Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

There are a range of psychological, social and psychiatric and neuro psychiatric problems. Um And it's very easy to overestimate the members of them because when they occur, they tend to be very debilitating and maybe long term. Then of course, the thing we've been discovering and discussing in great detail during the pandemic has been the topic of mel distress and moral injury. And I do think those two things are quite different for people who respond and intervene in events including therefore healthcare staff. The I think the biggest of the mural is the fourth bullet point. It's what uh disasters and conflict royal fair and individual emergencies due to your relationships and your sense of community. And as Fritz put it a long time ago, it's about disrupting the social context in which people and groups of people function from those I think stems some of the most pervasive effects. And if I go down to the next slide which just summarizes this is a dreadful slide because it does so much injustice to the sciences. Um But for simplicity, I break things down into these kind of blocks of effects. We have learned a lot about distress. I have said that it's universal and that is different to acute stress reactions which the British began to study in the First World War. But what we found in Manchester was that almost all our subjects in the research we did still were distressed. Despite us telling people that it would go away within a fortnight to a month. They were still distressed three years later. And that is a very important outcome from that research because I think it debunks some of the mythology. And then of course, we mustn't forget grief and it's in that background, against that background that we need to think of the diagnosable mental disorders, which some people in some cases, quite a large number of people may develop. I always stress, substance use disorders because they're very frequent. There's adjustment disorders and post traumatic stress disorder, depression and anxiety disorders. If I go to the next slide, it is to examine the effects of being exposed more than once to traumatic events. And I don't set any time limit on this because it can be, there can be a 20 year gap, there can be a 20 minute gap, but it seems from the initial summaries that have been done with this. What we're realizing now is just how many people have had multiple exposures. A preliminary analysis breaks down the ways in which traumatic events or multiple exposures to traumatic events, cumulative effects where one event piles on top of another. And as I say, the intervals can be quite long, but it's noticeable in these people, there seems to be a greater likelihood of common mental disorders and post traumatic stress disorder and a much greater rate of deliberate self harm. And then they're interactive effects where the joint effect seems to produce a more complex experience for the p people who have suffered. For instance, they enable powerful combinations of physical and mental health impacts. And I think we saw that after the events in Paris in 2015, it was the police and particularly those who have been to other events before who seemed to become physically incapacitated and some of them never got back to work. And then we get what I call indirect effects that is usually due to changes in the social conditions, a social fabric of communities and society. So that by multiple exposures, people suffer increased poverty, domestic and community violence. In addition to any other violence that may be offered, there are threats to people's human rights and changed relationships. And all of those are the kind of conditions that actually propel the prevalence of mental disorders very powerfully. Let's look at the experiences that characterized distress. If we divide it into emotional cognitive, social and physical reactions. The right experiences in this slide are those that are common in people who are mildly affected. The green ones have a much more serious indication for people who are much more likely to go on and develop mental health conditions. So for instance, people who experience anger and guilt are much more likely to develop things like post traumatic stress disorder and people whose cognitions are affected are also in that category. And people who experience conflict between them and other people also and then headaches. Somatic complaints are not good indicators of a good outcome. I'm now just moving very briefly to intervention. All this leads us to review that early interventions, the things that you do in the days and first few weeks after some traumatic event should be about supporting people and bolstering the environment in which they're recovering. And that of course, is much more difficult where wholesale changes take place in people's social conditions or they're going to be exposed to further violence. We need to help people to restore their sense of being an agent of having power over there, what's going to happen to them. And those are also things that are diminish in the course of warfare. People need to see themselves as effective person's in the first World War. The French developed this notion that we now call pies. There are two very good hopers that show that if we use pies, people have much better outcomes, lower rates than you would expect of posttraumatic stress disorder and swifter recovery's and it stands for proximity that is delivering supportive straightforward interventions close to where people are with speed immediately with an expectancy that people will recover. And as I say, these responses should be simple throughout the pandemic. I've been working with a lot of staff in healthcare services with a review view to using those kind of approach is what we have often done is to focus on removing secondary stresses. That's the things like not having access to sufficient protective equipment. And we've also instituted a network of programs of peer support. We teach nurses to support each other quite straightforward ways just to summarize that coping, adjusting and recovering to very substantially on being supported. And there is a definition of social support. But social support consists of social interactions that provide people with assistance, but also embed them in a web of relationships that they are perceived to be caring, loving and readily available. The second thing that's important is ensuring that everybody and they may be soldiers or they may be healthcare staff, whatever has access to somebody else. But the military has that for a long time, worked on a buddy, buddy system and that appears to be very good from a psychological point of view. So we need to make sure that our buddies who make sure that we're that we're wearing our equipment properly. Um Also need to think about us as people and how we're coping social cohesion and