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about : trauma
  
 
 
 
      << back to about us index  
 
     
 
• definitions of trauma
• post-traumatic stress disorder
• legal compensation for PTSD
• other traumatic stress-related disorders
• information/guidelines for people affected by trauma
• common signs and signals of a traumatic reaction
• helpful advice for people affected by trauma
• advice to family members and friends
• published articles
 
     
  Definitions of Trauma  
 
•
“A term used freely either for physical injury caused by some direct external force or for psychological injury caused by some extreme emotional assault”. (Penguin Dictionary of Psychology)
•
The result of “exposure to an extreme stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate”. (DSM-IV, 1994)
•
The experience of “a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone”. (ICD-10)
 
     
  Post-Traumatic Stress Disorder  
 
How to Recognise PTSD

According to the 10th revision of the International Classification of Diseases (ICD-10), Post-Traumatic Stress Disorder (F43.1) arises as “a delayed or protracted response” to the experience of a trauma. “Predisposing factors, such as personality traits (e.g. compulsive, asthenic) or previous history of neurotic illness, may lower the threshold for the development of the syndrome or aggravate its course, but they are neither necessary nor sufficient to explain its occurrence. Typical features include episodes of repeated reliving of the trauma in intrusive memories (“flashbacks”), dreams or nightmares, occurring against the persisting background of a sense of “numbness” and emotional blunting, detachment from other people, unresponsiveness to surroundings, anhedonia, and avoidance of activities and situations reminiscent of the trauma. There is usually a state of autonomic hyperarousal with hypervigilance, an enhanced startle reaction, and insomnia. Anxiety and depression are commonly associated with the above symptoms and signs, and suicide ideation is not infrequent. The onset follows the trauma with a latency period that may range from a few weeks to months. The course is fluctuating but recovery can be expected in the majority of cases. In a small proportion of cases the condition may follow a chronic course over many years, with eventual transition to an enduring personality change”.
 
     
  Legal Compensation for PTSD  
 
The circular instruction below clarifies the position in regard to compensation of claims for Post Traumatic Stress Disorder (PTSD). This circular instruction came into effect on 01 April 2003 and supersedes all previous circular instructions in respect of Post Traumatic Stress Disorder:

COMPENSATION FOR OCCUPATIONAL INJURIES AND DISEASES ACT, NO. 130 OF 1993, AS AMENDED (COIDA)

Post Traumatic Stress Disorder is regarded as an occupational injury in terms of the Compensation for Occupational Injuries and Diseases Act, no. 130 of 1993, as amended (COIDA); therefore, an extreme traumatic event or stressor must be an accident as defined in section 1 of the Compensation for Occupational Injuries and Diseases Act, no. 130 of 1993, as amended (COIDA). An occupational injury is an injury caused by an accident arising out of and in the course of an employee’s employment and resulting in a personal injury requiring medical aid or resulting in disability or death and does not include an occupational disease in any form except if that occupational disease results from an occupational injury.

1. Conditions for Eligibility for Compensation
Post Traumatic Stress Disorder is a mental disorder following exposure to an extreme, traumatic event or stressor. A claim for Post Traumatic Stress Disorder shall not be eligible for benefits under the Act unless:

 
     
 
1 1. The employee was exposed to an extreme, traumatic event or stressor, and
2
2. The employee experienced an extreme, traumatic event or stressor that arose out of and in the course of his / her employment, and
3
The employee experienced symptoms of the Post Traumatic Stress Disorder within six months of the accident with medical reports to prove it, and
4 The employment-related trauma or stressor was a pertinent factor in the development of Post Traumatic Stress Disorder or played an active role in the course of Post Traumatic Stress Disorder, and
5
Notice of the claim for compensation was made to the employer or the Compensation Commissioner or the employer individually liable or the mutual association within one year after the date of accident.
 
