 Well, today we are going to take up another topic related to stressful experiences, but this time our discussion would be little different. What we have done till now is that we had looked at certain situations which are otherwise designated as a stressor by the individual and how that situation, that stressor induces certain physical, behavioral and psychological changes. And we had talked about how stress actually evolves and overpowers an individual. Today what we had done was we had taken certain stressful situation at the workplace which can ultimately make a person feel completely emotionally exhausted, that was the state of burnout. Now the condition for a stress and burnout is that at the given point in time when you develop those symptoms, you should be having such situation around you. Today we are going to talk about post traumatic stress or popularly called as post traumatic stress disorder PTSD, where the actual stressful situation has already taken place. So as of now you exactly do not have the stressful situation in front of you, it has occurred in the recent past and now you are showing certain symptoms and therefore it is called post traumatic. So the traumatic state is over, during that state you did not develop these symptoms, but once that state is over you will start showing certain types of symptoms. I have deliberately written here post traumatic stress, I have removed disorder, but when we go ahead the next slide onwards, we will be referring it as PTSD basically which refers to disorder, because the classification proposed by the diagnostic and statistical manual consider this to be a disorder. But the last slide pertaining to PTSD would be where we would talk about the recent arguments which says that it should be considered only as post traumatic stress and should not be considered as disorder. Now historically if you look at PTSD it is a relatively new addition to the DSM and it is also you know popularly called as post Vietnam syndrome. There is a interesting history you know as to how PTSD got included in the list of disorders in the DSM, we are not going into that. But it found a place in DSM 3 the diagnostic and statistical manual which is considered to be a bible of diagnosis for different type of psychological disorders. So this was a special type of symptoms which were realized during the Vietnam war in many of the soldiers and this is how people coined the new word called post traumatic stress. In fact if you look at the whole you know history of clinical psychology and how different types of disorders were identified, how their symptoms were identified. You would realize that you know two wars have really contributed a lot to the development in these two areas. One is the second world war a large number of you know psychological disorders and their symptoms were identified during the war and then PTSD which is actually a byproduct of the Vietnam war. Now we directly would jump to the major criteria that is used to diagnose PTSD. I will recommend that you should not write it you know because you are not going to practice as clinical psychologist in future. So there is no point noting it down, we will understand it. A brief summary I will again you know forward it to you. Now these are the diagnostic criteria for PTSD and what you find written here is actually what has been written in the DSM. When you read it I will read it here now and then we will explain it. Understand two three things know what plays key role in terms of identification of the disorder. So we will have A, B, C and then again we will have one, two, three likewise. The person has been exposed to a traumatic event in which both of the following were present. Means the major important criteria is that the person who is being diagnosed with PTSD should have actually been exposed to a traumatic event a precondition. Now this clause A has three sections one, two and three. One says the person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury or a threat of physical integrity of self or others. So it has again a very wide spectrum. You should have either experienced it personally one, two, you were not involved somebody else was experiencing it first hand but then you were a witness to it or was confronted with an event or events that involved actual death or threatened death or actual serious injury or threatened serious injury. So finally what you realize is that somewhere you realize that your survival is at stake one, two somebody else's survival was at stake but then you were a witness to it. Say somebody has been shot dead and you were a witness should be covalent to death. The first clause, the second clause which says that the person's response involved. So now when you personally experience it or when you witness it what actually you should have what should have been your response and it includes intense fear, helplessness or horror. And it says that in children this manifestation could be in terms of extremely agitated behavior. So section A which basically says that you should have had threatening stimuli in your environment and it says that either you should have personally experienced it or you should have witnessed it and your personal experience or witnessing the situation should have been accompanied with reactions like horror, like intense fear, like helplessness. So this is the first important denominator. Second important denominator the traumatic event is persistently re-experienced in one or more of the following ways. Now comes the interesting dynamics of this PTSD. The first clause that we discussed was there is a traumatic event and you are the first and experience of it, you have that first and experience or somebody else is experiencing it and you are a witness to it. Now it says that whatever you saw at the first place now it starts coming back to you. So you are now persistently re-experiencing it in certain forms what