128 Chapter 13
exposure therapy, it was developed for use in low-resource countries
affected by crises and conflict. Intensively trained local lay therapists
work with individuals to recreate a detailed narrative of their whole life
from birth up to the present situation, particularly focusing on obtaining
detailed reports of the traumatic experiences. The aims are to habituate
the exaggerated emotional response to trauma-related reminders and to
build up a non-fragmented autobiographical memory. Initial data from
randomised controlled trials are encouraging. For example, an 8-session
treatment by local lay therapists resulted in substantially greater reduction
in PTSD symptoms among former child soldiers in Uganda than did either
of two control conditions: being on a waiting list; or an academic catch-up
program with elements of supportive counselling.
Eye movement desensitisation and reprocessing(EMDR) is a method devel-
oped in the early 1990s in which affected individuals are asked to conjure
up an image of the traumatic event while simultaneously moving their
eyes to follow the therapist’s hand, which travels widely across the visual
fields. Unlike cognitive-behavioural approaches, few verbal interventions
or interpretations are offered. In some cases, the images lose their anxiety-
provoking qualities and substantial improvement is seen. In adults, the
effectiveness of EMDR has been convincingly demonstrated – the evidence
that it works in children and adolescents is less conclusive, but it is widely
used in clinical practice.
Difficulty getting to sleep may be helped by simple techniques such as
listening to a music or story tape when in bed to help banish unpleasant
intrusive thoughts. Bad dreams can be retold during the day with the
affected individual giving them a happy ending. In addition to treating the
specific symptoms of PTSD, it may be necessary to address wider issues.
For example, when children have lost their parents in the disaster, it may
be vital to help them and their new caregivers adjust to one another’s
needs. They may need help to distinguish grief from fear aroused by the
incident.
Prevention
Prevention of PTSD through debriefing early (within a fortnight) after
a traumatic event is controversial since in adults several randomised
controlled trials have been carried out and these do not show unequivocal
benefit, and some suggest that early debriefing may be harmful. It could
be that focusing early on symptoms interrupts normal healthy processing.
However, leaflets that alert young people and their parents to possible
emotional sequelae are likely to be helpful and are increasingly available
from charities such as the Child Accident Prevention Trust.
Acute stress disorder
This diagnosis is applied when a range of symptoms are present for at least
two days, but under a month, following a traumatic event that involved