cooperation, ineffective teams is absolutely vital, which is probably why soldiers tend to do better than perhaps you might imagine they do because that social occasion becomes camera dory and is part of the thing that keeps people functioning. But it's this sense of belonging to a valued social group or community, which is really critical and being well lead. I have two final comments. One is to say that if you look carefully at that list of things which are helpful, they're all quite simple in many ways but also difficult to do. And in our health service in the UK, uh we've got into big troubles with staff and large. It's because many of these things that I've listed on that slide have been eroded were never there. At the time of pressure. We need these things more than they can be available. I'm now going to hand over to John Bisson who was going to talk about some much greater things to do with psychiatric ill health. So I'm going to talk about post traumatic stress disorder. One of my favorite series I have several is this study, which is an Australian study that looked at just over 1000 people admitted with a traumatic injury that required hospitalization of at least one day. So a lot of people would be presenting obviously with orthopedic injuries. So one year following the admission to hospital, 31% of individuals satisfied the criteria for a psychiatric disorder. And interestingly of those, about two thirds of them had a new psychiatric disorder. So one big message from this talk really is that people have psychiatric disorder before they get injured and we'll continue to have psychiatric disorder after they have been injured. So it's important not to always think that the psychiatric disorder, if you like is secondary to the injury, and if we look at the types of condition, then depression and generalized anxiety disorder with a communist 9% with post traumatic stress disorder and agoraphobia 6% each. So, in other words, post traumatic stress disorder, although we perhaps think of it as being the disorder that occurs following traumatic events isn't the commonest condition that people will suffer from following exposure to traumatic events. And in 91% of people with post traumatic stress disorder, they also had a diagnosable comorbid condition. So in other words, post traumatic stress disorder rarely occurs in isolations from other conditions. And interestingly, the rates of psychiatric disorder were stable over time. So about a third of people had psychiatric disorder at three months and at one year, but actually they weren't the same people. So there were 40 to 45% new people with conditions of anxiety, depression at a year. And that means that 40 or 45% no longer had a diagnosis who had a condition at three months. So in other words, it's a rapidly changing picture often in, in people, if you diagnose somebody with a condition at three months, they're not necessarily going to have it at a year. In fact, in this study you had about a 60% chance of still having it at a year and off the people who had a diagnosable condition, then a third sort mental health treatment and that's in a well resourced country. The World Health Organization has shown in research that you're much less likely to seek mental health treatment in a less well resourced country. So really, this points to something that Richard has done a lot of work on is the different trajectories of symptoms that people have. And if you look at the natural course of traumatic stress symptoms in individuals, then they vary a lot. You get some people like on the yellow line who get immediate symptoms, they stay high. Other people as in the pink line at the bottom half have no symptoms at all and never get any. And then you get some people who have none and then they increased, some people who have a lot and they decrease and some who have very fluctuating pictures. So it's very important when you're treating individual to monitor their own trajectory of symptoms rather than making assumptions that they may go higher or lower or whatever. So what is post traumatic stress disorder? This is complicated somewhat because we now have two separate classification systems that have kind of diverged from each other. The diagnostic and statistical manual of mental disorders, which is the American Psychiatric Association and the ICD 11, which is the World Health Organization's classification system. Post traumatic stress disorder is one of the very few psychiatric conditions where a prerequisite for the diagnosis is having an event occurring before it. And the two definitions I've listed here are the, the DS um 51 exposure to actual threatened death, serious enduro sexual violence and the 11 1, which is a bit broader exposure to an event or situation, either short or long lasting of an extremely threatening or horrific nature, Which evidence definition we go for clearly, these are very extreme events and I suspect events that the majority of people will satisfy. So they will have had a PTSD qualifying traumatic event. I'm going to focus on the I C D 11 definition of post traumatic stress disorder. I personally prefer, it's um it's simpler and it's designed to facilitate clinical utility. So to satisfy the criteria for ICD 11 PTSD, you need one of two re experiencing symptoms, either flashbacks or powerful images of the events with a sense that you're actually back there in the situation again or nightmares. Do you need one of two avoidance symptoms? Why either avoiding thinking or the feelings that you experience from the trauma or situations like places people activities that may trigger reminders of what happened. And then you need one of two hyperarousal symptoms, increased sense of threats where you might be very jumpy, have an increased started reaction to sudden bangs or noise is and also hypervigilance where you're very wary of danger and very, very concerned about the risks that maybe around you with my CD 11 post traumatic stress disorder as, as I described it. But there's also a sibling condition called complex post traumatic stress disorder, where you need additional symptoms. In addition to the three groups of symptoms I described for post traumatic stress disorder. So these are emotional regulation difficulties where individuals may have difficulty controlling their emotions, for example, getting very angry and not being able to call that in or becoming very detached. Associated as a response to a stress or the next group of symptoms and negative self concepts are feeling diminished, defeated, worthless, shame, guilt, despair, to very negative feelings about oneself. And then the final group of symptoms are disturbed relationship. So persistent difficulties in feel close to other people and little interest in relationships or social engagement. So becoming quite detached really from other people. We diagnose post traumatic stress disorder and complex post traumatic