Under Siege

by Belinda Neil

  CHAPTER

  23

  PTSD and what can be done

  Policing is sometimes to referred to as a contact sport. It is an occupation that carries risks to both physical and emotional health. The issue is when it is known how risk can be minimised, but the appropriate steps are not put in place. Since I succumbed to PTSD a series of measures have been adopted, including additional psychological and welfare checks on police in the areas I worked. The real concern, however, is the constant exposure to traumatic situations. I believe there is scope for change in this area that would benefit the NSW Police Force and its officers.

  Psychiatrist Dr Greg Wilkins, who has been treating NSW police officers for over twenty-five years, has said, ‘If the police serviced their cars the same way they service their personnel, it would mean removing all warning lights, oil and water gauges from the dashboard, welding down the bonnet, and as soon as the vehicle stops going or starts blowing smoke, discard the vehicle and get a new one!’

  Professor Alexander McFarlane, a leading world expert in PTSD and the head of the University of Adelaide Centre for Traumatic Stress Studies, says the more people are exposed to trauma on a regular basis, such as soldiers, police or paramedics, the more their brain changes and the body’s stress system becomes more sensitive. ‘The idea is that people get tougher and get used to things and the effects of stress go away,’ he states. ‘The fascinating thing is that the body actually does keep score and so next time around you are so much more vulnerable.’

  Early intervention is crucial in treating PTSD, and the best person to detect signs of potential psychological dysfunction is a supervisor or family member. One of the first things a PTSD-affected person loses is the ability to monitor their own emotional state and track their internalised world.

  This may explain why I never believed I had a problem. If I had, I could have sought assistance many years earlier and perhaps my symptoms would not have been so severe. Perhaps I could have taken time out before the next trauma exposure.

  A joint paper by Professor Alexander McFarlane and Professor Richard Bryant (University of NSW), ‘Post-traumatic stress disorder in occupational setting: anticipating and managing the risk’, states that:

  …it can be useful if supervisors can detect signs that may indicate an individual is experiencing some PTSD reactions. The negative impact of traumatic events can manifest in a variety of indirect ways which employers should be alert to.

  • Increased alcohol use

  • Interpersonal and/or family conflict

  • Social withdrawal

  • Depression

  • Somatic distress (physical pain and discomfort)

  • Performance deterioration

  In June 2011, anonymous survey results were published as a result of a review of injury management practices in the NSW Police Force. Taking into account the signs listed by professors McFarlane and Bryant, it is interesting to note the different perceptions of the police hierarchy and the psychologically injured worker. Managers, duty officers and commanders expressed frustration that psychological injury claims were accepted as a result of workplace conflict or conduct issues. No consideration was given that workplace conflict and conduct issues could possibly stem from a psychological injury.

  Injured workers expressed frustration at the lack of support from their commanders and management, believing there needs to be a change in culture and perception of injured officers. One person surveyed referred to ‘comments by commander that they thought my injury was not genuine’.

  This survey was initiated seven years after I was diagnosed with PTSD, but these were the very same attitudes I encountered with my own commander and a duty officer when I went off on sick leave.

  As a result of this review the NSW Police Force introduced the Workforce Improvement Plan, a major part of which advocated improved education and awareness in all police, combined with training in injury management and interpersonal communication skills for supervisors and senior management. Another notable recommendation was increasing leadership development to all ranks. If these recommendations are properly carried out they will constitute an important and well overdue change in the current culture. The recommendations must be implemented to have an effect.

  The Australian Army has taken a similar approach. Retired General Peter Cosgrove has admitted his former scepticism about psychological health programs and adds, ‘I have changed my mind, because what the evidence shows is the earlier the intervention and support given to any soldier diagnosed with a psychological problem, the better the chance they have to minimise its effects … The key is the availability of, and access to, experts in post-traumatic stress’ (Newcastle Herald, 24 April 2013).

  Early intervention can involve anything and everything, including

  • Supervisors tracking their individual team members’ trauma load

  • Supervisors identifying potential psychologically affected officers

  • Discreet one-on-one conversations between the injured officer and an appropriate supervisor with follow up and support

  • Removal or respite from frontline duties or from further exposure for a specific period

  • Referral to mental-health professionals who have credibility and experience in PTSD

  • The prescription of appropriate medication if required

  The credibility of both supervisors and mental-health professionals is paramount, otherwise the psychologically affected officer will never declare his or her concerns. I know of incidents within the NSW Police Wellcheck program where officers have been sent for health checks to junior psychologists who have little or no experience with PTSD. Sometimes they have been sent to a different psychologist each time so no continuity or significant building of rapport was possible.

  While there is much research to support early intervention, the situation of the psychologically injured worker who has seen horror or been continually exposed to trauma also needs to be considered. It may be impossible to minimise the effects of PTSD for someone in this situation. It is these emergency and defence-force personnel that I especially feel for. I have been there, as have close friends of mine.

  The best advice I can offer to fellow sufferers is this. Firstly, psychoeducation is critical. Gather knowledge about your condition, whether it’s PTSD or another ailment. Ask your mental-health professional for information about your illness, and speak to others who have been in a similar position. They understand! My research helped me gain insight into my condition, and into why I was acting in a particular way. It served to make me feel less alienated and gave me a focus on how I could help myself.

