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The psychology of terror: primary care presentations
THE PSYCHOLOGY OF TERROR: PRIMARY CARE PRESENTATIONS Nada L. Stotland, MD, MPH
This paper is written in the aftermath of the September 11th attacks on New York and Washington D.C. and in the midst of partially controlled general panic over anthrax infection. By the time it is published, concerns may have moderated, or new acts of terrorism may have occurred. In either case, the psychological impact of terrorism will continue to affect primary care patients for years to come. (Prim Care Update Ob/Gyns 2002;9:90 –93. © 2002 Elsevier Science Inc. All rights reserved.)
Terrorist attacks on New York and Washington D.C. have affected people all over the world. Assumptions about what is possible, what is conceivable, have been found wanting. Our sense of comparative safety has been shaken. Acts that we have taken for granted, like traveling and opening the daily mail, are now fraught with unknown levels of danger. Practical and psychological effects operate in concentric waves, from those killed or wounded; to their families, friends, and fellow workers; to employees of businesses destroyed or downsized, resulting in unemployment and economic deprivation; to adults and children watching horrific scenes repeated endlessly on television; to innocent individuals attacked in their communities because they are perceived to belong to groups responsible for terrorism. The psyFrom the Departments of Psychiatry and Obstetrics and Gynocology, Rush Medical College, Chicago, Illinois.
90
chological effects of these acts are pervasive, widespread, and longlasting. Many of these effects are manifest, directly and indirectly, in the primary care setting. Patients who have narrowly escaped being killed or maimed, and who have observed others injured or dying, have acute and posttraumatic stress reactions and survivor guilt. Those who have lost loved ones are grieving and angry, deprived in most cases even of bodies to bury. Patients whose jobs are lost or threatened are anxious about the support of their families. Over the coming months and years, primary care clinicians will see increases both in mood and anxiety symptoms and in somatic complaints and conditions. They will need to counsel patients about general coping and risk calculation and avoidance and to distinguish normal responses from psychiatric pathology.
Common Sense Counseling Terrorism is meant to evoke terror. Like the aftershocks of an earthquake, further terrorist acts are unpredictable. Unlike natural disasters, terrorism exposes the darkest side of human psychology, making all our fellow creatures, even ourselves, suspect. There are ultimately unanswerable questions about what makes people behave this way. The survivors are the victims not only of physical and psychological damage but of vicious human hatred. The very occurrence of the disaster makes it clear that
© 2002 Elsevier Science Inc., all rights reserved. 1068-607X/02/$22.00
●
existing systems are not adequate to anticipate or prevent such events, despite authorities’ protestation. There is ongoing fear that governmental response will be inadequate or, even worse, provoke worse disasters. In the wake of a terrorist event, all patients should be counseled to strictly limit their exposure to media accounts of the disaster. Repeatedly seeing and/or hearing about an event creates the sense that more events have occurred. Once a day, or at most, the morning and evening news, will suffice to keep people informed about developments. Children, especially, should not be permitted to watch horrific scenes on television. Televisions and radios should be tuned to other kinds of educational and entertainment programs; they will be interrupted by the authorities if the populace needs to be informed of some immediate emergency. Most families will feel most comfortable spending time at home together. Patients need to understand that perceptions of risk are distorted by images and direct experiences of disaster. The overwhelming majority of flights are completed without incident. The likelihood of anthrax contamination of household or office mail is miniscule. If the family cannot contain its anxiety, they can take simple common sense measures rather than continuing to worry. If they absolutely must, they can open the mail on a newspaper, with rubber gloves; they can take the train rather than a plane. They can assemble a disaster kit, with
PII S1068-607X(02)00095-1
Prim Care Update Ob/Gyns
PSYCHOLOGY OF TERROR
flashlight, nonperishable food, bottled water, and supplies of medications they regularly take, and put it in a safe place. They may want to establish a plan of communication by asking a friend or relative who lives some distance away to serve as the message coordinator if members of the family cannot communicate directly for a time. People directly involved with a disaster, including those who volunteer to counsel survivors, need to remind themselves of the greater context before returning to their families with raw emotions; they need to read a pleasant book or listen to music on the ride or walk home, for example. It is best to maintain routines. That is especially reassuring to children. Getting to the grocery store, sports practice, and other activities is a distraction, and safe accomplishment of these activities facilitates the return of a sense of normalcy and safety. Children need reassurance that disasters are very rare and that their families will keep them safe. Parents should also be made aware that children readily absorb both factual information (although they may not be able to interpret it) and emotions while appearing to be oblivious, and that childrens’ distress may manifest differently than adults’. Children may have nightmares or become withdrawn or hyperactive, clinging, and fearful without articulating, or even recognizing, the source of their anxiety. Ritual and reassurance at bedtime, and tolerance of temporary neediness, are helpful. The crisis offers the opportunity to reinforce positive health behaviors while reminding patients of the more likely risks to their health. When people ask how they can best protect themselves and their families, clinicians can tell them that using their seat belts, getting regular exercise, and eating wisely are more likely to decrease their risk of death than are acquiring gas masks and Volume 9, Number 3, 2002
decontamination suits and stockpiling one antibiotic or another.