stress disorder according to the symptoms I describe but complex post traumatic stress disorder is definitely commoner in individuals who have experienced multiple traumatic events and more complex traumatic situations in a lot of the military veterans that I see in the United Kingdom. Their presentation is more one of complex post traumatic stress disorder than of post traumatic stress disorder alone. You're probably very familiar with different guidelines in the orthopedic world in the mental health world. We tend to follow evidence based guidelines when we're recommending treatments. And these are three examples. The National Institute for Health and Care, excellent guidelines in the United Kingdom, the International Society for Traumatic Stress. That is and also guideline. It's called Matrix Camry Matrix Plant, which are are Welsh NHS guidelines for treatment. So the good news is that there are a lot of treatments that can be helpful that people with post traumatic stress disorder. So both talking therapies and pharmacological therapies have been shown to be helpful for people of all the ages. So in terms of prevention, this is a paper that we had published last year, which was a systematic review of all studies that have tried to look at preventing post traumatic stress disorder, both psychological and pharmacological and the results are disappointing actually. So in terms of prevention, there's nothing we can hand on heart, say definitely prevents people from developing post traumatic stress disorder. But there's some limited evidence for a few different interventions, which really means more work is needed before we would recommend them. It's important to note that there were only 84 people included in those four studies and we've got quite a lot of heterogeneity. So in other words, our confidence in this is not high, but it shows some evidence that EMDR is effective when you treat people with early symptoms of post traumatic stress disorder, when it comes to treatment is far better evidence. So for people who've had their symptoms for three months or more, we can be very confident that various forms of psychological therapy, cognitive processing therapy, cognitive therapy, individual CBT with a trauma, folk, prolonged exposure are effective. And the thing that all of these treatments have in common is that they're based on cognitive behavioral therapy. So, therapists that try and affect the way you think and the way you behave and also they focus on the traumatic events itself. And then there are some other interventions that have a lower level of evidence guided internet based cognitive behavioral therapy with the trauma focus by research into that. And we've just completed around the mice controlled trial that show equivalent effectiveness to face to face CBT with a trauma focus. We're working with colleagues to try and think about developing an internet based CBT with the trauma focus that could be adopted at scale. And then for pharmacological treatment, drug treatments, there's good evidence that the drugs, FLUoxetine, paroxitine surgically and Venlafaxine or commonly used antidepressants can help with symptoms of post traumatic stress disorder, some evidence but lower evidence for QUEtiapine and antipsychotic drug and then lower levels still for other pharmacological therapists. So for post traumatic stress disorder, we have different psychological and pharmacological treatments that can be effective for complex post traumatic stress disorder. Inevitably, the treatment is a bit more complex and the evidence isn't as good or as strong for what works and what doesn't work. And when I'm recommending management and I would do this for everyone. I always recommend a full biopsychosocial assessment. So looking at the individuals, any biological factors or physical factors, psychological factors and also social factors, all of which are going to impact on an individual's presentation and may be addressed in separate ways. And for complex post traumatic stress disorder, usually the treatment is longer, it needs different types of treatments. So it's multidisciplinary and it's important to co produce management plans. So to discuss with the individual what they would like to receive within the availability according to their needs. And even though trauma focused work can be very helpful for complex PTSD, we often do things in a more phased approach. So we're focusing on stabilization of an individual situation, their social situation, looking at their basic needs before moving onto formal treatment. I mean, I would say that for everybody as well. So really, I mean, I think from an orthopedic surgeon standpoints, there are some overarching principles of support that that I would recommend to you. So practical pragmatic support provided in an empathic and collaborative manner and then building on existing socio economic support structures, especially families and communities are critical to supporting anyone following a traumatic event. The honest and open provision of information is important. It's very important to be on open and honest with people and also to promote safety, a sense of self and community efficacy, connectedness, calming and hope. The factors that Steffan hopeful has advocated as Richard pointed out before avoiding over medicalization and further harm. And I guess one of the key roles that you will have is to identify individuals who you feel are at high risk and arrange for them to have further assessment and treatment. When indicated, you know, I recommend this booklet to you, which is a World Health Organization booklet which describes the psychological first aid framework of the World Health Organization. And this advocates a look listen link approach where you're observing for safety, basic needs, serious distress, listening to what people have to say in helping them to feel calm and also giving people information and addressing their basic needs and then helping them get additional support if they need it. And the book look goes through a variety of different coping mechanisms, how to encourage positive coping strategies in people to discourage negative ones. And I think these are all good basic principles of psychological first day interventions that care providers can deliver even if they're not mental health specialists. And then there are lots of resources out there. Now, this is something that we've produced, which is a toolkit to help people with some basic techniques like relaxation, grounding themselves, helping themselves if they're having a flashback or dissociating. And again, these sorts of resources are things that it really advocates to you. They can be downloaded handed to people or people can be given links to download them themselves. And I think can be very helpful basic early interventions to help people developing more difficulties or even to manage difficulties that they have.