  Secondly, accept that you have a problem. With acceptance comes the ability to receive the right treatment. You will no longer struggle to understand why you are behaving in an unusual way. You will have the tools to help you manage your condition, even though there will still be good and bad days. Let your family in, and they will help you. You need support, and once you accept this you will better manage your symptoms.

  You can’t stop the waves, but you can learn to surf.

  Joseph Goldstein

  I recall a day in 2012 where I was surfing beyond the break. I was still a novice board rider but I caught an amazing wave. I stood up and rode this green unbroken wave for what seemed like forever. It felt as if I almost made it onto the shore before it broke.

  It was exhilarating. Grinning from ear to ear, I paddled back out to where the seasoned surfers were all waiting for a wave. A few of them gave me a smile and a couple made comment on the ‘good wave’, or ‘good ride’ I had. I laughed, saying, ‘I finally felt like a real surfer.’

  After years of struggling in the surf, trying to swim against the current and being smashed by the waves I no longer feel as if my head is underwater and I am gasping for breath. I am finally enjoying the ride and I am confident of the journey ahead.

  It has been a very difficult journey and there have been setbacks, but each day life gets b
etter.

  APPENDIX

  The use of Putative Cerebellum Exercises to Control and Relieve Symptoms of PTSD

  by Greg Wilkins

  Post-traumatic Stress Disorder (PTSD) is a disabling disorder that affects approximately 8% of the population at some point in their life. The disorder is associated with significant morbidity and functional impairment. The pathophysiology of PTSD involves a complex interaction between trauma-related factors and the neurobiological and psychosocial influences that determine individual differences in resilience and vulnerability1.

  Patients who present with PTSD exhibit a change in their cognitive function which manifests as specific problems with attention shifting, attention splitting, following instructions, short-term memory, poor impulse control, and a distorted sense of linear time.

  In the early 1990s, Prof McFarlane2 referred to PTSD as sharing some of the cardinal features of Attention Deficit Hyperactivity Disorder (ADHD). Several programs report improvement in cognitive function of patients with ADHD3 using physical exercise techniques believed to stimulate the cerebellum. They also report improvement in several other features of patients with ADHD, i.e., impulse control, short-term memory, sense of time, connectedness to others and communication ability. While the neurophysiological processes underlying these benefits are unclear, the empirical evidence prompted us to examine the benefits of such exercises on PTSD.

  Two patients with (PTSD) are presented who used ‘cerebellar-stimulating’ exercises as means of managing their PTSD symptoms.

  A thirty-five-year-old female patient who had been exposed to multiple traumas over many years presented with long-standing symptoms of PTSD. She had participated in several types of therapy including medication and cognitive behavioural therapy (flooding, cognitive reframing) with minimal impact on her symptoms. Specifically she described avoidance, hyperarousal, preservative thoughts reliving specific traumas, physical symptoms of anxiety, flashbacks, intrusive thoughts, nightmares, poor sleep, emotional numbing, a distorted sense of linear time, poor short-term memory, poor concentration, poor planning and execution of tasks, difficulty following conversations and feelings of depersonalisation.

  She was introduced to a novel physical exercise designed to stimulate her cerebellar function. The patient stood and balanced on a wobble board while juggling two balls. This exercise was performed for five minutes twice daily.

  The patient reported a marked improvement in all aspects of her symptoms within the first two weeks of commencing this exercise regime. Of note was a marked shift in her ability to recall details of her various traumas, and to talk about them without developing dissociation and anxiety seen prior to commencing the exercise. She stopped the exercises after twelve weeks. Three months after ceasing the exercises she had maintained her recovery. She has not received other treatment since the time of commencing the exercises and she has remained well. Her initial PTSD Checklist – Civilian score was 78 and fell to 25 after performing the exercise4.

  The second patient was a twenty-four-year-old male who had suffered a single horrific incident several months prior to presenting in which he had sustained several physical injuries and seen several close colleagues seriously injured. He described persistent symptoms of hyperarousal, re-experiencing specific sounds and pictures of the trauma, physical symptoms of anxiety, intrusive thoughts, nightmares, poor sleep, emotional numbing, social withdrawal to the point of not being able to leave his house, a distorted sense of linear time, poor short-term memory, poor concentration, poor task completion, unable to participate in conversations other than brief and superficial interactions with his partner and a feeling of depersonalisation.

  He was diagnosed as suffering with acute PTSD. He was introduced to the putative cerebellar exercise. He was asked to stand on one leg and close his eyes until he became unstable when he would either open his eyes or lower his leg to regain his stability. Once stable he would repeat the exercise and this continued for five minutes twice daily. His initial PTSD Checklist – Civilian score was 72 and fell to 42 after performing the exercise.

  He continued the exercise for six weeks and reported a marked improvement, which continued for further six weeks after ceasing the exercise. He described a calming effect and was also able to give a detailed account of the trauma without the recurrence of his symptoms. He was able to feel the anger and fear without re-experiencing the actual trauma as he had invariably done prior to commencing the exercises.