Primary Care Crisis Intervention Many people exposed to a disaster begin to startle easily, feel nervous, and have difficulty concentrating. All over the country, in the days after September 11th, employers and employees reported that they could not accomplish much meaningful work. After a disaster, people have difficulty getting to sleep, and, when they do sleep, their rest may be interrupted by nightmares. It is important for people to use whatever soothing responses work for them. Some take comfort from being with others who have been through the same trauma, whereas others prefer to leave the scene behind, if possible. People sharing experiences in a group can either support and validate each other or exacerbate each others fears. Though the magnitude of the recent disasters exceeds anything that most Americans have experienced, most people will derive relief from the same approaches that have helped them with less horrific experiences in the past. Very short-term use of benzodiazepines and hypnotics is useful for some patients. There is no evidence that blunting acute anxiety either speeds or prolongs ultimate recovery. Many patients simply need permission to take a break from work and worries related to the disaster, to enjoy a normal diversion. Clinicians are well placed to provide that permission in the form of a medical recommendation. Birth rates tend to increase 9 months after some disasters. The fear of the future has a paradoxical effect; people consciously and unconsciously want to have progeny to survive after them, or dismiss the future consequences of present behaviors. Access to contraception
may be complicated by the inability to get home or to refill prescriptions or buy condoms at local stores. People tend to spend more time at home together rather than pursuing their usual activities. Emotions are heightened; concentration is diminished; sex feels life-affirming. Obstetrician/gynecologists can remind patients that they may be vulnerable to unplanned pregnancies.
The Role of Religion Religion is a tremendous solace for many people affected by disaster. At the same time, clinicians should be aware of 2 potential problems. Disasters and losses also cause some people to question their long-held faith. They cannot imagine how God would let such a thing happen. If they are furious at God, they may find it hard to believe that God will still support them. It is useful to remind believers who feel this way that God created human beings, understands that some events are beyond their understanding and provoke their rage, and loves and comforts them throughout. The other problem is the exclusive dependence on prayer when medical intervention is indicated. Believers other than Christian Scientists, who will probably not be consulting clinicians in the first place, understand that medical care is one form of help provided by God. Neither the diabetic nor the individual with depression serves God or demonstrates faith by refusing medical care.
When Is Grief Pathological? What is a normal response to a disaster, and what is the clinical significance of normal, as contrasted with abnormal, responses? The fact that a response is understandable, even inevitable, under 91
STOTLAND
given circumstances does not mean that it is not pathological or susceptible to intervention. Normal people can be expected to develop infectious diseases if heavily exposed to infectious agents, burns if exposed to fire, and broken limbs and contusions after collisions. Some patients have difficulty acknowledging the extent of their psychological distress. They feel that they should be grateful to be alive and whole when others have died or been injured. They do not want to consume health resources that might be needed by others more directly affected. They believe that they should be able to cope with trauma using their own resources or by calling on God for help. As in other situations, sometimes one of the jobs of the clinician is to help patients accept the help they need. It is useful that in the aftermath of the September 11th attacks, government and private officials underscored the need for mental health services, and many brave policemen and firefighters asked for them. Grief and depression share many signs and symptoms, including sadness or irritability and disruptions in sleep, eating, and concentration. Unwarranted guilt is more likely to be associated with depression than with grief, although terrorist events may provoke guilt among survivors, who by luck or active efforts were able to escape the fate of those whom they grieve. Americans seem to have little patience with grief; we sympathize for a week or two and soon expect the bereaved to form new relationships and get on with life. Grieving for an intense, longterm relationship can last for years, even for life. Elderly widows and widowers, if closely questioned, report that the departed partner is very much with them, commenting on events and advising on decisions. Nevertheless, grief does diminish over time, and normal people are able to return to their responsibilities within weeks or 92
months. When signs and symptoms interfering with function persist beyond 3 to 6 months, professional consultation should be obtained. Medication does not appear to alter the course of grief one way or the other.