     
 
2. How Diagnosis is Made
The internationally accepted diagnostic criteria for Post Traumatic Stress Disorder (at any given time) should be used to make the diagnosis of Post Traumatic Stress Disorder. The diagnostic tools available are the latest publication of the Diagnostic and Statistical Manual of Mental Disorders referred to as DSM and the International Classification of Diseases, known as ICD. All suspected Post Traumatic Stress Disorder cases must be referred to a psychiatrist for assessment within one month from the date of suspected diagnosis. Only a psychiatrist should confirm the diagnosis of PTSD. The Medical Officers in the Compensation Office will determine if the diagnosis was made according to acceptable medical standards.
  
     
 
3. Impairment
Impairment shall be assessed on the strength of the Final Medical Report. The Compensation Commissioner shall, whenever she deems it fit, constitute a panel made up of psychiatrists, clinical psychologists, and when necessary, occupational therapists, with a view to assess impairment of the employee. An employee who claims compensation shall when so required, after reasonable notice submit himself at the time and place mentioned in the notice to an examination by the panel. The Compensation Commissioner shall determine the disability in consultation with the said panel whenever deemed necessary. The guide to the percentage permanent disablement shall be based on percentage as guided by Schedule 2 of the COID Act and the degree of impairment and disablement according to psychiatric scales. The impairment will be evaluated using the following:
  
     
 
•
Social and Occupational Functioning Assessment (SOFAS), and
•
Global Assessment Functioning (GAF) Scale, and
•
South African Society of Psychiatrists Management of Disability Claims on Psychiatric Grounds Second Edition (SASOP Guidelines)
 
     
  4. Benefits
The benefits payable according to the Act:
  
     
 
4.1 Temporary Disablement
Payment for temporary total or partial disablement shall be made for as long as such disablement continues, but not for a period exceeding 24 months from the date of the accident. Monthly progress reports must be submitted to the office of the Compensation Commissioner.
4.2
Permanent Disablement
Payment of permanent disablement shall be made, where applicable, when a Final Medical Report and/ or the report from the panel is received. Permanent disablement shall only be determined after 24 months of optimal treatment. The Compensation Commissioner shall calculate the permanent disablement and 100% impairment due to PTSD shall be equivalent to 65% permanent disablement whereas impairment less than 20% will not be awarded permanent disablement.
4.3
Medical Aid
Medical aid shall be provided for a period of not more than 24 months from the date of accident, or longer, if in the opinion of the Director-General, further medical aid will reduce the extent of the disablement. Medical aid covers costs of diagnosis of PTSD by a psychiatrist, any necessary treatment provided by any health care provider and hospitalisation when motivated for by the psychiatrist. The Compensation Commissioner shall decide on the need for, the nature and sufficiency of medical aid supplied.
 
     
  5. Reporting
The following documentation should be submitted to the Compensation Commissioner or the employer individually liable or the mutual association concerned:
  
     
 
• (W.Cl.2) Employer’s Report of an Accident.
•
(W.Cl.3) Notice of Accident and Claim for Compensation.
•
(W.Cl.4) First Medical Report in respect of an Accident / First Psychiatric Report.
• (W.Cl.5)(P) Progress Medical Reports in respect of an Accident / Progress
Psychiatric Reports.
• (W.Cl.5)(F) Final Medical Report in respect of an Accident/ Final Psychiatric
Report.
• Detailed psychiatric/ psychological report.
• All other relevant reports pertaining to the accident, diagnosis and treatment,
where applicable.
 
 
 
6. Claim Processing
The Office of the Compensation Commissioner shall consider and adjudicate upon the liability of all claims. The Medical Officers in the Compensation Commissioner’s Office are responsible for medical assessment of a claim and for the confirmation of the acceptance or rejection of a claim.
 
     
  Other Traumatic Stress-Related Disorders  
 
The ICD-10 includes in its diagnostic coding system other stress-related disorders which arise from exposure to severe stressors.

1. Acute Stress Reaction
“A transient disorder that develops in an individual without any other apparent mental disorder in response to exceptional physical and mental stress and that usually subsides within hours or days. Individual vulnerability and coping capacity play a role in the occurrence and severity of acute stress reactions. The symptoms show a typically mixed and changing picture and include an initial state of ‘daze’ with some constriction of the field of consciousness and narrowing of attentions, inability to comprehend stimuli, and disorientation. This state may be followed either by further withdrawal from the surrounding situation, or by agitation and over-activity (flight reaction or fugue). Autonomic signs of panic anxiety (tachycardia, sweating, flushing) are commonly present. The symptoms usually appear within minutes of the impact of the stressful stimulus or event, and disappear within two to three days (often within hours). Partial or complete amnesia (F44.0) for the episode may be present. If the symptoms persist, a change in diagnosis should be considered.