forms one recurrent and intrusive distressing recollection of the event including images thoughts or perceptions. This means that you can know it comes to you as certain flashbacks whatever had happened it comes to you in the form of recurrent. So periodically that experience comes to you it is intrusive means you are involved in some other task suddenly this experience intrudes your conscious awareness and this recollection of the event is very distressing for you. It might come in the form of images suddenly you know somebody who has been stabbed at visual comes, you sit in the class you look at the slide and suddenly that visual comes that is intrusive thought, intrusive image. It could be intrusive thought now that whole process you start thinking of it or it could be you know intrusive perception. So that is one, two recurrent distressing dreams of the event you do not have the conscious recollection but it repeatedly comes in the form of your dream. So you reportedly have the content that experience which you had yourself experience or witnessed in the form of dream. 3 acting or feeling as if the traumatic event was reoccurring and this can have many, many, many, many symptoms. 4 intense psychological distress at exposure to interval or external cues that symbolizes or resembles an aspect of the traumatic event. Now you experience that situation or you were a witness to that situation. Anything that comes in the present time which resembles to any of the cue that was available there that suddenly you know makes you psychologically feel extremely distrustful your reaction changes. I will give an example real life example of this and the fifth one the physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. Now you have your entire physiological mechanism also reacts to it. So basically what it says is first criteria, criteria A was that you should have either experienced it yourself or you should have been a witness to it. The second criteria says that the hopelessness, the fear, the horror that you experience know when you personal experience or witnessed it comes back to you in the form of intrusive thoughts, intrusive images. You have perception of it which basically disturbs you and if that does not happen it might come back to you in the form of repeated dreams. Finally anything which resembles to the earlier experience of yours if anything that resembles very much closure to it again comes back to you your psychological reactions and your physiological reaction matches that of the actual stressful event. I will give you a real life example long back there was massive earthquake in Uttarakhand Pitholagar was the area which was which had the which was the primary sufferer and there were many many casualties and the major problem basically was that those in that locality there were many houses which were basically not cemented properly. So you had piles of stones put over each other and there was no adhesive to put all of them together many people died. Now this event happened long after this I think more than 2, 3 months after this event somebody a labour who was working at a construction site suddenly started having tremor. His whole hand started shaking whole body started shaking he had profuse sweating. What was the event at that time? A truck had come with the boulders that was a construction site. So some concrete and stone chips were needed for construction. So this whole truck had come with big boulders it was a truck with the hydraulic facility. So the moment it reached the construction site the driver had just put one end you know go little up so that the boulders can automatically fall down. This labour who was working somewhere nearby heard this sound and suddenly had tremor and profuse sweating. The labour's around him thought that perhaps he had you know some extreme physical problem anticipation was some type of cardiac arrest or something like that. So he was taken to a primary health centre nothing was diagnosed he was taken later on to a hospital nothing was diagnosed later on it was realized that this man happened to be from Pythagore and was one of the survivors of the earthquake that had taken place there. He lost his family members in the earthquake and therefore he had to migrate all the way from Pythagore to one of the urban areas of UP for his livelihood. This whole sound of stone chips rolling down from the hill top that sound resembled the sound of the boulders falling from the hydraulic truck. So the queue he got from here and immediately he associated with the earthquake in Pythagore and all that traumatic experience was recollected within fraction of seconds. This is what this means know that once you have any internal or external queue that resembles to the traumatic event your trauma gets reactivated. Your psychological and physiological mechanism will start reacting the way it had done in the actual scenario. So this is criteria b. Now we come to criteria c persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness as indicated by 3 or more of the following. Now you have a list of 7 different types of reactions minimum 3 or more you should certainly show in your behavior to be diagnosed with PTSD. One efforts to avoid thought feeling or conservations associated with the trauma. So there is a desperate attempt shown by the individual to avoid the thoughts and the feelings associated with trauma. Two efforts to avoid activities places or people that arouse recollections of the trauma. So any person place or any activity that gets associated with the earlier experience the person always would try to avoid confronting them. Third inability to recall an important aspect of the trauma. So you were completely conscious in that entire process but then a significant cue which is considered to be much more traumatic in nature you deliberately erase it. You say that I am not able to recollect it. Four markedly diminished