Edna B. Foa; Kelly M. Johnson; Norch C. Feeny; Kimberli. R.H. Treadwell: The ... Cuffe, S.P.: Addy, C.L.; Garrison C.Z., et al (1998). Prevalence of PTSD in a ...
traumatic stress
PTSD SYMPTOMS AMONG CHILDREN AND ADOLESCENTS AS A RESULT OF MASS TRAUMA IN SOUTH ASIAN REGION: EXPERIENCE FROM KASHMIR Mushtaq A. Margoob MD., Akash Yousuf Khan MBBS, Huda Mushtaq MA*, Tasneem Shaukat MBBS Exposure to trauma has a lasting impact on the emotional, behavioural and other aspects of personality in children. To assess these effects, a study was carried out on 56 children, diagnosed with PTSD using DSM-IV guidelines, at Govt. Psychiatric Disease Hospital, Srinagar. The children were in the age range of 3-16 yrs. The observations were made under four categories, Trauma, Re-experiencing, Avoidance and Hyperarousal. The most common mode of exposure to trauma was by witnessing it (75%). Commonest form of re-experiencing the event was through distressing dreams/nightmares (85.71%). Avoidance of people and places related to the original event was the major avoidance mechanism (85.17%). Most patients had an acute onset of PTSD (92.85%), while most of the cases were diagnosed in the chronic stage (71.43%), indicating a delay in diagnosis and treatment. (JK-Practitioner 2006;13(Suppl 1):S45-S48 Keywords : Trauma, childhood PTSD, reexperiencing, avoidance, hyperarousal, chronic PTSD.
Adverse early life experiences, especially traumatic events can have a profound and lasting impact on the emotional, cognitive, behavioral and physiological functions of an individual for the whole of his life. Millions of children are exposed to traumatic experiences even in developed countries like USA which increases the risk of developing PTSD in event of a traumatic experience in 1 2 adult life each year . The triad of symptoms following a traumatic experience has been termed as Post-Traumatic 3 Stress Disorder (PTSD). Approximately, 20 percent of individuals exposed to a significant traumatic event will 4,5 develop (PTSD) and children may be at an even higher 6 risk. Posttraumatic stress Disorder (PTSD) codified in DSM III in 1980 has been a subject of debate regarding its nature and origin. On the one hand there are those who say that it is a timeless disorder, which has only recently been recognized, on the other are those who say that as a culturally determined diagnosis it reflects contemporary 7 interpretations of trauma and memory. Mental health professionals have recently begun to examine the prevalence of trauma exposure among 8,9 children and the effects of such exposure. This research reveals that traumatic experiences are common among the 10 youth. Although there are no epidemiological studies on the incidence of post-traumatic stress disorder (PTSD) in youth, a number of studies have converged to suggest that traumatic events can lead to severe and debilitating PTSD in them with rates of PTSD varying greatly across 11 studies. The high prevalence of PTSD in children traumatized by exposure to community violence or war trauma is well established. Macksoud and Abram (1996) found PTSD rates of 43 percent in Lebanese children upto 10 years after
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exposure to war trauma. Among displaced Kurdish children in Iraq following the Ist Gulf War all had PTSD 13 symptom reactions and 20 percent had PTSD. ServusSchreiber, et al. (1998) reported a 30 percent rate of PTSD 14 in Tibetian refugee children in India. Historically childhood studies of trauma expanded from clinical case reports to systematic comparisons using a ‘dose of exposure’ design with inclusions of 15,16 contemporaneous, comparison and control groups. Over the past decades, there have been advances in the characterization and investigations of post-traumatic stress studies in children and adolescents experiencing catastrophes. In 1987, for the first time, the diagnostic criteria for posttraumatic stress disorder (PTSD) included 17 specific childhood presentations. DSM IV took a step forward with the introduction of developmental modifications to criterion A (experience of trauma) and the symptom cluster B criteria (Reexperience). Although symptom clusters C (Avoidance and numbing) and D (Hyper arousal) have not had developmental modifications, each of these symptom cluster criteria must be met before diagnosis is assigned in 18 children and adoloscents. There is little empirical evidence that the tripartite clustering of symptoms that depict adult PTSD approximately characterize paediatric PTSD. To our knowledge so for just one study has examined the clinical importance of the occurrence of 18 symptom clusters in a paediatric population. A variety of circumstances call for assessment of paediatric PTSD, including referral to mental health clinics and identification of children at risk for developing PTSD after exposure to large-scale trauma such as natural 19 disasters or witnessing violence. Efficient identification of traumatized children at risk would allow clinicians to focus limited resources on these 19 children who are most in the need of clinical attention. 20 As recently pointed out by Shalev et al huge data is available on the psychological consequences of trauma experienced by individuals, but there are few studies on the acute and long term facts of mass trauma on victimized communities. The greatest risk for PTSD among persons having experienced mass trauma are those with significant losses or those without adequate psychological and social S45