2. Adjustment Disorders
States of subjective distress and emotional disturbance, usually interfering with social functioning and performance, arise in the period of adaptation to a significant life change or a stressful life event. The stressor may have affected the integrity of an individual’s social network (bereavement, separation experiences) or the wider system of social supports and values (migration, refugee status), or represented a major developmental transition or crisis (going to school, becoming a parent, failure to attain a cherished personal goal, retirement). Individual predisposition or vulnerability plays an important role in the risk of occurrence and the shaping of the manifestations of adjustment disorders, but it is nevertheless assumed that the condition would not have arisen without the stressor. The manifestations vary and include depressed mood, anxiety or worry (or mixture of these), a feeling of inability to cope, plan ahead, or continue in the present situation, as well as some degree of disability in the performance of daily routine. Conduct disorders may be an associated feature, particularly in adolescents. The predominant feature may be brief or prolonged depressive reaction, or a disturbance of other emotions and conduct.

3. Dissociative [Conversion] Disorders
The common themes that are shared by dissociative or conversion disorders are a partial or complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of bodily movements. All types of dissociative disorders tend to remit after a few weeks or months, particularly if their onset is associated with a traumatic life event. More chronic disorders, particularly paralyses and anaesthesias, may develop if the onset is associated with insoluble problems or interpersonal difficulties. These disorders have previously been classified as various types of “conversion hysteria”. They are presumed to be psychogenic in origin, being associated closely in time with traumatic events, insoluble and intolerable problems, or disturbed relationships. The systems often represent the patient’s concept of how a physical illness may be manifest. Medical examination and investigation do not reveal the presence of any known physical or neurological disorder. In addition, there is evidence that the loss of function is an expression of emotional conflicts or needs. The symptoms may develop in close relationship to psychological stress, and often appear suddenly. Only disorders of physical functions normally under voluntary control and loss of sensations are included here.

  
     
  Information/Guidelines for People Affected by Trauma  
 

Trauma is a shocking, unexpected experience that is characterised by extreme fear and/or horror. It is the kind of experience that would shake up most people, although individuals may react quite differently. What may seem like a minor event to one person could be a traumatic experience to another. Typical examples of trauma experiences are: violence, natural (or man-made) disasters, explosions, shootings, motor vehicle accidents, rape, robberies, hi-jacking, etc.

Following a trauma most people experience some unusually strong, even frightening reactions, emotionally and physically. These reactions are the typical after shock of a horrible event - they are normal reactions to an abnormal experience. Most often these reactions appear shortly after the event, but there can sometimes be a delay. In fact, it may seem one is coping well, and then suddenly you are overwhelmed by intense emotional and physical reactions.

 
     
  Common signs and signals of a traumatic reaction  
 
Physical Feelings Behaviour Thought
Tremors, heart racing, dry mouth, sweating, indigestion
Extreme vulnerability.
Panic when a memory of the event is triggered.
Need to talk about the event / need to not talk about it.
Social withdrawal

Tendency to avoid anything related to the event
Flashbacks

Preoccupation with recurring memories and thoughts about the event
Change in sleep patterns, difficulty sleeping, bad dreams, nightmares
Insecure, frightened, suspiciousness
Restlessness, irritability.
Poor problem solving
Tiredness, lack of energy and drive
Violated
Exploited
Increased use of chemical substances
Poor concentration, absentmindedness
Change/loss of appetite
Helpless, powerless
Tearfulness
Hyperventilation, dizzy
Out of control
Headache, muscle ache
Self-doubt
Chest pains
Anger
 
     
  Helpful Advice for People Affected by Trauma  
 

Remember: you will not be your usual self for a while. Keep in mind: your reactions are normal – you are not falling apart or losing your mind – your reactions are a part of the normal recovery process

  
     