Specific Psychiatric Sequelae It is impossible to predict with certainty which patients will develop signs and symptoms of diagnosable psychiatric disorders in response to a disaster. Previous or ongoing psychiatric illness, a history of abuse or childhood trauma, poor social supports, and female gender increase risk.
ANXIETY DISORDERS It is likely that generalized anxiety disorder, panic disorder, agoraphobia, and other phobias can be precipitated and exacerbated by disasters, but the disorder that has received the majority of scientific attention is posttraumatic stress disorder, or PTSD. PTSD is characterized by the following; ●
● ● ● ● ● ● ●
Flashbacks, during which the individual relives the trauma in vivid, immediate sensory and affective details, Emotional numbing, Loss of a sense of a future, Nightmares about the trauma, Avoidance of places and events reminiscent of the trauma, Irritability, Hypervigilance, and A tendency to startle easily.
One medication, sertraline, has been approved by the United States Food and Drug Administration as effective for PTSD. Cognitive– behavioral psychotherapy is useful as well. There is some evidence to indicate that early intervention with one or both of these modalities can mitigate the onset or severity of
PTSD. Unfortunately, little is known about the natural course of PTSD; we cannot prognosticate or reassure patients on that score. We do know that untreated PTSD can have a dire effect on quality of life, relationships, and job functioning. Preoccupation with avoiding any reminder of a trauma severely constrains choices of residence and job location, whereas the loss of a sense of future interrupts planning and making provisions for that future.
DEPRESSION Up to 10% of women in their childbearing years are clinically depressed at any point in time. Women with past episodes of mood disorders, including severe premenstrual syndrome or postpartum depression, are at increased risk. Most of the people in New York City and in Washington, D.C. and many elsewhere, probably had depressed mood for a week or two after the September 11th attacks. If the signs and symptoms persist for 2 weeks or more, most of the day, every day, the diagnosis of a depressive episode, and pharmacologic and/or psychotherapeutic treatment for it, is indicated. Clinicians may wish to propose restarting medication for traumatized patients with past episodes and increasing medication dosages for patients on low-level maintenance regimens.
SOMATIZATION In a time of acute life-threatening crisis, many people are not aware of symptoms of acute injury or chronic disease. After the acute emergency, however, residual anxiety may manifest in the form of new, recurrent, or more severe somatic symptoms. Clinicians can expect to see flare-ups of irritable bowel, headache, backache, menstrual, and similar symptoms. Patients may or may not relate these to the traumatic event or events and may even take umbrage at the suggestion that they Prim Care Update Ob/Gyns
PSYCHOLOGY OF TERROR
are related. Some, however, will be relieved to have the possible connection pointed out. Significant medical diseases can and do occur in somatizing patients, and the severe anxiety of a terrorist situation may trigger or exacerbate medical conditions such as cardiac events, asthma, or colitis. There is always a diagnostic dilemma with these patients. Nevertheless, in the trauma context, it may be wise to offer reassurance and counseling before launching a major diagnostic workup for dubious symptoms. When the terrorist acts raise the ongoing possibility of infection or contamination, people’s focus on bodily sensations and functions is heightened. Studies have demonstrated that for every individual physically affected by a disaster, as many as six present in clinical settings for treatment. The welter of information and misinformation on the Internet and in the media exacerbates the problem. The most effective interventions are reassurance and the provision of clear, simple, accurate information. Often such information is available at government sites, such as the one of the Centers for Disease Control and Prevention on the World Wide Web, and can be downloaded, printed, and distributed to patients.
ALCOHOL AND SUBSTANCE ABUSE Specialists in alcohol and substance abuse disorders report a wide range of patient reactions to terrorist events. Certainly there was not a wholesale relapse, but some patients did resort to alcohol and sub-
Volume 9, Number 3, 2002
stances in attempts to deal with their anxiety. Clinicians should consider discussing with all patients the need to use healthenhancing, rather than healthdestroying (including tobacco smoking), ways of coping, rather than compounding the destruction of the disaster by using it as an excuse to engage in addictive behaviors.
