CHRONICISED POSTTRAUMATIC STRESS DISORDER IN ADOLESCENTS

ABSTRACT:

Post-traumatic stress disorder is characterized by recurrent re-experiencing a trauma (e.g. memory problems, flashbacks high-lighting moments of experienced trauma, nightmares, etc.), developing a phobia about certain people, places that recall an event trauma, sleep disturbances, trouble concentrating, irritability, anger, difficulty concentrating, hypervigilance to threatening act. In posttraumatic disorder with chronic evolution the clinical picture is atypical at first consultation, and the positive and differential diagnosis is more difficult because of psychotic symptoms, panic attacks and dissociative disorder. To illustrate these statements we present two cases who were admitted in our hospital with a atypical clinical picture which would have raised suspicion of an acute psychotic disorder, anxiety or a dissociative disorder. A careful history and evolution over time led to the diagnosis of chronic posttraumatic stress disorder. In both cases the intervention was done with high-doses of medication and psychotherapy and the evolution was favorable.

The Posttraumatic Stress Disorder is a recent condi-tion, recognized as such in the early 1980s, which cur-rently defines its clinical features and therapeutic mo-dalities. The core characteristics of this condition have been excellently defined in DSM IV, 1994, as the trig-gering of an immediate response of intense fear, help-lessness or horror. The traumatic experience is relived in the next period by recurrent, intrusive, memories, including images, thoughts, perceptions with obsessive character, dreams, and nightmares refiecting what had happened. In addition, there is a sense of living the experience again,with fiashbacks and anxiety states, with anxiety at the contact with stimuli that evoke the event, followed by avoiding the places and people involved, by feelings of detachment or estrangement from others.

The effect of major psycho trauma during childhood and adolescence tends to be larger, leading to the idea of a more severe post traumatic disorder, which was called Complex Post Traumatic Stress Disorder (C-PTSD described by J. Ford) that includes a whole range of difficulties arising from the early damage of the self-regulatory systems. These disorders tend to chronic evolution.

The following features characterize the Complex Post-Traumatic Disorders:

1. Emoţional disorders,
2. Pathological dissociation,
3. Somatic disorders triggered by stress.

EMOŢIONAL DISORDERS

Emoţional disorders are defined by marked af-fective instability; emotions are very intense, chang-ing colour several times during the day, varying from anger, despair, paralyzing guilt, and self-depreciation.

The individuals cannot regain their control and the ability to think clearly for long periods, even if others try to calm them or to assure adequate support.

In the case of a 15-year-old adolescent, the emoţional disorder, which debuted two years before, used to alternate between sharp anxiety, up to restlessness, discontent, and anger crises resulting in destruction of objects triggered by the recall of the traumatic scenes and in states of inhibition, depression. On admission to hospital, at times, the patient seemed psychotic, especially because he had severe accusations against his par-ents who allegedly had not protected him sufficiently and had allowed strangers to touch one of his objects.

In the second case, a 16-year-old girl suffered from a state of anxiety, with periods of inhibition that, in moments of vexation, could lead to crises of anger with loud manifestations leading to pseudo-convul-sion events, with fainting. Disturbances occurred al-most a year before.

DISSOCIATIVE DISORDERS

They imply immediate and involuntary loss of the ability to know who one is, the patients do not know who their interlocutors are and do not recognize their own feelings or thoughts. There is a process of nar-rowing of the field of consciousness and the patients feel they are in a dream state. Dissociation may lead to feelings that the patient has no control over his/her body or mind, experiences derealisation, feels that he/ she is unreal. Hart, Nijenhuis and Steele (2005) have recently highlighted the importance of dissociation phenomena in complex posttraumatic stress disorder, considering them a major feature, incorporating the iniţial comments submitted by P. Janet in the early nineteenth century. The complex includes all the clas-sic manifestations of the dissociative group.

In the case of the 15 year old boy, feelings of dep-ersonalization (“I am not, I do not know who I am”) or derealisation (“I no longer know where I am”) have been described. They used to occur during extreme panic states, followed by alarming blackouts.

In the case of the 16-year-old girl, the state of dep-ersonalization occurring during the anxiety states and during the moments of confrontation with colleagues was followed by pseudo-convulsions with functional-hysterical aspect.

These disorders appear to be a sign of a biologi-cal, emoţional and cognitive overload with persistent character requiring adequate recognition in order to avoid wrong diagnosis and to place them in the psychotic register.

SOMATIC DISORDERS

Individuals suffering from the complex posttraumatic stress disorder may have poor health, which can be explained neither by a somatic disease nor by physical trauma. Patients complain from chronic pain or say they feel as if their body were broke and loose.