 
•
Structure your time - keep occupied.
•
Talk to others; explain to others what you have been through. If you find it easier, you may choose to write about your experiences
•
Structure your time; keep occupied
• Be careful of drugs, alcohol and medication to make things easier. Tranquillisers and sleeping tablets are highly habit forming and could complicate your recovery process.
• Reach out for others; ask for support – do not try to be “strong” or carry it all by yourself.
• Maintain your normal daily routine as far as possible; try to keep to your exercise routine.
• Give yourself permission to feel rotten, to feel afraid and out of sorts. Be patient with yourself - you will not be yourself for a while.
• Try to do the things you usually find relaxing and enjoyable.
• It is useful to seek professional counselling before problems have started, even if you feel you are coping fine. The object of counselling is to prevent complications, rather than try to fix problems afterwards.
• The natural tendency is to avoid the place where a trauma happened. This is normally not a problem, but if the trauma happened in your normal living or working environment, it is very important to not get into a pattern of avoidance - it is important to get back onto the horse immediately when you have been thrown.
• Do not make any big life decisions for a while.
• Eat well-balanced and regular meals, even if you do not feel like eating.
 
     
 
The typical trauma reactions diminish after a few days and in most cases your life will return to normal after approximately three to four weeks. If it takes longer you should get treatment as soon as possible from a properly trained psychologist.
  
     
  Advice to Family Members and Friends
 		 
 
•
Listen carefully, give them time to talk.
•
Try to understand that what they went through is very real and very distressing. Show empathy - it is not their fault. What they need most of all is for you to recognize and accept their feelings and that you understand their reactions.
•
Spend time with them.
• Help them regain a sense of safety.
• Do not expect them to cope fully with their responsibilities initially. Help them re-establish their routine gradually, not all at once.
• Do not panic or worry that something is wrong if they cannot stop crying or if they seem to be overwhelmed by their feelings. Intense emotional turmoil and physical upheaval is normal after a trauma, and it will settle down if you give it time and support.
• Do not take their anger or other feelings personally.
• Do not tell them that they are “lucky it wasn’t worse” - traumatised people are not consoled by those statements. Show understanding and empathy, in stead, for what they are going through.
• Advice like “Think positively”, “Put it behind you”, “Don’t think about it”, does not help – it tends to make victims of trauma feel weak or incapable because they cannot get the bad experience out of their minds.
 
     
  Publications and Papers by traumaClinic Staff  
 
Van Wyk, G. (1987). Divorce in South Africa. Struik Publishers: Cape Town

Van Wyk, G. (2003). Trauma in the workplace. Working document for the traumaClinic.

Van Wyk, G. (2003). Taking on the challenge to trauma counselling: A new model for assisting the victims of trauma. Paper presented at 2nd South African Conference for Psychotherapy, Grahamstown, 24 - 26 June, 2003.

Van Wyk, G. (2004). Trauma debriefing debunked: A proposed alternative model for assisting trauma victims. Paper presented at 4th International Congress of Psychic Trauma and Traumatic Stress, Buenos Aires, 24 - 26 June 2004

Van Wyk, G., & Edwards, D. (2005). From trauma debriefing to trauma support: A South African experience of responding to individuals and communities in the aftermath of traumatising events. Journal of Psychology in Africa, 15 , 135-142.

Van Wyk, G. (2005). R eview of early intervention with a group of South African survivors of the Tsunami. Paper presented at 9th Conference of the European Society for Stress Studies, Stockholm, June 2005.

Van Wyk, G. (2006). A business model for delivering large scale early trauma intervention. 4th World Conference on Traumatic Stress, Beunos Aires, June 2006.

Van Wyk, G. (2007). The problem of work-related trauma. 10th European Conference on Traumatic Stress, Opatija, June 2007.

Van Wyk, G. & De Jong, J. (2009) Introduction to trauma and traumatic Stress: An African perspective on practice, intervention and policy. In print.

By other authors
Bisson, J.I., McFarlane, A.C., & Rose, S. (2000). Psychological debriefing. In E.B. Foa, T.M. Keane, & M.J. Friedman (Eds.), Effective Treatments for PTSD. New York: The Guilford Press.