● ●
●
●
DISORDERS AFFECTING COGNITION Terrorist acts have not been associated with increased episodes of psychosis. Some patients with dementia and psychotic disorders seem to be too preoccupied with their own disordered cognitions to take much note of outside events. There are patients, however, who attribute disasters to their own behaviors or to a delusional cause. Clinicians caring for patients with disorders of cognition might ask them whether they know what has happened and why they think it happened, and attempt to correct misconceptions.
Advice for Patients In summary, patients can benefit from the following recommendations from their clinicians: ●
● ● ●
Turn off the television and radio, or tune them to music or to other soothing and distracting programming. Spend quality, peaceful time with family and friends. Maintain perspective. Reassure children that acts of ter-
●
rorism are extremely rare and that you will keep them safe. Follow your normal routine as much as circumstances allow. Take especially good care of yourself and your family. Eat well, get regular exercise. If there are safety measures that you feel compelled to take, put them in place and then forget about them. Use contraception if you don’t want to get pregnant. Consult your physician if difficulty concentrating, sleeping, or eating persist beyond a week or two after the disaster or interfere with your ability to carry out your family and employment responsibilities. Help is available.
Suggested Reading American Academy of Child and Adolescent Psychiatry. How to talk to children and parents after a disaster. Washington, DC: American Academy of Child and Adolescent Psychiatry, 1999. http://www.aacap.org/ publications/DisasterResponse/ cp_disas.htm North CS, Nixon SJ, Shariat S, et al. Psychiatric disorders among survivors of the Oklahoma City bombing. JAMA 1999;282:755– 62. Pfefferbaum B, Seale TW, McDonald NB, et al. Posttraumatic stress two years after the Oklahoma City bombing in youths geographically distant from the explosion. Psychiatry 2000; 63:358 –70. Schuster MA, Stein BD, Jaycox LH, et al. A national survey of stress reactions after the September 11, 2001, terrorist attacks. N Engl I Med 2001;345:1507– 12. Address correspondence and reprint requests to Nada L. Stotland, MD, HPH, Rush Medical College, Chicago, IL.
93
This paper is written in the aftermath of the September 11th attacks on New York and Washington D.C. and in the midst of partially controlled general panic over anthrax infection. By the time it is published, concerns may have moderated, or new acts of terrorism may have occurred. In either case, the psychological impact of terrorism will continue to affect primary care patients for years to come. (Prim Care Update Ob/Gyns 2002;9:90 –93. © 2002 Elsevier Science Inc. All rights reserved.)
Terrorist attacks on New York and Washington D.C. have affected people all over the world. Assumptions about what is possible, what is conceivable, have been found wanting. Our sense of comparative safety has been shaken. Acts that we have taken for granted, like traveling and opening the daily mail, are now fraught with unknown levels of danger. Practical and psychological effects operate in concentric waves, from those killed or wounded; to their families, friends, and fellow workers; to employees of businesses destroyed or downsized, resulting in unemployment and economic deprivation; to adults and children watching horrific scenes repeated endlessly on television; to innocent individuals attacked in their communities because they are perceived to belong to groups responsible for terrorism. The psyFrom the Departments of Psychiatry and Obstetrics and Gynocology, Rush Medical College, Chicago, Illinois.
90
chological effects of these acts are pervasive, widespread, and longlasting. Many of these effects are manifest, directly and indirectly, in the primary care setting. Patients who have narrowly escaped being killed or maimed, and who have observed others injured or dying, have acute and posttraumatic stress reactions and survivor guilt. Those who have lost loved ones are grieving and angry, deprived in most cases even of bodies to bury. Patients whose jobs are lost or threatened are anxious about the support of their families. Over the coming months and years, primary care clinicians will see increases both in mood and anxiety symptoms and in somatic complaints and conditions. They will need to counsel patients about general coping and risk calculation and avoidance and to distinguish normal responses from psychiatric pathology.