interest or participation in significant activities. Now you have a marked decline in you know sharp decline in your interest or participation in activities which otherwise you considered to be significant and used to participate. Feeling of detachment or estrangement from others. Restricted range of affect means you show selected emotions only you do not show the normal range of emotion that normal human being show. Notice of foreshortened future. This means that you cut short on the expectation that you have from certain major things such as career, marriage, children. Usually what happens we usually know keep on keep on thinking and would think of the prospective things that can happen in the future. So if I marry today then and then you have the whole lot of things that you imagine. If I have children then and then there is a lot of things that you imagine. Here what happens the person starts making it much and much shorter. Next persistent symptoms of increased arousal. In the earlier case here see it was all avoidance. In this case this whole bodily arousal is involved. So persistent symptoms of increased arousal which is indicated by minimum of two of these five. One difficulty falling or staying asleep. So you cannot sleep or if you sleep then you suddenly you have frequent wake up sessions. Irritability or outbursts of anger very easily you get irritated and you burst. Very concentrating hyper vigilance. Hyper vigilance is that we all are vigilant about our surroundings but you do not show hyper vigilance. For example, if you have to come to this room you would come and very quietly go and take a chair. But imagine somebody who enters the room and then very suspiciously looks at each and every corner. Whenever you sit on your chair you look at it from left to right, front to back turn the chair or even shake it does not fall everything you test and then you sit. That is hyper vigilance that you should not be vigilant but then there is no point being no excessively vigilant. So here one becomes excessively vigilant. Exaggerated startle response, startle response basically is the physiological reaction that the body shows immediately means it would be few seconds after once the actual stressor comes into being. So say for example, if I take say you remember we had talked about cortisol when we were talking about stress two days back. Now say what is the cortisol level in your body as of now? What is your blood pressure, heartbeat, pulse rate, skin temperature, skin conductance all these physiological parameters say I attach senses to have a look at it. The easy thing for measuring cortisol would be you put a cotton ball in the mouth and the saliva that the cotton will soak you can analyze it using certain chemicals to find out the cortisol level available in the blood. So very small thing now you can just put a cotton ball in the mouth attach senses and then you say that fine now take rithi is taking place and you go and see the events just hypothetical example I pray this does not happen and suddenly there is a blast somewhere one spark and your entire system will show certain reaction. The immediate reaction that fractional reaction that your body had shown in terms of physiological reaction to such type of extreme situation would be considered as straddle reaction. So what happens if you graphically plot it it would be something like this and then suddenly there will be a big jerk and then it will know start following a steep increase but before this is steep increase there is suddenly a quantum jump that is called the straddle reaction and therefore you would realize that in many situations people would explain to you that when this event happened for few moments I could not realize what has happened I could not realize what actually I should do. So sudden bomb blast and then you freeze and after sometime you say oh no this is the time for me to run away this is the time for me to look at others this is the time for me to sensibly know see what actually has happened but momentary complete closure of all the functions and within that process you suddenly realize that the whole bodily reaction has gone very high that is the straddle reaction. So that is exaggerated straddle reaction so out of the five minimum of two should be achieved and then the most important thing and which is uniformly utilized for you know diagnosing each and every psychological disorder all psychiatric issues is the duration of the problem. Since how long you have been suffering from this type of say hyper vigilance arousal and avoidance reaction and here you see that it says that total duration of having these symptoms should certainly be more than one month. So if the event has taken place and after that till one month if you have these symptoms it is considered to be normal because you had experienced no extremely catastrophic type of situation so catastrophic experiences and therefore you have all these numbing experiences hyper vigilance arousal avoidance reactions for one month it is fine but then after one month if you still show these then you would be classified as a sufferer of post traumatic stress disorder. The disturbance caused clinically significant distress or impairment in social occupational or other important areas of functioning. The reason why you know psychologists are interested in PTSD one because of you know different type of psychological processes attached to the symptoms and two because it impairs your social functioning your occupational functioning and other areas where you could have you know done the job much better but because of these symptoms you refrain from participating in the event and you do not do that. Before I come to something else you remember the very first topic that we were discussing know where we said that the whole construct of normality can be analyzed in terms of statistical averages. In your mid sem exam also the