ARCHIVES OF NEUROSCIENCES
AND PSYCHOSOMATICS
ANNUS II - 2013
Some post traumatic syndromes and their social and health relevance: the global dimension
It is fact that violence in human beings -whether toward individuals, as specific criminal acts o torture, or on mass scale, as in wars, persistent terroristic acts or catastrophes – does not seem to diminish. Victims of violence represent a various (for their age, gender, etc.) group with health and psycho-social problems that is often forgotten, overlooked or wrongly treated. An international organization such as World Health Organization has several times pointed out the importance to visualize both the problem and the victims. If natural and artificial catastrophes are recurring, but luckily not constantly present, other forms of violence, both individual and organized, are constantly active, day after day, in a place or in another of the planet. Considering that they are involved in violence millions of persons, it is clear why it is a relevant social and health question.
Among the latest emerged situations, more reported by mass media, are the violence against women, sex and human traffic (especially in some areas of the world), persistent death aggressions for religious reasons, persistent forms of slavery of children. Not to mention the more or less forgotten wars (including the internal civil wars) situations: Afghanistan, Iraq, Sudan, Ethiopia, Somalia, Tibet, quoting the relatively less unknown, and the people forced to migrate. All these are problems of our days BUT ALSO problems of the next years and of the next generation. A victim of today will probably remain hurt for the rest of her/his life (decades), potentially projecting the hurting socio-psychological effects on their families and direct descents. And what about the economic effects? Who will pay for treatments, medicines and/or indirect damages?
The KZ-syndrome and the Stockholm syndrome are names well known, but they represent only a partial percentage of the whole victims involved. For the wide public probably PTSD (post traumatic stress disorders) or DAS (diffused anxiety syndrome) are already unknown initials, even if they are among the most diffused stress events.
Someone could suggest that many of these considerations are mainly a question of medical ethics, I consider this point of view partially wrong. They are surely also a question of person-to-person relationship among health personnel and the persons for whom they take care but it is -and it has to be- mainly a social, collective, matter of ethics to promote and warrant the “highest possible level of health” (as WHO Constitution says) and, we could add. of respect for each person (referring to the many forms of tolerated, “invisible”, violence). If we watch the world map, published by WHO, of the estimated PTSD impact for each of its State members (it is the map reported at the top of this webpage) we notice that not one only area of the planet is excluded. Specific standardized data also shows that female population suffers higher rates than male population in spite that, in the most of armies, there are mainly male soldiers. As it happens for general statistical data related to wide areas, many specific aspects and differences result less visible, anyway the data gives the idea of the global dimensions and effects. To destroy permanently the trust in society, the perception to be totally helpless, the lack of any human solidarity, the loss of meaningful contexts are, by themselves, already traumatizing events.
Antonio Virgili, Professor at UNISED, Chair of Neurophysiology
© Copyright by Antonio Virgili
It is fact that violence in human beings -whether toward individuals, as specific criminal acts o torture, or on mass scale, as in wars, persistent terroristic acts or catastrophes – does not seem to diminish. Victims of violence represent a various (for their age, gender, etc.) group with health and psycho-social problems that is often forgotten, overlooked or wrongly treated. An international organization such as World Health Organization has several times pointed out the importance to visualize both the problem and the victims. If natural and artificial catastrophes are recurring, but luckily not constantly present, other forms of violence, both individual and organized, are constantly active, day after day, in a place or in another of the planet. Considering that they are involved in violence millions of persons, it is clear why it is a relevant social and health question.
Among the latest emerged situations, more reported by mass media, are the violence against women, sex and human traffic (especially in some areas of the world), persistent death aggressions for religious reasons, persistent forms of slavery of children. Not to mention the more or less forgotten wars (including the internal civil wars) situations: Afghanistan, Iraq, Sudan, Ethiopia, Somalia, Tibet, quoting the relatively less unknown, and the people forced to migrate. All these are problems of our days BUT ALSO problems of the next years and of the next generation. A victim of today will probably remain hurt for the rest of her/his life (decades), potentially projecting the hurting socio-psychological effects on their families and direct descents. And what about the economic effects? Who will pay for treatments, medicines and/or indirect damages?
The KZ-syndrome and the Stockholm syndrome are names well known, but they represent only a partial percentage of the whole victims involved. For the wide public probably PTSD (post traumatic stress disorders) or DAS (diffused anxiety syndrome) are already unknown initials, even if they are among the most diffused stress events.
Someone could suggest that many of these considerations are mainly a question of medical ethics, I consider this point of view partially wrong. They are surely also a question of person-to-person relationship among health personnel and the persons for whom they take care but it is -and it has to be- mainly a social, collective, matter of ethics to promote and warrant the “highest possible level of health” (as WHO Constitution says) and, we could add. of respect for each person (referring to the many forms of tolerated, “invisible”, violence). If we watch the world map, published by WHO, of the estimated PTSD impact for each of its State members (it is the map reported at the top of this webpage) we notice that not one only area of the planet is excluded. Specific standardized data also shows that female population suffers higher rates than male population in spite that, in the most of armies, there are mainly male soldiers. As it happens for general statistical data related to wide areas, many specific aspects and differences result less visible, anyway the data gives the idea of the global dimensions and effects. To destroy permanently the trust in society, the perception to be totally helpless, the lack of any human solidarity, the loss of meaningful contexts are, by themselves, already traumatizing events.