  Since these exercises involved balance and postural control, they stimulate the cerebellum. The role of the cerebellum in cognitive function has come under increasing scrutiny. In an examination of carefully matched cohort of children who had experienced significant psychological or emotional trauma, De Bellis demonstrated that the cerebellum of the traumatised subjects was significantly reduced in volume from that of the controls5. The traumatised subjects were also likely to suffer from an ADHD-like syndrome.

  A group of fourteen patients suffering with PTSD have been assessed and treated with the conventional treatment for PTSD and the putative cerebellar exercise. The duration of treatment ranges from four to twelve weeks. The results confirm a benefit in the relief of PTSD symptoms as indicated by the PCL-C scores (see figure 1).

  Figure 1

  McFarlane6 has proposed a neural network model of PTSD, which is relevant for our current understanding:

  in PTSD repetition instigates the mechanisms of iterative learning, top-down activation and pruning. The development of the symptoms of PTSD being explained by current knowledge about modelling disturbances of parallel distributed processing. The noradrenergic neurones play a central role in co-ordinating the interaction of multiple cortical regions, which is an essential aspect of parallel distributed processing. Disturbances of this system in PTSD are likely to manifest as a dysfunctional modulation of working memory and involuntary traumatic recollection. Modifications of neural networks have a secondary effect of kindling in the hippocampus that further moderates the individual’s sensitivity to a range of stressors. Therefore, a neural network model of PTSD provides a method for conceptualising the onset of PTSD symptoms and their subsequent modification with the passage of time.

  Consistent with this model is that the cerebellum has been referred to as an adaptive controller7, i.e., a system having the capability to adjust or optimise its own parameters automatically. One of the likely functions of the cerebellum is to provide the ‘timing or clock’ by which neural networks are set and regulated, timed and co-ordinated. In PTSD and ADHD, symptoms may come about as a result of some flaw in this ‘clock’. This disruption or flaw would account for many of the cardinal symptoms of both disorders.

  The dramatic reduction in symptoms in this group of patients suggests that this mode of treatment warrants systematic investigation. If the efficacy is indeed established, the underlying neurobiological processes can be investigated.

  The current hypothesis is that the exercise(s), which is (are) relatively complex and require considerable processing of data by the cerebellar, may invoke some restoration / correction of the adaptive controller, i.e., cerebellar function.

  Footnotes

  1. Connor KM., MD. and Marian I. Butterfield, MD., M.P.H. Focus Posttraumatic Stress Disorder REVIEW 1:247–262 (2003) © 2003 American Psychiatric Association

  2. McFarlane AC., Weber DL. and Clark CR., Abnormal stimulus processing in posttraumatic stress disorder., Biological Psychiatry. 34(5):311–20, 1 September 1993

  3. The DORE Program, Mind Gym

  4. DeBellis M., Developmental Traumatology: Neurobiological Development of Maltreated Children with PTSD. Paper presented at the Royal Australian and New Zealand College of Psychiatrist on 24 May 2005, Sydney, Australia

  5. Weathers F., Litz, Huska & Keane, Posttraumatic Stress Disorder Symptom Checklist – Civilian Version (PCL_C for DSM-IV), National Centre for PTSD (11/1/1994)

  6. McFarlane AC., Yehuda R. and Clark CR., Biologic models of traumatic memories
and post-traumatic stress disorder. The role of neural networks. Psychiatric Clinics of North America. 25(2): 253–70, v, June 2002

  7. Barlow, John S., in ‘The Cerebellum and Adaptive Control’, Chapter 17, pp273, The Cerebellum as an Adaptive Controller, pub Cambridge University Press, 2002

  SOURCES

  This book is drawn from my memory of various incidents with help from my duty books, police incident reports, briefs of evidence — including statements and transcripts of interviews — NSW police negotiator reports and course notes, fellow investigators, negotiators and tactical police, the Australian Police Journal, court reports, and my diaries. In addition I acknowledge specific assistance in the listed chapters.

  Chapter 2 Sydney Morning Herald article dated 23 June 1989. ‘Sweethearts at 6am: Shots and a man dies’.

  Chapter 3 The National Guidelines for the Deployment of Police in High Risk Situations – Australasian Centre for Policing Research. Police Commissioners’ Policy Advisory Group, 1992.

  State Protection Group, Negotiation Unit, Lecture notes

  Tactical Advice: thanks to Rob, former Senior Instructor Level 3 and Tactical Team Leader.

  State Protection Support Unit Course report 1994

  Chapter 5 Recollections from Rob concerning incident at Burwood.

  Chapter 6 R v De Gruchy [2000] NSWCCA 51 (2 March 2000)

  Chapter 7 R v Mailes [2003] NSWSC 707 (1 August 2003)

  Chapter 9 R v Martin and Cushman [1999] NSWSC 1048 (14 September 1999)

  Chapter 10 NSW Police Service Weekly Vol 8 No 3, 22 January, 1996 p8

  Chapter 13 Regina v Offer [2000] NSWSC 839 (25 August 2000)

  R v Offer [2002] NSWCCA 341 (20 August 2002)