User:Jwinship/Continuous traumatic stress

CONTINUOUS TRAUMATIC STRESS DISORDER (CTSD)

•	DEFINITION OF CONTINUING TRAUMATIC STRESS DISORDER (CTSD)

•	DIFFERENTIATING CTSD FROM PTSD AND C-PTSD

•	HISTORY OF TERM

•	SYMPTOMS /AREAS OF FUNCTIONING AFFECTED IN CTSD, PTSD AND C-PTSD

•	TREATMENT IMPLICATIONS

•	REFERENCES

DEFINITION OF CONTINUING TRAUMATIC STRESS DISORDER (CTSD)

Continuous Traumatic Stress Syndrome/Disorder is a term introduced into the trauma literature by Gill Straker (1987). It was originally used by South African clinicians to describe the effects of exposure to frequent, high levels of violence usually associated with civil conflict and political repression. The term is also applicable to the effects of exposure to contexts in which gang violence and crime are endemic as well as to the effects of ongoing exposure to life threats in high-risk occupations such as police, fire and emergency services.

DIFFERENTIATING CTSD FROM PTSD AND C-PTSD

The essential feature of CTSD is that the stress underlying the syndrome is current and not historical. This differentiates it from Post Traumatic Stress Disorder (PTSD) and Complex-Post Traumatic Stress Disorder (C-PTSD)and has treatment implications even though the effects of CTSD overlap with those reported in PTSD and C-PTSD.

HISTORY OF TERM

The term continuous traumatic stress syndrome/disorder (CTSD) was first used by South African clinicians to describe the effects they observed in township activists resisting apartheid. The term was originally introduced into the literature by Gill Straker (1987) to indicate that for those living under apartheid, traumatic stressors were all too present and current and that in addition to the symptoms of PTSD there were further effects of living with continuous traumatic stress.

Initially the term continuous traumatic stress syndrome was used rather than the term continuous traumatic stress disorder, This was a political choice, meant to indicate that the effects of exposure to continuous traumatic stress may be predictable but they do not indicate mental illness as indicated by the incorporation PTSD into DSM. However, as the symptom pattern flowing from continuous traumatic stress overlaps so much with PTSD, the term continuous traumatic stress disorder was later adopted. Despite the wish not to pathologise those suffering from CTSD there was also recognition of the importance of the syndrome being recognized by the medical fraternity and its treatment funded. This was especially the case as the effects of immersion in a context of frequent exposure to life threatening stressors are more extensive than those implicated in PTSD where the exposure is more limited.

The effects of contexts of high-level exposure to traumatic stress were subsequently developed by Judith Herman (1992) in her notion of C-PTSD. However, at the point of intervention in C-PTSD, the stressors are in the past and this differentiates it from CTSD where the stressors are current. Furthermore, the contexts that were the focus of Herman’s work were predominantly contexts of domestic violence rather than political, criminal or occupational violence. This has implications for both symptom pattern and treatment.

SYMPTOMS/AREAS OF FUNCTIONING AFFECTED IN CTSD, PTSD AND C-PTSD

The symptom profile of CTSD includes all of the symptoms of PTSD, as does C-PTSD. However, the difficulties of those suffering from CTSD and C-PTSD are more extensive. According to Herman there are there are eight areas of functioning affected in C-PTSD. These include affect regulation, consciousness, somatization, self-perception, perception of the perpetrator, relations with others and systems of meaning.

In CTSD these seven areas are affected but less pervasively than in C-PTSD. In contexts of CTSD, there are islands of safety that promote resilience. There is more possibility of escape in contexts of CTSD and, unlike C-PTSD, the locus of violence in CTSD is not the family. Refuge may be sought in the family and in community groups. The family may also be successful in shielding younger children from some of the worst stressors in the CTSD environment. Thus the effects of CTSD are not as pervasive as those associated with C-PTSD but they are still more pervasive than those associated with PTSD.

