MedscapeWire When Disaster Strikes, a Call to Clinicians

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By Robert Kennedy and Martin L. Korn, MD

New York - Disasters such as the recent terrorist attacks on World Trade Center in New York and the Pentagon in Washington offer a challenge to clinicians in dealing with stress and trauma.

The many unique characteristics of the current tragedy make these events extremely difficult to handle psychologically. Not only has the sheer horror and volume of death and destruction affected people, but suddenly, with startling rapidity, we are now confronted with a sobering psychological reality. The conflict has permeated the
national borders that were previously viewed as generally secure. The combination of these factors has generated a widespread sense of helplessness, anger, anxiety, and fear throughout this country and in many other parts of the world.

Untold thousands of family members have been affected by the deaths and severe injuries suffered by the victims. Rescue workers are exposing themselves to personal risk as well as the trauma of viewing extreme human horrors and tragedy. Indeed, many of the victims they scour through the rubble to find are fallen coworkers who had worked with them side by side before perishing in the rescue attempts.

Across the globe, there is also a much wider group of people who are affected by these events. Through television and the Internet, the public is being saturated with dramatic details and graphic images of the traumatic events as they unfold. Although not directly exposed to the events, the repeated exposure to these startling images may also result in acute and, at times, severe stress reactions.

Clinical Presentations

Clinicians are now faced with the formidable challenge of dealing with the stress and trauma engendered by these horrific events. A wide spectrum of responses may be manifested in the face of severe trauma. Stress reactions may be short-lived and vary widely in intensity. In a significant minority of exposed individuals, a more severe pattern of posttraumatic stress disorder (PTSD) may emerge.

The term "stress response" is often used to characterize an array of emotional and behavioral reactions occurring when an individual's normal functioning is disrupted or challenged. Traumatic stress is an extreme form of the stress response. There is a varied array of responses that may be manifested under stress. It is important for the clinician to be aware of the following presentations:
Somatic complaints. These may include a wide variety of forms, including generalized and nonspecific "aches and pains," headaches, backaches, abdominal cramping, chest pain, among others. Alterations in sleep patterns and appetite frequently occur. A heightened startle response may be present, and there may be a lowered immunity to
infections.

Emotional reactions. The full spectrum of emotional reactions may be manifested. Some of these responses include anxiety, dysphoria, anger, shock or disbelief, grief, irritability, and restlessness. Alternatively, denial and/or "numbing" may be the most prominent presentation. Survivor guilt may be prominent. Nightmares and flashbacks may herald the onset of PTSD.

Substance abuse. New onset or exacerbation of substance abuse may signal the maladaptive ways that an individual is adjusting.

Clinical Interventions

Some individuals find it difficult to express the emotional responses they are experiencing. It should not be assumed that all people are willing and ready to discuss the events. Although verbalization of the experience should be encouraged, this should not be forced. Denial or minimalization of stress can be a coping mechanism for dealing with overwhelming events, especially in the acute situation.

Mobilization of family and community supports is often a key element to stabilizing the situation. Religious institutions can provide extensive emotional and community support. The clergy may serve as a source of moral and spiritual guidance. This is particularly helpful at a time when the basic beliefs and foundations of an individual or society are called into question.

When dealing with reactions to trauma, people may be frustrated or embarrassed by their reactions. It may take weeks, months, or longer to recover or feel comfortable, and people may be surprised by the length of time it takes for recovery to occur. The clinician who is
accepting of the emotions and behaviors manifested can play an important role in helping the individual to accept and overcome these feelings.

Friends and family can also be a great source of support, but they can also push an individual to get better or "get over it" quickly. Professionally run or peer support groups can be extremely helpful in combating this attitude. Not only do they offer needed support, but they also help the individual realize that others are experiencing similar symptoms and problem. Medications may also be of significant help. Acute stress responses may be handled with the judicious use of benzodiazepines. The SSRIs sertraline and paroxetine have both been shown to be efficacious in PTSD and are approved by the US Food and Drug Administration for this disorder. Other psychiatric syndromes such as panic disorder and depression are frequent and should be treated vigorously.

Pediatric Clinical Issues

Children are frequently overwhelmed by their emotional reactions to events they have difficulty understanding. A world that they may have viewed as safe and secure may now be perceived as dangerous and unpredictable. Children should be encouraged to talk about their
feelings and ask questions openly about things that they saw or heard. Emotional "joining" by adults is often helpful. Sharing with the child that the situation is frightening for adults as well as children may help youngsters to express their own feelings.

It is important for children to feel as safe and secure as possible in the face of these upsetting events. They should therefore be reassured that everything is being done to ensure their safety. Children should not, however, be given false reassurances; a negative
turn of events may undermine the sense of trust in the adult's statements. Concrete supportive actions such as collecting money or designing cards for victims may be helpful. This focuses the child's attention and helps teach the child how to offer support in times of crisis. Television may be too stimulating or frightening for the child and experts suggest limiting TV viewing. A normal routine should be encouraged to stabilize the situation.

As clinicians, we need to be aware that the impact of such a traumatic series of events is not localized and may, in fact, have widespread psychological implications for many people. Reactions can manifest in many ways from mild to severe and in adults and children. A sensitive approach is crucial but clinicians should not be reluctant to ask questions, and as healthcare professionals we need to be ready to hear the answers, remain supportive, and make appropriate interventions.