Common Sense Counseling Terrorism is meant to evoke terror. Like the aftershocks of an earthquake, further terrorist acts are unpredictable. Unlike natural disasters, terrorism exposes the darkest side of human psychology, making all our fellow creatures, even ourselves, suspect. There are ultimately unanswerable questions about what makes people behave this way. The survivors are the victims not only of physical and psychological damage but of vicious human hatred. The very occurrence of the disaster makes it clear that
© 2002 Elsevier Science Inc., all rights reserved. 1068-607X/02/$22.00
●
existing systems are not adequate to anticipate or prevent such events, despite authorities’ protestation. There is ongoing fear that governmental response will be inadequate or, even worse, provoke worse disasters. In the wake of a terrorist event, all patients should be counseled to strictly limit their exposure to media accounts of the disaster. Repeatedly seeing and/or hearing about an event creates the sense that more events have occurred. Once a day, or at most, the morning and evening news, will suffice to keep people informed about developments. Children, especially, should not be permitted to watch horrific scenes on television. Televisions and radios should be tuned to other kinds of educational and entertainment programs; they will be interrupted by the authorities if the populace needs to be informed of some immediate emergency. Most families will feel most comfortable spending time at home together. Patients need to understand that perceptions of risk are distorted by images and direct experiences of disaster. The overwhelming majority of flights are completed without incident. The likelihood of anthrax contamination of household or office mail is miniscule. If the family cannot contain its anxiety, they can take simple common sense measures rather than continuing to worry. If they absolutely must, they can open the mail on a newspaper, with rubber gloves; they can take the train rather than a plane. They can assemble a disaster kit, with
PII S1068-607X(02)00095-1
Prim Care Update Ob/Gyns
PSYCHOLOGY OF TERROR
flashlight, nonperishable food, bottled water, and supplies of medications they regularly take, and put it in a safe place. They may want to establish a plan of communication by asking a friend or relative who lives some distance away to serve as the message coordinator if members of the family cannot communicate directly for a time. People directly involved with a disaster, including those who volunteer to counsel survivors, need to remind themselves of the greater context before returning to their families with raw emotions; they need to read a pleasant book or listen to music on the ride or walk home, for example. It is best to maintain routines. That is especially reassuring to children. Getting to the grocery store, sports practice, and other activities is a distraction, and safe accomplishment of these activities facilitates the return of a sense of normalcy and safety. Children need reassurance that disasters are very rare and that their families will keep them safe. Parents should also be made aware that children readily absorb both factual information (although they may not be able to interpret it) and emotions while appearing to be oblivious, and that childrens’ distress may manifest differently than adults’. Children may have nightmares or become withdrawn or hyperactive, clinging, and fearful without articulating, or even recognizing, the source of their anxiety. Ritual and reassurance at bedtime, and tolerance of temporary neediness, are helpful. The crisis offers the opportunity to reinforce positive health behaviors while reminding patients of the more likely risks to their health. When people ask how they can best protect themselves and their families, clinicians can tell them that using their seat belts, getting regular exercise, and eating wisely are more likely to decrease their risk of death than are acquiring gas masks and Volume 9, Number 3, 2002
decontamination suits and stockpiling one antibiotic or another.
Primary Care Crisis Intervention Many people exposed to a disaster begin to startle easily, feel nervous, and have difficulty concentrating. All over the country, in the days after September 11th, employers and employees reported that they could not accomplish much meaningful work. After a disaster, people have difficulty getting to sleep, and, when they do sleep, their rest may be interrupted by nightmares. It is important for people to use whatever soothing responses work for them. Some take comfort from being with others who have been through the same trauma, whereas others prefer to leave the scene behind, if possible. People sharing experiences in a group can either support and validate each other or exacerbate each others fears. Though the magnitude of the recent disasters exceeds anything that most Americans have experienced, most people will derive relief from the same approaches that have helped them with less horrific experiences in the past. Very short-term use of benzodiazepines and hypnotics is useful for some patients. There is no evidence that blunting acute anxiety either speeds or prolongs ultimate recovery. Many patients simply need permission to take a break from work and worries related to the disaster, to enjoy a normal diversion. Clinicians are well placed to provide that permission in the form of a medical recommendation. Birth rates tend to increase 9 months after some disasters. The fear of the future has a paradoxical effect; people consciously and unconsciously want to have progeny to survive after them, or dismiss the future consequences of present behaviors. Access to contraception
may be complicated by the inability to get home or to refill prescriptions or buy condoms at local stores. People tend to spend more time at home together rather than pursuing their usual activities. Emotions are heightened; concentration is diminished; sex feels life-affirming. Obstetrician/gynecologists can remind patients that they may be vulnerable to unplanned pregnancies.