Boscarino, J.A. (1995). Post-traumatic stress and associated disorders among Vietnam veterans: The significance of combat exposure and social support. Journal of Traumatic Stress, 8, 317-366.

Bremner, J.D., Southwick, S.M., Johnson, D.R., Yehuda, R., & Charney, D.S. (1993). Childhood physical abuse and combat-related posttraumatic stress disorder in Vietnam veterans. American Journal of Psychiatry, 150, 235-239.

Brewin, C.R., Andrews, B., Rose, S., & Kirk, M. (1999). Acute stress disorder and posttraumatic stress disorder in victims of violent crimes. American Journal of Psychiatry, 156, 360-365.

Bryant, R.A., Harvey, A. G., Dang, S.T., Sackville, T., & Basten, C. (1998). Treatment of acute stress disorder: A comparison of cognitive behaviour therapy and supportive counselling. Journal of Consulting and Clinical Psychology, 66, 862-866.

Conte, J.R., & Schuerman, J.R. (1987). Factors associated with an increased impact of child sexual abuse. Child Abuse and Neglect, 11, 201-211.

Davidson, J.R.T., Hughes, D., Blazer, D.G., & George, L.K. (1991). Post-traumatic stress disorder in the community: An epidemiological study. Psychological Medicine, 21, 713-721.

Eagle, G.T. (1999). Trauma intervention: Charting the territory. New Therapist, 4, 24-31.

Eagle, G.T. (1998). An integrative model for brief term intervention in the treatment of psychological trauma. International Journal of Psychotherapy, 3 (2), 135-147.

Edwards, D. (2003). Understanding the psychological effects of trauma: Implications for supportive counselling, debriefing and psychotherapy. Paper presented at 2nd South African Conference for Psychotherapy, Grahamstown, 24 - 26 June 2003.

Ehlers, A. and Clark, D.M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319-345.

Everly, G.S., & Mitchell, J.T. (2000). The debriefing “controversy” and crisis intervention: A review of the lexical and substantive issues. International Journal of Emergency Mental Health. 2, 211-225.

Foa, E.B., Keane, T.M. and Friedman, M.J. (Eds.) (1998). Effective Treatments for PTSD: Practical Guidelines from the International Society for Traumatic Stress Studies.

Foa, E.B., & Rothbaum, B.O. (1998). Treating the trauma of rape: Cognitive-behavioural therapy for PTSD. New York: Guilford.

Forbes, A., & Roger, D. (1999). Stress, social support and fear of disclosure. British Journal of Health Psychology, 4, 165-179.

Gelpin, E., Bonne, O., Peri, T., Brandes, D., & Shalev, A.Y. (1996). Treatment of recent trauma survivors with benzodiazepines: Prospective study. Journal of Clinical Psychiatry, 57, 390-394.

Gist, R., & Woodall, S. (2000). There are no simple solutions to complex problems. In J.M. Volanti

Harvey, A.G., & Bryant, R.A. (1999). Predictors of acute stress following motor vehicle accidents. Journal of Traumatic Stress, 12, 519-525.

Herman, J.L. (1992). Trauma and Recovery: From Domestic Abuse to Political Terror. New York: Basic Books.

Hobfoll, S.E., Dunahoo, C.A., & Monnier, J. (1995). Conservation of resources and traumatic stress. In J.R. Freedy and S.E. Hobfoll (Eds.), Traumatic Stress:From Theory to Practice. New York: Plenum Press.

Hodgkinson, P.E. (1998). Coping with Catastrophe: A Handbook of Post-Disaster Psychosocial Aftercare. Routledge.

Joseph, S.A., Brewin, C.R., Yule, W. & Williams, R. (1991). Causal attributions and posttraumatic stress in adolescents. Journal of Clinical Psychology and Psychiatry, 34, 247-253.

Joseph, S.A., Brewin, C.R., Yule, W. & Williams, R. (1991). Causal attributions and psychiatric symptoms in survivors of the Herald of Free Enterprise disaster. British Journal of Psychiatry, 159, 542-546.

Kessler, R., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048-1060.