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resources.21 Kashmir currently is among the most vulnerable places for various psychological sequelae not only due to the recent natural disasters (snowstorm Feb. and earthquake Oct.2005), but more so because of long standing conflict of more than 15 years. The main aim of the present exercise however is to look for the problems like the one mentioned above among the children and adolescents who have been spending their childhood days in a perpetual situation of mass trauma for more than a decade. Method This study was carried out on the PTSD patients seeking treatment at the Psychiatric Diseases Hospital, Srinagar of Kashmir valley. This hospital being the sole psychiatric disease hospital gets patients from all parts of the Valley. Therefore, the outpatient population does reflect to a satisfactory level the community scenario. The sample comprised of 56 consecutive cases of posttraumatic stress disorder (PTSD). Only one case from each individual family seeking treatment from April 2003 onwards was taken up for study. Patients were diagnosed according to DSM IV laid down criteria. After detailed history and mental status examination, patients were screened for any associated medical problems. Inclusion criteria 1) Age 3 years – 16 years irrespective of sex were included in the study. 2) Patients with common comorbid psychiatric disorders like depression, anxiety disorders and substance use disorders were included in the study. Exclusions criteria i) Those who did not consent ii) Age less than 3 years iii) Age > than 16 years iv) Those with comorbid psychiatric disorders like autistic and other psychotic disorders. v) Those with comorbid medical conditions including cerebral palsy, epilepsy, congenital genetic disorders, deafness and mutism. Results The nature of traumatic experience and frequency of symptom cluster was as follows: (No) (%) A. Trauma Witnessed (42) 75 % Experienced (10) 17.85 % Confronted (04) 7.14% B. Re-experiencing Distressing Dreams/Nightmares Distressing recollections Psychological re-activity Feeling of Reoccurrence
(48) (32) (28) (04)
85.71 % 57.14% 50% 7.15%
C. Avoidance Avoidance of people, places and related activity
(48)
85.17%
S46
Avoid thoughts and conversations Diminished interest Inability to recall an important aspect of trauma Sense of foreshortened future
(24) (32)
42.85% 57.14%
(06) (02)
10.71% 3.59%
D. Hyper arousal Sleep problems Hyper-vigilance Irritability/outbursts of anger Exaggerated startle Difficulty concentrating
(48) (38) (32) (20) (14)
85.17% 67.85% 57.14% 35.71% 25%
E. Onset Acute Delayed
(52) (04)
92.85% 7.15%
F. Longitudinal course (as on first contact) Acute PTSD (16) Chronic PTSD (40)
28.57% 71.43%
Discussion The study of traumatic stress confronts clinicians and researchers alike with a need to approach their subjects with a blend of objective science and awareness of sociopolitical contexts in which the trauma is embedded.22 The present study assessing the PTSD cluster symptom profile of children and adolescents seeking treatment for PTSD, in turmoil affected Kashmir valley, is one of the first kind from South Asian region witnessing chronic conflict situation of more than a decade. Millions of children are exposed to traumatic events each year. Over thirty percent of these traumatized children have been reported to develop post-traumatic stress disorder.23 Despite high number of traumatized children, the clinical phenomenology, treatment and neurophysiological correlates of childhood PTSD remains under studied. The clinical phenomenology of trauma related neuropsychiatric sequelae are poorly charcterised24,25. The least characterized are very young children and children with multiple or chronic traumatic events23. Children’s initial response to trauma is often characterized by physiological and behavioral changes and when the trauma is ongoing the response becomes complicated by dissociation.26,27 Trauma not only overwhelms the individual’s psychological and biological coping mechanisms but also leads to drastic changes in the perceptions of the whole socio-cultural systems which may never be the same again. Death is a new experience for most of the children who might not know what to expect after the loss of a family member or friend. They may be confused or get frightened by the reactions of the other family members, more so in the event of a traumatic death.28 In such a traumatic context the children can present with complicated grief and bereavement which can hamper the diagnosis of PTSD especially among younger children who instead of displaying the core symptom cluster of adult PTSD may mask these underlying symptoms of hyperactivity, distractibility and increased impulsivity that are likely to get confused with ADHD thereby worsening the substantial challenges that PTSD poses to healthy physical, cognitive and emotional development of JK-Practitioner2006;13(Suppl1)