Antonio Virgili, Professor at UNISED, Chair of Neurophysiology
© Copyright by Antonio Virgili
Diffusione e sintomatologia dei disturbi da stress post traumatico (PTSD)
Negli anni recenti, lo studio del disturbo da stress post traumatico (noto con il diffuso acronimo anglosassone PTSD) e degli stati fisiologici associati ha suscitato enorme interesse nella comunità scientifica, anche perché i traumi sono purtroppo eventi abbastanza diffusi ovunque. Si è anche documentata una maggiore morbilità e mortalità generale negli individui colpiti da PTSD, tutto ciò ha reso gli effetti dei traumi un problema di rilievo sociale internazionale. Gli studi sui traumi sono numerosi ma molto diversificati a seconda del tipo di trauma (disastri naturali, guerre, violenze fisiche di natura sessuale, ecc.), la durata del trauma (periodo limitato vis à vis, traumi di lunga durata), l’età della persona che ha subito il trauma (bambino o adulto), il tempo intercorso tra il trauma, la presa di coscienza della gravità dell’evento e le possibili conseguenze rischiate (possibile perdita della vita, dei beni, degli oggetti personali, ecc.). Non tutti i dati sono quindi direttamente comparabili, ma nell’insieme essi hanno chiarito sempre di più i meccanismi e le conseguenze meno visibili. La diagnosi di PTSD si basa su vari criteri. Prima di tutto la persona deve essere stata esposta ad un evento traumatico con minaccia di morte o lesioni gravi rispondendo con intensa paura, orrore e senso di disperazione e/o di impotenza.
Si considera che tre gruppi di sintomi devono essere presenti per una diagnosi attendibile e corretta:
1) REEXPERIENCING: si rivive il trauma frequentemente (flashbacks, incubi, senso di disperazione alla vista di oggetti o immagini che ricordino l’evento, pensieri ricorrenti ed invadenti relativi all’evento, reazioni fisiologiche alla rievocazione dell’evento come brividi, tachicardia, sudorazione, pianto, ecc.).
2) AVOIDANCE/NUMBING -evitamento/ottundimento-: si evita di pensare all’evento; evitamento di attività, luoghi e persone che possano ravvivare il ricordo dell’evento, incapacità di ricordarne gli aspetti significativi, disinteresse nei confronti di ogni attività, sensazione di distacco dagli altri, incapacità di provare sentimenti d’amore e minori aspettative in merito al futuro.
3) INCREASED AROUSAL -stato di allerta persistente o iper-vigilanza- : viene espresso dalla difficoltà di concentrazione, incapacità di prendere sonno, irritabilità e risposte di allerta /allarme esaltate.
Questi gruppi di sintomi devono essere presenti contemporaneamente per almeno un mese perché si possa porre diagnosi di PTSD. Già Kardiner, nel 1942, osservò che i malati di “nevrosi traumatica”, come era allora classificata, diventavano vigili e iperattivi nei confronti delle minacce ambientali. L’iperattività fisiologica si manifestava rispetto a stimoli uditivi, ma anche in risposta a stimoli quali la temperatura, il dolore e stimoli tattili improvvisi. Dal punto di vista fisiologico si manifestava un abbassamento della soglia della stimolazione e dal punto di vista psicologico uno stato di sollecitudine a reazioni spavento. Ne conseguivano esplosioni di aggressività che erano estranee alla personalità pre-patologica ed impossibili da controllare.
Tra le manifestazioni comportamentali e neurofisiologiche che si associano al PTSD, due aspetti in particolare vanno segnalati come tipici: la reattività fisiologica e l’alterazione delle emozioni come segnali.
Circa la reattività fisiologica, nel DSM-IV (il manuale diagnostico e statistico dei disturbi mentali) è evidente quanto la risposta al trauma sia di natura complessa: l’ipermnesia, l’iperattività agli stimoli e la ri-esperienza traumatica coesistono con l’intorpidimento psichico, l’evitamento, l’amnesia e l’anedonia. Appare quindi un tipo di evento che bene si presta ad una analisi sistemica integrata, ad esempio sul modello PNEI (psico-neuro-endocrino-immunologico).
Nel PTSD il problema sembra essere che gli individui reagiscono in modo eccessivo ed estremo anche in presenza di fattori non direttamente collegati all’esperienza traumatica. Nei soggetti traumatizzati tale iperattività, da un lato, provocherebbe un pattern d’eccitazione perennemente attivo -per cui si viene ad essere continuamente perseguitati dai ricordi del trauma- dall’altro, sembrerebbe condurre, per compensazione, ad una “chiusura totale” a livello comportamentale. Tale circuito si tradurrebbe in una sensibilità intorpidita nei confronti dell’ambiente, intercalata da iperattività intermittente i risposta a stimoli di origine emotiva[1]. E’ evidente la ricaduta sociale potenziale di tali situazioni a rischio, non è raro che a fronte di comportamenti improvvisi ed inattesi ci si sorprenda, almeno tra non addetti ai lavori, della “inspiegabilità” di essi. Sommando le centinaia di migliaia di persone coinvolte ogni anno su fronti di guerra, in atti di terrorismo, in persecuzioni, criminalità, catastrofi naturali ed in violenze individuali, è facile intuire come si tratti di una popolazione sociologicamente e demograficamente rilevante.
Prof. Antonio Virgili
[1] van der Kolk, MD, The Neurobiology of Childhood Trauma and Abuse, in Child and Adolescent Psychiatric Clinics, 12, pp. 293 – 317, 2003
© Copyright by Antonio Virgili