King, L.A., King, D.W., Fairbank, J.A., Keane, T.M., & Adams, G.A. (1998). Resilience/recovery factors in posttraumatic stress disorder among female and male Vietnam veterans: Hardiness, postwar social support, and additional stressful life events. Journal of Personality and Social Psychology, 74, 420-434.

Litz, B.T. (Ed.) (2004). Early Intervention for Trauma and Traumatic Loss. Guilford, New York.

Litz, B.T., Gray, M.J., Bryant, R.A. & Adler, A.B. (2002). Early intervention for trauma: Current status and future directions. Clinical Psychology Science and Practice, 9. 12-134.

McFarlane, A.C. (1989). The aetiology of post-traumatic morbidity: Predisposing, precipitating and perpetuating factors. British Journal of Psychiatry, 154, 221-228.

McFarlane, A.C. (1988). The longitudinal course of posttraumatic morbidity: The range of outcomes and their predictors. Journal of Nervous and Mental Disease, 176. 30-39.

Mitchell, J.T. (1998). Stress development and Functions of a Critical Incident Debriefing Team. JEMS, December, 43-46.

Mitchell, J.T. & Everly, G.S., Jr. (1995). The critical incident stress debriefing (CISD) and the prevention of work related traumatic stress among high risk occupational groups. In G. Everly & J. Lating (Eds.) Psychotraumatology: Key Papers and Core Concepts in Posttraumatic Stress, (pp.159-169). New York: Plenum Press.

Newman, E., Riggs, D., & Roth, S. (1997). Thematic resolution and PTSD: An empirical investigation of the relationship between meaning and trauma-related diagnosis. Journal of Traumatic Stress, 10, 197-214.

Nishith, P., Mechanic, M.B., & Resick, P.A. (2000). Prior interpersonal trauma: The contribution to current PTSD symptoms in female rape victims. Journal of Abnormal Psychology, 109, 20-25.

Prout, M. F. and Schwarz, R.A. Post traumatic stress disorder, a brief integrated approach. International Journal of Short-Term Psychotherapy, 6, 113-124.

Resick, P.A. (2001). Stress and Trauma. Psychology Press, UK.

Resick, P.A. (1988). Reactions of female and male victims of rape and robbery. (A final report, Grant No. 85-IJ-CX-0042). Washington, DC: National Institute of Justice.
Resick, P.A., Calhoun, K.S., Atkeson, B.M., & Ellis, E.M. (1981). Social adjustment in victims of sexual assault. Journal of Consulting and Clinical Psychology, 49, 705-712.

Rose, S., Bisson, J and Wessely, S. (2003). Psychological debriefing for preventing ost traumatic stress disorder (PTSD) (Cochrane review). The Cochrane Library, Issue 1. Oxford: Update Software Ltd.

Rothbaum, B.O & Schwartz, A.C. (2002). Exposure Therapy for Post-Traumatic Stress Disorder.
Am. J. Psychotherapy, p.56.

Ruch, L.O., & Leon, J.J. (1983). Sexual assault trauma and trauma change. Women & Health, 8, 5-21.

Ruch, L.O., Chandler, S.M., & Harter, R.A. (1980). Life change and rape. Journal of Health and Social Behaviour, 21, 248-260.

Shelby, J.S. and Tredinnick M.G. (1995). Crisis intervention with survivors of natural disaster: Lessons from Hurricane Andrew. Journal of Counseling and Development, 73, 491-497.

Sierles, F., Chen, J., McFarland, R., & Taylor, M. (1983). Posttraumatic stress disorder and concurrent psychiatric illness: A preliminary report. American Journal of Psychiatry,140, 1177-1179.

Straker, G. (1987). The continuous traumatic stress syndrome: The single therapeutic interview. Psychology in Society, 8, 48-79.

Wenninger, K., Ehlers, A. (1998). Dysfunctional cognitions and adult psychological functioning in child sexual abuse survivors. Journal of Traumatic Stress, 11, 281-300.

Wirtz, P.W., & Harrell, A.V. (1987). Assaultive versus nonassaultive victimization: A profile analysis of psychological response. Journal of Interpersonal Violence, 2, 264-277.