first question perhaps was you know related to statistical average. Now, if you ask that how did psychiatrist realize that these symptoms if they are available for first 30 days then it is normal and beyond 30 days then it is pathological. What is so sacrosanct about 30 days? This question can be asked know that what is so sacrosanct know if this is a symptom then on the first day also it is a symptom on the 31st day also it is a symptom. So, how does one classify that know till 30 days it is fine and beyond that it is not fine. It is a big change know because psychiatrist will you know consider that post traumatic stress is a disorder so you are no more normal just because you have know bypass the limit by one day and therefore, you become pathological. And here comes the whole issue of again the statistical average. People with post traumatic stress symptoms they have been examine their whole process has been carefully looked at and people have seen that those who do not carry on their symptoms beyond 30 days limit are the people it is like say the graph will go up and 30 days it will come down and the person becomes normal. So, that is the reason how know they have computed it, but then again this is a good indicator that again it is a statistical average. And will once again refer to it little later when we come to the epidemiological data pertaining to PTSD. And these are you know interesting intellectual things to think about know that say if I am on the 29 day with the same symptom I am normal I cross the limit and then you say this is pathological. Now, PTSD is know considered as it could be considered as acute and chronic depending on the duration of the symptoms know the avoidance hyper vigilance and the arousal symptoms if the symptoms less than 3 months. So, it is between 1 month and 3 month then it is considered to be acute, but if the symptom carries forward even after know the 3 months period then it is considered to be chronic. Now, it primarily means that this is an exceptional type of a life circumstance exceptional type of a situation that one has experienced and therefore, somebody who have the frequent recollection of it, somebody who develops numbness, somebody who become hyper vigilant now these are considered to be normal range of reactions within 1 month period 1 month to 3 month it is acute in nature beyond 3 month it becomes chronic. Now comes this debate in 2005 Joseph and Williams this was know basically the supervisor and the PhD student pair they said that PTSD symptoms what we talk about are actually normal reactions experienced by people in a response to a stressful and traumatic situations indicative of need for cognitive emotional processing rather than an abnormal state of mind. So, they said again the same argument that we were taking know that because the experience that I had was of a very extreme nature. And because I saw something of a very extreme nature therefore, it primarily says that it also demands know a cognitive emotional processing which will be of a very extreme order and therefore, because the situation is extreme in nature the response is extreme in nature therefore, there is no point saying that this is an abnormal state of mind. I do not know if you have ever got a chance to interact with people who had some type of a very catastrophic type of experiences I will just share one or two with you and then we will move forward. It was at one of the railway stations in UP only where a group of students who had come to participate in an exam you know that we have exams which are basically for recruitment where large number of students would migrate from different places in India to a particular city to appear in the exam banking, railways there are hundreds and hundreds of such exams in our country a group of students had given the exam they were returning back they had come all from small places so they were not aware of the high tension wire and what it means to know when you say caution and these many volts in the overhead cables of for the railways. So they very joyfully try to go to the top of the train because the whole train was flooded with students and other passengers and the moment the first person reached there and there was a trail of students going trying to go to the roof top there was a big spark and it was moment you know fraction of seconds and this whole body was completely charred and it was not only one know three four people who were very very close to that student this entire episode you know there was not even a time to know blink you know so one blink and the event was over it was a crowded railway platform and many people saw this event. Somebody I know who saw this event and was you know later on in his life he became extremely scared of you know going by trains pulled by electric engines and he can see that know the all the bogies are made of metals and he knew that metals are good conductor of electric currents how whatever explanation you give to him it does not work. This weekend I was in a place very close to Kanpur and I was told that you know there is a temple where next day on the occasion of Mahashivratri there would be whole lot of crowd coming here for worshipping Lord Shiva two years back and an accident had taken place a whole lot of mob was there to celebrate this occasion religious festival some dance event was taking place and then somebody went to the rooftop and once again the high tension wire happened to cross in and because it had rained therefore the current could know immediately pass on to this in that entire wet region and there were 2000 casualties again momentary but what was further told was even worst many people died they were their bodies were completely charred know because of that high intensity of the current and few who you know were either completely shocked and therefore frozen or those who had still had life in them the police evacuated the