Medical-Journals.com
UK
Europe
USA&Canada
Aust.&NZ
Asia
|
|
NEJM Volume 346:130-132 ,January 10, 2002,Number 2 Post-Traumatic Stress Disorder Terrorist attacks require our health care system to prepare for the unspeakable. The primary goal of terrorism is to erode the security of a nation, to disrupt the continuity of society, and to destroy the nation's social capital - its morale, cohesion, and values. Both the health care system and individual physicians are critical to the safety and future of our nation. In this issue of the Journal, Yehuda1 updates our knowledge of post-traumatic stress disorder (PTSD), including its epidemiology, psychological and biologic origins, and treatment. PTSD is not uncommon after many types of traumatic events, from motor vehicle accidents to industrial explosions, and it can develop even in people with no history of psychiatric disorders. Nearly all people have the acute form of the disorder at some time in their lives, but they recover rapidly. If it persists, PTSD can be debilitating and require psychotherapeutic and pharmacologic intervention. Study of natural disasters and terrorist acts such as the Oklahoma City bombing confirms that PTSD is a probable outcome for many people who were directly exposed to the events of September 11. Thus, there may be hundreds of thousands of new cases of PTSD in New York alone. In addition, much of our nation was indirectly exposed to the tragedy through the media, resulting in a lost sense of safety and hypervigilance. In a survey of 560 adults in the United States conducted the week after September 11, 44 percent of the adults reported one or more substantial symptoms of stress.2 Persons at greatest risk for PTSD are those directly exposed to a traumatic event and persons, such as rescue and health care workers, who are the first ones on the scene after the event. Early symptoms usually respond to a number of approaches, such as helping patients and their families identify the cause of the stress and limiting further exposure (e.g., by avoiding news coverage of the traumatic event) and advising patients to get enough rest and maintain their biologic rhythms (e.g., by going to sleep at the same time each night and by eating at the same times each day). Educating patients and their families can also help them to identify worsening or persistent symptoms. PTSD, however, is not the only trauma-related disorder, or perhaps even the one most commonly seen by primary care physicians. After a traumatic event, pathologic forms of grief (so-called traumatic grief),3 unexplained somatic symptoms, depression,4 sleep disturbance, and increased use of alcohol and cigarettes, as well as family conflict and family violence, are not uncommon, but in each case, the role of the traumatic event may be easily overlooked. Patients who present with these symptoms should be questioned about the possible occurrence of a traumatic event. Traumatic grief on the part of the parents of adult children who have died unexpectedly or as a result of trauma is often overlooked by physicians and others, unlike grief on the part of the spouse or partner and children of the deceased. Anxiety and family conflict can be triggered by the fear of new threats to safety or by the economic impact of the loss of a job after a traumatic event. Clinicians can reassure patients that such events are not uncommon after a traumatic event. Such interactions may pave the way for a discussion about referral and prevent further conflicts. Somatic symptoms are frequently increased after disasters and can be an expression of anxiety or depression. In patients with these symptoms, conservative management, which includes education and reassurance, forms the core of medical treatment of somatic and psychological symptoms after traumatic events. Discussion of a patient's specific worries and fears can initiate the normal process of stress resolution or clarify the need for further treatment or referral. The normal process of recovery involves talking with others about the event, learning coping strategies, and seeking help. Traumatized persons who become withdrawn or reclusive are particularly difficult to treat. Depression may be a primary factor in such patients and requires evaluation and treatment. The biologic and psychosocial effects of traumatic events are complex and interrelated.1,5 Overidentification with the victims (e.g., "It could have been me") and their pain and grief can perpetuate the fear response.6 The cases of bioterrorism-related anthrax that have occurred since September 11 have highlighted the need for changes in the health care system. Substantial funds and effort are needed to render the system capable of handling a serious attack of bioterrorism, whether it involves biologic, chemical, or radiologic weapons. How health care providers address the psychological response to an attack is critical to the success of public health efforts.7 For example, after the Aum Shinrikyo cult released sarin gas on Tokyo subway trains, killing 12 persons, more than 5000 people sought care for presumed exposure. In Israel, after a SCUD-missile attack during the Gulf War, fear of exposure to chemical weapons was the reason for nearly 700 of 1000 war-related visits to emergency rooms.8 At least one person died from misuse of a gas mask. We assess risk and threat on the basis of our feelings of control and our level of knowledge. Therefore, the consumption of foods laden with saturated fat may not be recognized as a risk to health, whereas air travel may be seen as overly risky. During or after an attack of bioterrorism, fear can disrupt communities as people try to feel safe by distancing themselves emotionally from those who have been exposed or who are ill. Physicians can counter their patients' fears by educating them about the degree of actual risk, providing information on ways of decreasing risk, and teaching coping strategies. Most people will eventually resume their normal lives after a traumatic event. Resiliency is the rule in the long run, but physicians can help their patients cope with the devastating psychiatric effects of terrorism.
References
|