In our cases, no somatoform disorders were re-ported, the symptoms remained in the psychic spec-trum. An important aspect is disorder in the sphere of identity, self-esteem and finding a purpose in their lives.They tend to be self-critical and even hate them-selves, and have great relaţional problems. They often feel desperate and that life is meaningless. They may engage in risky behaviours such as fights, accidents or phobic avoidance of situations at risk for aggression. When traumas that had occurred represent intenţional attacks, an alteration of the aggressor’s perception takes place too, being imaginatively hypertrophied or magnified. Negative beliefs and emotions appear, in-cluding powerlessness, chronic hatred, intimidation.

In our case, the boy was very self-critical, he felt powerless, had the deşire to punish those who humili-ated him, but he felt unable to do so, he wanted to be brave, to be able to revenge his humiliation. He was shy and avoided encounters with his aggressors.
The psycho-traumas consisted of harassment, in-sults, possible impacts caused by a group of children envious of his family’s good material condition. The aggressors used to call him names in classroom, on the street or even at his window, using mocking humiliating words. His exaggerated pride and shy nature prevented him to ask for help or to respond to other colleagues in a proper manner. It was difficult for the patient to blame himself and he directed his anger to his parents who would have to guess the difficulties their son was facing and to take action, which might have created the image of a paranoiac development.

The content of the psycho-traumas is interesting, possibly specific to adolescence: conflicts, physical aggression or aggressive, repeated harassment, creating an atmosphere of rejection with humility, which leads to marginalization. Self-esteem is affected, a narcis-sistic injury, particularly painful at this time of a fragile ego. It gets worse, especially if patients have no resources to meet the challenge adequately, are shy, too well bred, lacking the experience of physical confrontation and living the experience of the defeat in a painful manner. In fact, it is considered that trauma is what happens inside the individual who lives it and not the actual content of the aggression.

In both cases, there were verbal abuses, and in the case of the girl, there was a physical aggression too. Only the energetic intervention of the family and authorities, with complaints registered by the police, could stop the violence.

Even if the attacks have been stopped, once the psychopathological process had started it could no longer be stopped and it continued its evolution, with no clear trend of chronicisation and without the pos-sibility of spontaneous closing of what suggests a process of internai self-organization. The classic concept, “removal of the trauma will erase the symptoms”, did not work. Durable psychopathological nuclei had been constituted.

The essential factor in diagnosis was the psychopathological complex, which is easily overlooked if the haunting images come in the first plan, sometimes so vivid that they can be considered visual or auditory hallucinations, when the victim recalls the insulting words in his/her consciousness.

The boy in question, recalled the images hundreds of times per day, they had an obsessive character (were intrusive recollections) triggering a state of great ten-sion, of fury associated with other disorders, typical for the posttraumatic stress syndrome.

The importance of the perceptual factor, of the psychic tension and agitation led to the diagnosis of schizophrenic psychosis, which in turn led to the rec-ommendation of a treatment with neuroleptics. The patient followed this treatment for a few months with moderate, rather insignificant results. Psychotherapy treatment was applied, too rather far from the psy-chopathologic nucleus.

The procedure was similar for the patient who also had obsessive images and dissociative disorders. She had psychotherapy treatment, too, but with endless repetition of the description of the psycho-trauma-tizing event that the patient felt as an inopportune reminder, activating the psychopathology.

The therapeutic management started from the reality of severe biochemical disorder reflected in agitation, anxiety or intense and lasting anger, obsessive images. Cures of neuroleptics were prescribed, (clopixol, risperidone, levomepromazine, antidepres-sants, anxiolytics and mood stabilisers), and main-tained for a long period.

To this medication, for the boy, a psychotherapeu-tic cure was added, which was performed on several stages according to the model of psychotherapy coun-selling. A first stage of empathic listening, with de-tailed description of the trauma and suffering endured was followed by focusing on the feeling of anger, on the deşire for revenge; then, the description of actions taken by him was resumed and his deşire for punish-ment by choosing a future career as judge. Together with sedation, the therapy went on to his conduct in relation to his feeling of anger, concluding that the patient does not make any effort to control it and that he loves acting like that as a sign of manhood.

From the combative attitude, one may infer the transition to a new stage of adolescent development, of assertion, characterized by nervousness, parental criticism, and discontent. It was concluded that, it is fit for a man to go from being a whiny person to one characterised by self-possession, and control over the states of anger through various methods. Further, during the next meetings, the focus was on developing self-control, on the appropriate methods and on how he can become a “real man”. Counselling sessions for the family were conducted, too. Parents were advised to listen to the boy without fear or excessive sympathy and to involve the adolescent in fun activities.

The evolution has been very good at the control, with the obsessive images deleted, emoţional balance recovered and a successful return to school. The teen-ager could not help himself and slammed one of his former offenders in the face several times, who did not understand the significance of the gesture. When he was asked why he acted like that, he could give no explanation.

For the girl, a supportive attitude on the part of the family was proposed, with minimum attention given to psychopathological aspects and with encour-aging attitudes of confrontation with the dangers.The evolution was good, but slow (over 6-8 months).

Thus, psychotherapy in adolescents includes mea-sures of personality maturation, of increasing resil-ience, together with increasing the capacity to con-front difficulties.

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