entire area you know overnight and all these bodies were dumped into the river gang is just one kilometer from there so all these bodies were dumped into the river police did not think of checking or themselves or getting checked by a medical expert whether X had died or still he has some life and therefore there was no point making a distinction who should be cremated and who should be sent to hospital uniformly everybody was thrown in the river so those who didn't die out of electric shock died because of drowning in river gang is now if you become a witness to events like this these are not small events in life know these would change your life forever I do not know if you have seen this clip when 26 11 attack took place in Bombay the young worker who was there in Shamyana restaurant in Hotel Taj later on he gave his interview I use his video clip for some other course now where he explained the whole situation know and he said that I was there in the Shamyana restaurant when this attack took place I don't remember the number of guests he said some number 24 26 some number he said that these many guests were there in the restaurant when the terrorist attack took place but what he beautifully explains and in a very pensive state is that he said that no I had asked everybody to hide somewhere because there was a place to hide and there was a gate leading outside the hotel from that area so I asked everybody to hide there and I told them that once there is a silence I will open that gate and you all can go out of the hotel from there and at that time a young couple said that you know their small child had gone to the toilet which was on the other side of the corridor and the corridor was where these terrorists were moving and they said that we need to go there we can't go out of the hotel without taking our child so we will go to the rest to the toilet and then this boy thought that if he goes to the toilet the terrorist will know that there are there could be few more people in the restaurant hiding here so all of them will die so he said that don't worry you stay here in a hidden thing and then I will go and bring back your child he crossed that area that corridor and the moment he was in the corridor he could hear the bullet shots aimed at him he could narrowly escape and then suddenly one of the terrorist had thrown that hand grenade that the whole area would explode and this man would die fortunately that hand gradient didn't explode and because of other movements this boy could manage to go to the toilet bring the child back and all these people survived now this boy says in that tape he says that you know since then that sound of the hand grenade falling in the corridor the whole audio effect it comes to me repeatedly you know wherever I am suddenly you know that audio comes to me what happened when that hand grenade fell on the ground and he anticipated death now so it just frozen moment and that sound and then he realized nothing has happened and terrorist anticipated that this area will blow and therefore he also ran away and this boy could manage to go to the toilet and come back with the small baby now these are unique experiences in life not many people will have it but those who would have it okay the other camp in psychology therefore says that no these are all extreme situations in life and therefore when you think of a statistical average you cannot have the statistical average no because there would be a handful of people who would have experienced it we are getting my point so why don't you consider this as a extreme reaction to a extreme situation rather than saying that this is a pathological state of mind this is a debate there you will find if you read literature in psychology pertaining to PTSD you will find no many many psychologist endorsing this viewpoint that this should be considered as post-traumatic stress and disorder should be deleted from this term okay but then you have the whole camp of psychiatrist still arguing that this should be considered as post-traumatic stress disorder I just thought I will make you aware of both the facts okay I am not taking a side whether you should go accept this or you should accept that you should have your in case you are interested read details and have your own opinion now if you look at the prevalence rate okay prevalence rate is once again no you have data from multiple sources and then you try to figure out the percentage of victims okay who develop certain types of symptoms after experiencing a catastrophic event it has been realized that 55% of the rape victims they develop PTSD post-traumatic stress 35% of the victims of child sexual and physical abuse they also develop post-traumatic stress 17% of those who experience physical or armed assaults they also experience post-traumatic stress and 7% of the survivors of severe accidents they also experience post-traumatic stress now if you look at the prevalence data then again you come forward with a question so if 55% of the rape victims know suffer from post-traumatic stress what happens to the remaining 45% that can be a question no what happens to the remaining say 65% in the case of childhood sexual and physical abuse okay what happens to the remaining 93% in the case of severe accidents okay and this was something once we had the prevalence data that was the time when no a group of psychologists started thinking that what happens to the left out percentage and that led to another area of research in psychology which finally led to a construct what is called as post-traumatic growth okay I must tell you that in the recent years there have been several several several development and if you remember the very first topic that we had discussed as part of this course where we were talking of the biomedical model you remember that so one of the important things in biomedical model was that there have been changes in the area of medical