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children.29 This study also needs to be seen in the background of the socio-cultural milieu of our place which is quite different from the west, where from most studies related to traumatic stress have been derived so far. Cluster symptomatology a. Trauma Majority (75%) of cases in our study had witnessed a traumatic event followed by experiencing (17.855) and confronting (7.14%) . The findings of our study are in agreement with the earlier study on PTSD in children and adolescents living in orphanages in Kashmir, conducted by Margoob et al, which reported that 77% of the sample had witnessed violent traumatic event.30 The findings of this study differ from one conducted by Zaffar et al. which was based on treatment seeking adult PTSD population and found that (50%) of cases had experienced traumatic event and only 35% had witnessed a traumatic event.31 The reasons for this could be difference in the age group of sample. b. Re-experiencing Majority (85.71%) of patients in the study had a reexperiencing of traumatic event in the form of disturbing dreams/nightmares (57.41%) and distressing recollections. The findings of our study differ from that of Cuffe et al. (1998), who reported distressing recollections as the most re-experiencing symptom.32 The reasons for the difference could be that the age group of patients in the study conducted by Cuffe et al. was 16-22 years while as the age group of our patients was 3-16 years. c. Avoidance Majority (85.71%) of the cases in our study had avoidance in the form of avoidance of people, places and activities followed by avoidance of thoughts and References: 1. Zaidi LY, Foy DW. Childhood abuse experience and combat related PTSD. J. Trauma stress 1999; 7:33-42. 2. Sedlock AJ, Broad Hustod. Third national incidence study of child abuse and neglect. Washington DC; US Dept. Health Human Services: 1996. 3. American Psychiatric Association (1994). Diagnostic and statistical manual of moods disorders, 4th edition (DSMIV). Washington DC,American PsychiatricAssociation. 4. Breslau, N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P (1998), Trauma and post-traumatic stress disorder in community. The 1996 Detroit area Survey of trauma.Arch Gen Psychiatry, 55: 626-632. 5. Breslau N, Chilcoat HD, Kessler RC, Petersons EL, Lucia VC (1996). Vulnerability to assaultive violence, further specifications of the sex difference in post traumatic stress disorder. Psychol Med 29: 813-821. 6. Breslau N, Chilcoat HD, Kessler RC, Davis GC (1990). Previous exposure to trauma and PTSD effects of subsequent trauma, Results from Detroit area of Survey of Trauma.Am J. Psychiatry, 156: 902-907. 7. Edger Jones and Simon Wessely. PTSD the history of a concept. Aramuc Psychiatry, Vol. 1:1 September- October 2003, page 16. 8. Nemeroff. C. B. Neurobiological consequences of childhood trauma J. Cl. Psychiatry 2004: 65 (Sup.). 9. Stein M.B., Walker J.R., Enderson J.E. et al. Childhood physical and sexual abuse in patients with anxiety disorders JK-Practitioner2006;13(Suppl1)
conversations (42.85%). The findings of our study are in agreement with findings of study conducted by Cuffe et al. (1998), that efforts to avoid thoughts and feelings and efforts to avoid activities that facilitate recollections of trauma are the commonest avoidance symptoms. The findings of our study differ from that of Carrion et al (2002), who reported that avoidance of thoughts, feelings and conversations, were present in the majority (83.1%) followed by avoidance of places 18 and people (59.3%). The reasons for this difference could be due to the difference in sample size, cluster symptoms and traumatic events. In the study by Carion et al., 59 children meeting criteria for only one or two symptom clusters were also included in the study, in contrast to the sample of 156 children meeting criteria for all the three symptom clusters. d. Hyper arousal Majority (85.17%) of the cases in our study had sleep problems/insomnia followed by hyper vigilance (67.85%) . The findings of this study are different from those of Carrion et al, (1998), which concluded that the commonest hyper arousal symptom was difficulty concentrating (65.44%) followed by sleep problems (59.3%). The reasons for this difference could be, that in our study the commonest re-experiencing symptom was distressing dreams/nightmares, which could explain, the increased cases of sleep problems/insomnia. e. Onset/Longitudinal course Majority (92.85%) of the cases in our study had an acute onset and (7.15%) had delayed onset. Majority of the cases (71.43%) were running a chronic course. The findings of our study are in agreement with study conducted by Margoob et al. where they concluded that majority of the cases had an acute onset of symptoms but where running a chronic course.
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