In regard to the seven areas of functioning outlined by Herman (1992)as pertinent to C-PTSD, the greatest areas of overlap with CTSD are in affect regulation, consciousness and systems of meaning. Those suffering from CTSD show considerable difficulty regulating affect. Consciousness is affected as there is both numbing and hyperactive vigilance, as is the case in PTSD, and beyond this there are also transient episodes of dissociation. Systems of meaning are affected but as the context of CTSD is often one of political resistance, systems of meaning may not only be undermined but also may also be strengthened and consolidated.

The areas, which most differentiate between those suffering CTSD and those suffering C-PTSD are relationship to the self, relationship to the other and relationship to the perpetrator. Unlike those suffering C-PTSD, individuals in contexts of CTSD often are not isolated but are strongly connected into social support networks as there is solidarity in resisting the adversity of the context. Individuals suffering CTSD are also less likely to see themselves as different from all others as their adversity is often communal and is witnessed. It is not secret as is often the case in contexts of C-PTSD, which are usually domestic contexts. Individuals suffering CTSD are also not likely to develop a relationship of gratitude to perpetrators, as is sometimes the case with those suffering C-PTSD. Those experiencing CTSD may however become preoccupied with notions of revenge in regard to powerful others who uphold the system of oppression. The main area of difference between CTSD and both PTSD and C-PTSD remains however the approach to treatment, which is dictated by the current nature of the stressors in CTSD.

TREATMENT OF CTSD

In treating both PTSD and C-PTSD the first priority is to provide physical safety so that the work of coming to terms with what has happened may commence. This provision is not possible in contexts of CTSD. Furthermore, therapists in this context are often under threat themselves, a fact which complicates issues of transference and counter-transference, and the interventions that are possible (see Straker, 1988 and Straker and Moosa, 1994 ).

Interventions into CTSD often take place in circumstances that provide temporary relief but there can be no permanent provision of physical safety in contexts of ongoing political and community violence. This means that the provision of safety has to be carried by supporting those psychological defenses that maximize the individual’s capacity to live in a hostile world.

These defenses include

•	vigilance in regard to external dangers,

•	mobilizing social networks

•	intra-psychic compartmentalization so that a differentiation can be maintained between internal self-other states associated with danger and internal self-other self states associated with safety

•	isolation of overwhelming affect from thought

•	adherence to overarching ideologies and/or faiths that promote internal coherence

The provision of safety also has to be carried by modifications in the framework within which therapy usually occurs. For example rather than having regular times for sessions and a regular venue, these need to be varied to reduce the risk of attack by the state or gangs.

Eagle (2010), who has worked extensively with traumatic stress in South Africa, summarizes the modifications and techniques suggested by Straker and colleagues (1987) as follows: Each session needs to be a standalone intervention as it is not certain if the person will return for further sessions. Given this, sessions should not be time limited. Not only does trust need to be established at the beginning of each session but special care must be exercised to ensure that at the end of the session the person feels adequately contained and present enough to function in the hostile environment to which they are returning.

A strong focus on coping mechanisms and defenses that are useful in managing fear and the real dangers in the outside world is advocated. As far as possible, the individual is helped to distinguish real from imagined potential risks. In other words, there is a focus on enhancing the capacity to reality test and discriminate real from imaginary threats bearing in mind that there are indeed real threats in the environment. Realistic fears are not diminished and survival strategies are explored.

In speaking through past traumas, the discussion is as far as possible factual and limited to understanding cognitive components of the events. Associations to sensory, emotional and physical aspects of the events are avoided but should they arise they are contained and an attempt made to help the individual contain their affect at least by the time the intervention is concluded. The reason for this is that strong affect may interfere with the capacity to judge risk in a context that is inherently dangerous. Nevertheless, some engagement with traumatic material is crucial. It is also important that therapist holds meaning and hope for the client despite the pull toward despair that may assail therapists who themselves are inserted into the same hostile environment as the client.