Stress Disorders 127the hypothalamic–pituitary–adrenal (HPA) axis, leading to an outpouring
of cortisol into the bloodstream. In the longer term, the SPS remains hy-
persensitive, responding more vigorously than normal to further stressors.
The long-term effect on the HPA seems more complex, with generally
below-normal blood cortisol levels (reflecting down-regulation as a result
of chronic over-stimulation), plus a tendency to over-secrete cortisol in
response to new stressors.
Treatment
Many traumatised children and adolescents have never had the opportu-
nity to talk freely about their experiences to a sympathetic and informed
adult. They may have feared that they were going mad when they began
to experience intrusive thoughts, and may have been very frightened by
what seemed to them to be inexplicable panic attacks. Hearing that these
are normal responses to abnormal experiences can help such children and
adolescents to make sense of their world and so begin to be reassured.
Parents and teachers may also need to be helped to acknowledge what
has happened and comfort the affected individual. When adults feel that
the trauma and its aftermath should not be talked about ‘so as not to make
things worse’, or because they are frightened about what they might hear,
children and adolescents often read the signs and keep obligingly quiet.
Cognitive-behavioural therapy(CBT) approaches have been effective for
adults with CBT, and there are some randomised controlled trials showing
the same for children and adolescents. Current cognitive models of PTSD
suggest that trauma memories differ from ordinary memories in being
situationally accessible(triggered by trauma-related reminders and then re-
experienced in the present in a vivid but fragmentary way) rather than
verbally accessible(deliberately retrieved from memory, more coherent, less
vivid, more clearly part of the past). Part of the therapeutic challenge is
to shift the balance towards verbally accessible memories that can then be
worked through. It is also important to tackle children and adolescents’
fears that experiencing situationally accessible memories shows that they
are going mad, or that the immediacy of these memories means that
the world continues to be very dangerous or that their life has been
ruined forever. Attempts to suppress intrusive thoughts and images make
things worse. So too may rumination. At a practical level, triggers for
anxiety attacks can be identified and then addressed by teaching relaxation
and other anxiety-reducing techniques. These can then be followed by
graded exposure to the distressing scene; exposure generally needs to be
vivid and long to overcome avoidance. Other cognitive techniques include
challenging maladaptive thoughts and using guided imagery to gain mas-
tery over distressing feelings. Group discussions with fellow victims and
their parents can be helpful, but need to go beyond the expression of
feelings (which may only renew anxiety) and take a more therapeutic
approach.
Narrative exposure therapyis a relatively brief treatment for survivors
of multiple traumas. Based on the principles of cognitive-behavioural