The Role of Religion Religion is a tremendous solace for many people affected by disaster. At the same time, clinicians should be aware of 2 potential problems. Disasters and losses also cause some people to question their long-held faith. They cannot imagine how God would let such a thing happen. If they are furious at God, they may find it hard to believe that God will still support them. It is useful to remind believers who feel this way that God created human beings, understands that some events are beyond their understanding and provoke their rage, and loves and comforts them throughout. The other problem is the exclusive dependence on prayer when medical intervention is indicated. Believers other than Christian Scientists, who will probably not be consulting clinicians in the first place, understand that medical care is one form of help provided by God. Neither the diabetic nor the individual with depression serves God or demonstrates faith by refusing medical care.
When Is Grief Pathological? What is a normal response to a disaster, and what is the clinical significance of normal, as contrasted with abnormal, responses? The fact that a response is understandable, even inevitable, under 91
STOTLAND
given circumstances does not mean that it is not pathological or susceptible to intervention. Normal people can be expected to develop infectious diseases if heavily exposed to infectious agents, burns if exposed to fire, and broken limbs and contusions after collisions. Some patients have difficulty acknowledging the extent of their psychological distress. They feel that they should be grateful to be alive and whole when others have died or been injured. They do not want to consume health resources that might be needed by others more directly affected. They believe that they should be able to cope with trauma using their own resources or by calling on God for help. As in other situations, sometimes one of the jobs of the clinician is to help patients accept the help they need. It is useful that in the aftermath of the September 11th attacks, government and private officials underscored the need for mental health services, and many brave policemen and firefighters asked for them. Grief and depression share many signs and symptoms, including sadness or irritability and disruptions in sleep, eating, and concentration. Unwarranted guilt is more likely to be associated with depression than with grief, although terrorist events may provoke guilt among survivors, who by luck or active efforts were able to escape the fate of those whom they grieve. Americans seem to have little patience with grief; we sympathize for a week or two and soon expect the bereaved to form new relationships and get on with life. Grieving for an intense, longterm relationship can last for years, even for life. Elderly widows and widowers, if closely questioned, report that the departed partner is very much with them, commenting on events and advising on decisions. Nevertheless, grief does diminish over time, and normal people are able to return to their responsibilities within weeks or 92
months. When signs and symptoms interfering with function persist beyond 3 to 6 months, professional consultation should be obtained. Medication does not appear to alter the course of grief one way or the other.
Specific Psychiatric Sequelae It is impossible to predict with certainty which patients will develop signs and symptoms of diagnosable psychiatric disorders in response to a disaster. Previous or ongoing psychiatric illness, a history of abuse or childhood trauma, poor social supports, and female gender increase risk.
ANXIETY DISORDERS It is likely that generalized anxiety disorder, panic disorder, agoraphobia, and other phobias can be precipitated and exacerbated by disasters, but the disorder that has received the majority of scientific attention is posttraumatic stress disorder, or PTSD. PTSD is characterized by the following; ●
● ● ● ● ● ● ●
Flashbacks, during which the individual relives the trauma in vivid, immediate sensory and affective details, Emotional numbing, Loss of a sense of a future, Nightmares about the trauma, Avoidance of places and events reminiscent of the trauma, Irritability, Hypervigilance, and A tendency to startle easily.
One medication, sertraline, has been approved by the United States Food and Drug Administration as effective for PTSD. Cognitive– behavioral psychotherapy is useful as well. There is some evidence to indicate that early intervention with one or both of these modalities can mitigate the onset or severity of
PTSD. Unfortunately, little is known about the natural course of PTSD; we cannot prognosticate or reassure patients on that score. We do know that untreated PTSD can have a dire effect on quality of life, relationships, and job functioning. Preoccupation with avoiding any reminder of a trauma severely constrains choices of residence and job location, whereas the loss of a sense of future interrupts planning and making provisions for that future.
DEPRESSION Up to 10% of women in their childbearing years are clinically depressed at any point in time. Women with past episodes of mood disorders, including severe premenstrual syndrome or postpartum depression, are at increased risk. Most of the people in New York City and in Washington, D.C. and many elsewhere, probably had depressed mood for a week or two after the September 11th attacks. If the signs and symptoms persist for 2 weeks or more, most of the day, every day, the diagnosis of a depressive episode, and pharmacologic and/or psychotherapeutic treatment for it, is indicated. Clinicians may wish to propose restarting medication for traumatized patients with past episodes and increasing medication dosages for patients on low-level maintenance regimens.
