A.C. McFarlane :UNDERSTANDING AND MANAGING THE CONSEQUENCES OF VIOLENCE AND TRAUMA

Since post-traumatic stress disorder (PTSD) was first included in the diagnostic nomenclature in 1980, a range of epidemiological studies have demonstrated that its prevalence is greater than originally anticipated. These studies suggest that PTSD accounts for a degree of disability and financial cost second only to major depressive disorder The more general question remains as to the extent to which traurnatic events convey significant risk for the onset of other disorders such as major depressive disorder, substance abuse and suicidal behaviour. What is particularly noteworthy from these epidemiological studies, is that events characterised by interpersonal violence involving the direct physical assault of individuals account for higher rates of morbidity than other traumatic events, such as accidents These findings are of particular importance, given the rates of communal violence and violent crime in countries where there are great divides of wealth or endemic poverty. The consequences of violence within these communities can create a cycle of revenge and hatred that locks those involved into a spiral of self-destructiveness. Similar patterns have been identified in indigenous communities struggling with the problems of substance abuse and social disenfranchisement An emerging body of evidence suggests that the rates of violence directed against psychiatric patients with disorders such as schizophrenia and bipolar disorder are an issue of maj . or concern. The impact of these assaults on the cïurse of their underlying mental illness has largely been unexplored to date. One of the challenges is to create a broad awareness of the importance of post-traumatic morbidity amongst mental health professionals and increase the levels of expertise in this domain. Traumatic events that effect large groups, such as disasters, can provide unusual opportunities to create better understanding of the effects of trauma among mental health professionals generally. Studies in a range of clinical populations indicate that PTSD is often missed as a diagnosis, preventing the instigation of the appropriate treatment. Also, a broader perspective using a public health approach should address the social disadvantage and structural issues that contribute to the prevalence of trauma within the cormunity. A variety of effective treatments exist for PTSD, including medication, cognitive behaviour therapy and eye movement desensitization and reprocessing (EMDR). There is a need for other treatments to be considered in treatment trials, because avoidance leads to less than optimal uptake for treatments using exposure. Also, for thevictims of rape and other forms of violence, addressing the social context and the needs for interpersonal safety are critical components to an effective clinical intervention. Medication can play an important role in facilitating the engagement in treatment and in the management of associated affective symptoms, hyperarousal and dissociation. At the core of effective treatment, is an understanding about the linking of the reactivation of the traumatic memory by triggers in the environment of the individuals, and giving them a degree of control and understanding of their reactivity. Failure to address the PTSD symptoms in the victims of criminal and politically inspired violence such as torture further disadvantages individuals who are already disadvantaged from the experiences they have to endure. Inadequate treatment further exacerbates this disadvantage.