentenced for them. But they were all false memories! He was innocent to these crimes and was released. The big problem was all therapists and researchers who made him confess things that he had not done. Questions can have expectations of the answer inside them.


It is also worth noticing that the American Psychiatric Association makes a lot of money on the different DSM books. So maybe they thought the C-PTSD was too hot and too great a risk to take.


Here are the criteria for Complex PTSD, a newer version of DESNOS which was used in research up to 2018.


Komplex PTSD 1


Occurs as a result of:

  • repeated or chronic exposures

  • to extremely threatening events

  • from which escape is impossible

  • Examples: torture, violence in close relations, childabuse with/without sexual abuse

Komplex PTSD 2


PTSD criterias must first be fullfilled and these additionell criterias:

  • Affect dysreulation

  • Negative self-concept

  • Interpersonal disturbances

Two of my C-PTSD patients


1. “Lisa”


Let’s look at one of my patients with C PTSD, Lisa. She was admitted to my ward, for coercive care. She was psychotic. I found her in the corridor talking to herself in a childish voice. When we came to my room I asked:

- How old are you?

- 8 years.

- Tell me what you are saying again?

- I don’t want to be with you today. I don’t want to play (sex) games in the forest!

- Please draw me a picture on this paper. I too want to see him.


She made the drawings above.


Drawing by "Lisa" #1.
Drawing by "Lisa" #1.
Drawing by "Lisa" #2.
Drawing by "Lisa" #2.

We learned that he was the farmland of the neighboring farm. She had regressed to the age of eight years, and was frightened. She felt that this situation went on forever. When she looked out of the window in her room she saw the man again, he was everywhere.


There is a risk that patients like her are treated as a psychosis with heavy medication. And it won’t help - on the contrary. Our patient needs to get this explained. Tell her about the flash backs, dissociation and help her to get rid of the massive guilt. It’s the child’s view, everything important that happens must depend on me.


“This bad treatment must indicate that I’ve done something wrong.”


2. “Madame Pirandello”


I met this patient in a psychiatric open care unit. She had done suicide attempts, had anxiety and her daughter had told her that she sometimes wasn’t herself. She had filmed her mother with her cell phone in the kitchen. My patient did not recognize herself and had no memories of what had happened.


Drawing by "Mme Pirandello" #1
Drawing by "Mme Pirandello" #1

She worked in the theatre so I asked if I could give her an alias as Mme Pirandello. Luigi Pirandello was an Italian play writer who 1921 wrote “Six Characters in search of an Author.”


She said that would be fine.


After some sessions together it was obvious that my patient was a multi personal person with seven different characters. One of them was filmed by a daughter.


Drawing by "Mme Pirandello" #2.
Drawing by "Mme Pirandello" #2.

I asked Mme Pirandello to draw her different personalities, and the next session she showed me seven drawings. Above we see the one in the kitchen her daughter discovered. Below we can see two more of the seven characters.


In the US it is a prevalence of about two percent of this trauma related disorder. I think we also have them among our patients if you are competent and curious. This diagnosis is called dissociative identity disorder in DSM 5.


Drawing by "Mme Pirandello" #3.
Drawing by "Mme Pirandello" #3.
Drawing by "Mme Pirandello" #4.
Drawing by "Mme Pirandello" #4.

Treatment


The treatment of Complex PTSD is different from that of regular PTSD.


If we focus on childhood abuse, the trauma took place many years ago. Children must go on, their whole life depends on that. So generally, their memories are put away, as if they were freeze-dried (like Nescafe!). But when you pour hot water on it, it is as fresh and painful as ever. The memories are just as when they happened, these memories don’t mature. That’s why it is so important to confirm the traumas but not going into details. It is as if it happened again if you do that.


You must work broader with C-PTSD than PTSD. Basil van der Kolk writes that ”the body keeps the score”. That’s why an integrated Mind- Body model is preferred. Psychotherapy (verbal) aims to work with —top- down in short. That’s fine, but we also need to work bottom- up; to work with the body and its memories. So we might also need EMDR, body- oriented therapy, expressing art therapy and mindfulness etc.


Or many of them.


Integrated Mind - body model. Image by Svante Bäck.
Integrated Mind - body model. Image by Svante Bäck.

If we mainly focus on the hidden memories, we might severely hurt our patients and might trigger suicide.


Dissociation is a very big issue and is something that can lead to new suicide attempts. We must learn to recognize it and teach our patients about it. And try to diminish and finally stop it. It probably was very useful when our patients started using it during the abuse, but when an adult it is of no use anymore.


Complex PTSD treatment advices. Image by Svante Bäck.
Complex PTSD treatment advices. Image by Svante Bäck.

Forensic Psychiatry


Professor Basil van der Kolk once said that at least 75% of all American patients in forensic psychiatry were exposed to child abuse. A depressing fact is that 80 percent of these perpetrators were the child’s parent.


Many of them had DESNOS or C-PTSD. But it was rarely discovered or treated properly. I know from my own experience that there are many patients also in our Swedish Forensic Psychiatry.


There is a gender difference in C-PTSD, women hurt themselves or make suicide attempts, but men hurt other people. That’s the reason why many women with C-PTSD are found in Intensive Care Units after suicide attempts. The men are found in prison or in the forensic psychiatry.