SOMATIZATION In a time of acute life-threatening crisis, many people are not aware of symptoms of acute injury or chronic disease. After the acute emergency, however, residual anxiety may manifest in the form of new, recurrent, or more severe somatic symptoms. Clinicians can expect to see flare-ups of irritable bowel, headache, backache, menstrual, and similar symptoms. Patients may or may not relate these to the traumatic event or events and may even take umbrage at the suggestion that they Prim Care Update Ob/Gyns
PSYCHOLOGY OF TERROR
are related. Some, however, will be relieved to have the possible connection pointed out. Significant medical diseases can and do occur in somatizing patients, and the severe anxiety of a terrorist situation may trigger or exacerbate medical conditions such as cardiac events, asthma, or colitis. There is always a diagnostic dilemma with these patients. Nevertheless, in the trauma context, it may be wise to offer reassurance and counseling before launching a major diagnostic workup for dubious symptoms. When the terrorist acts raise the ongoing possibility of infection or contamination, people’s focus on bodily sensations and functions is heightened. Studies have demonstrated that for every individual physically affected by a disaster, as many as six present in clinical settings for treatment. The welter of information and misinformation on the Internet and in the media exacerbates the problem. The most effective interventions are reassurance and the provision of clear, simple, accurate information. Often such information is available at government sites, such as the one of the Centers for Disease Control and Prevention on the World Wide Web, and can be downloaded, printed, and distributed to patients.
ALCOHOL AND SUBSTANCE ABUSE Specialists in alcohol and substance abuse disorders report a wide range of patient reactions to terrorist events. Certainly there was not a wholesale relapse, but some patients did resort to alcohol and sub-
Volume 9, Number 3, 2002
stances in attempts to deal with their anxiety. Clinicians should consider discussing with all patients the need to use healthenhancing, rather than healthdestroying (including tobacco smoking), ways of coping, rather than compounding the destruction of the disaster by using it as an excuse to engage in addictive behaviors.
● ●
●
●
DISORDERS AFFECTING COGNITION Terrorist acts have not been associated with increased episodes of psychosis. Some patients with dementia and psychotic disorders seem to be too preoccupied with their own disordered cognitions to take much note of outside events. There are patients, however, who attribute disasters to their own behaviors or to a delusional cause. Clinicians caring for patients with disorders of cognition might ask them whether they know what has happened and why they think it happened, and attempt to correct misconceptions.
Advice for Patients In summary, patients can benefit from the following recommendations from their clinicians: ●
● ● ●
Turn off the television and radio, or tune them to music or to other soothing and distracting programming. Spend quality, peaceful time with family and friends. Maintain perspective. Reassure children that acts of ter-
●
rorism are extremely rare and that you will keep them safe. Follow your normal routine as much as circumstances allow. Take especially good care of yourself and your family. Eat well, get regular exercise. If there are safety measures that you feel compelled to take, put them in place and then forget about them. Use contraception if you don’t want to get pregnant. Consult your physician if difficulty concentrating, sleeping, or eating persist beyond a week or two after the disaster or interfere with your ability to carry out your family and employment responsibilities. Help is available.
Suggested Reading American Academy of Child and Adolescent Psychiatry. How to talk to children and parents after a disaster. Washington, DC: American Academy of Child and Adolescent Psychiatry, 1999. http://www.aacap.org/ publications/DisasterResponse/ cp_disas.htm North CS, Nixon SJ, Shariat S, et al. Psychiatric disorders among survivors of the Oklahoma City bombing. JAMA 1999;282:755– 62. Pfefferbaum B, Seale TW, McDonald NB, et al. Posttraumatic stress two years after the Oklahoma City bombing in youths geographically distant from the explosion. Psychiatry 2000; 63:358 –70. Schuster MA, Stein BD, Jaycox LH, et al. A national survey of stress reactions after the September 11, 2001, terrorist attacks. N Engl I Med 2001;345:1507– 12. Address correspondence and reprint requests to Nada L. Stotland, MD, HPH, Rush Medical College, Chicago, IL.
93