practices there has been a changes in the area of psychological sciences also no say in medical practices you have something like community health services okay similarly in psychology also a new branch gradually came up what is called as positive psychology and if you read once again no literature in positive psychology you will read about post-traumatic growth resilience scoping healing these are no the very common topics that you will find in the text pertaining to positive psychology now this term was no formally introduced in 1995 by Trotsky and Cohen okay and they basically define post-traumatic growth as the positive psychological change experienced as a result of the struggle with highly challenging life circumstances so all the life circumstances that we were talking about the walker in the Shamayana restaurant when 26 11 took place the man on the railway platform who saw four students burning within three seconds the people who had gone to worship a god and saw 2000 casualties okay so he says that when you are put in difficult situations okay and when your life circumstances challenging life circumstances force you okay to struggle once that phase is over you could evolve like a much refined human being okay and those positive psychological changes are defined as post-traumatic growth means after the traumatic event has happened at a disorder developed that was the first thing that we discussed now we are discussing the opposite side of the continuum that the traumatic event is over and now you have evolved you have grown up much better and therefore it is called post-traumatic growth now there are three broad spheres where changes have been you know realized after the traumatic event is over one in the interpersonal relationship you start valuing relationship human relationships like anything okay so today your father gives you a call but your mother is hospitalized and you say nai papa te krithi is coming just this weekend so you please manage I won't be able to come and do let me know every day you know I will be in touch with you and let me know how mother is but papa please so importance is given to te krithi and mother is compromised with there are no several life situations know where you know what in psychology we called as conflicting choices no you come forward with cases in life where no you have two choices and you can opt for only one and both of them are equally compelling okay now what to do it is very difficult no there are conflicting choices what has been witnessed that after you know that traumatic event when one develops this post-traumatic growth when one evolves the major change that takes place is in terms of defining human relationship so now even your relationship with a stranger is extremely valuable to you forget about your own relatives okay you start valuing them more much more to self-perception the way you have been defining yourself that also undergoes a big change and three the philosophy of life changes okay so what you initially thought was extremely important and you should have certainly attended life now you think that come on here those things are just rubbish okay life needs much more okay so broadly the changes have been found under these three spheres okay so you start valuing family and friends you increase no self-disclosure means things that you always thought retaining with yourself may I would never share this with others now you feel there is no point no keeping several things within you take pride in sharing yourself with others you become much more kind to others okay altruism increases altruism is selfless type of service that you provide to others altruism increases and usually your gen you become generally much more open okay earlier you remember we see again with reference to the frame of reference no so the frame of reference suddenly becomes very porous okay the life philosophy has changed modification of self-perception also takes place wherein you find increase in your resilience your ability to fight back wisdom strength and acceptance of your limitations so you very gladly and very generously say that I am sorry I don't I can't do this something that you were very shy of in the beginning okay and change in the philosophy of life okay also takes place with added wisdom so you have more you become more and more wiser in the process three different models have been proposed which defines post-traumatic growth how it happens what are the factors that contribute to it the whole cycle of post-traumatic growth but even though I said at three models have been suggested I have put only two models I will just touch the third model in brief and I will tell you the reason why I am not going to the third model the first model is called the functional descriptive model again it was proposed by Trudisky and Cohen you remember Trudisky and Cohen was the first one to propose the concept of post-traumatic growth okay and this model was proposed in 1995 and by this time it has been revised four times okay I must tell you that this is a theoretical model and then there is another theory what is called as the Organismic Valuing Theory given by Joseph and Lille we had referred to Joseph and Lille's work of 2005 saying that this was a student supervisor pair okay and the third theory is called biopsychosocial viewpoint okay now this basically has a bit of psychology a bit of biology bit of sociology it has also evolutionary angle so it is just a viewpoint and that is the reason why we are not going to the third one these two models we would discuss at length tomorrow but I must tell you that both these models are still theoretical models okay and I will also share with you one of my students who did his PhD no trying to empirically test the functional descriptive model okay so tomorrow when we assemble we will talk about these two models and then we will move to two remaining topics resilience and coping