Kathleen discusses gender differences in PTSD diagnosis – women are almost twice as likely to experience PTSD, however this is largely due to differences in the types of traumatic experience experienced by women. For example, the rates of rape and domestic violence are far higher for women.
Kathleen makes the point that in domestic violence, safety should be the primary consideration, and treatment of the consequences of violence is impossible if they are still in an abusive situation.
PTSD is one of many psychiatric responses to trauma. Others include depression and anxiety disorders. Furthermore, most people who have faced trauma will meet criteria for other disorders. Kathleen argues that the comorbidity of PTSD with other diagnoses is an artefact of our diagnostic systems. Rather than trauma causing a number of different disorders, the symptoms experienced represent the complex somatic, cognitive, affective and behavioural effects of psychological trauma.
Post-traumatic sequelae are more likely in the context of a poor social support system, genetic and constitutional vulnerability, recent life stressors or changes, feeling loss of control, recent excessive alcohol or drug intake, and the subjective meaning of the stressor.
Are other factors involved in the gender differences seen in PTSD? Neurochemical responses are very different in men and women. For example, in PTSD, hypothalamic-pituitary-adrenal axis action is dysregulated and the cortisol feedback loop doesn’t function properly, so the flight or flight response continues without the normal level of negative feedback. In recent studies women have been shown to be more sensitive to HPA dysregulation caused by substances of abuse. Oxytocin also reduces the the fight or flight response and is associated with increases in caretaking and affiliative behaviour. Oxytocin is currently being studied as a potential therapeutic agent.
Pharmacotherapeutic treaments can reduce core symptoms, reducing associated symptoms, and facilitate the effectiveness of other therapies. Kathleen reported results of a number of studies which have shown that SSRIs can be effective for PTSD, however she emphasised that psychotherapy options are important, particularly those involving exposure therapy. Other techniques include stress innoculation training, eye movement desensitisation and reprocessing. She argued that there is no evidence for psychodynamic and other therapies in the context of PTSD. This provoked discussion in the questions and answer time around other therapies which are being used and about the importance of contextual factors in addition to therapeutic techniques.
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I would like to clarify the background to my questioning of Prof Bradley at the forum.
What she spoke of was the fact that men are more likely to be the perpetrators of violence and women more likely to be the victims! She spoke of the studies illustrating the different neurochemical responses for men and women. She spoke of the poorer outcomes for victims who have little social support. All true!
What she omitted which was my point is that bigger than differences in the brain, differences in the stereotypic diagram she put up of male and female brains(was meant to be funny, but it also just perpetrates dichotomies of sexuality when in the 21st century we are looking at continuums of sexuality) and something that goes beyond social supports which she spoke of in terms of PTSD outcomes is that:
Violence and gendered violent crimes aka domestic violence/ sexual assault is that it occurs with the prevalence it does, not because of our brains or alcohol or drugs, but also because of the ways in which males are socialised around what it means to be male, about what informs notions of masculinities and around dynamics of power and control! The WHO notes that where there is greater inequity in the law and in domestic life between the sexes you will find greater levels of interpersonal violence! ( a socio/ecological/political context is a perfectly valid perpsective and used by many international organisations in researching this area!)
The second point was about using ‘exposure’ which she did not speak to much at all, which was the problem!
Again there was no context! The use of exposure (in its many forms and it’s not exclusive to CBT) is in a context of SAFETY. The only time safety was mentioned was related to women in DV needing to be safe. This is very true however safety in the context of exposure to the traumatic material is the bedrock, the cornerstone of exposure therapy. close attention must be paid to ongoing, continuous assessing of safety.
”Flooding’ was on a powerpoint slide in the context of a general approach to treating PTSD. I would be concerned if there was no attention to the context of the PTSD given that ‘flooding’ is contraindicated in the treatment of sexual assault or domestic violence trauma.
The lack of attention to these important details meant the presentation was unbalanced and concerned me. There are ongoing discussions about the development of a trauma informed framework in mental health within a recovery oriented system/practice. In order to do this we MUST look at the bigger picture. The presentation seemed to support a focus on individual pathology without context.