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Currentp SYCHIATRY Currentp SYCHIATRY Terror-related stress How ready are you to deal with it? Peter A. Kelly Theresa Fiore Lavery After the Sept. 11 attacks and the anthrax scare, psychiatrists are seeing exacerbated or recurrent PTSD in existing patients and trauma-related symptoms in new patients. In this special report from the editors, we offer clues to the differential diagnosis from comorbid disorders and suggestions that can help manage ongoing public fears. ince September 11, America has carried on under a 4. Managing fear in your communities—in response to the cloud of fear. Though the cloud is lifting, it will not Sept. 11 attacks, to the anthrax scare, or in anticipation S disappear for months or years. The terrorist attacks of an impending catastrophe. on New York City and Washington, DC, the resultant mili- To bring you this special report, the editors of Current tary action in Afghanistan, and the anthrax scare—combined Psychiatry have reviewed the literature and interviewed psy- with pervasive, nagging doubts about homeland security and chiatrists nationwide and in countries such as Israel and the specter of another possible future terrorist attack—all are Colombia, where terrorism has been a fact of life for years straining the nation’s collective emotional well-being. (see “PTSD lessons from Israel, Colombia,” page 33). Psychiatrists in America have reported new cases of ter- ror-inspired acute stress disorder, anxiety, depression, and Terror and your patients other illnesses, as well as recurrences of posttraumatic stress Which symptoms are you most likely to see in existing disorder (PTSD) in existing patients, in the weeks after the patients subsequent to recent events? In the weeks following recent attacks and the anthrax scare. What will be the impact the Sept. 11 attacks, psychiatrists reported the most common- on psychiatric practice in the coming months and years? ly seen symptoms as increased anxiety and worsened depres- “We are all at ground zero,” says Kenneth S. Thompson, sion. Sleep disturbances, agoraphobia, suicidality, and severe MD, of Pittsburgh, an experienced disaster psychiatrist. But reactions among patients with personality disorders also were he and other subspecialists have identified four critical areas reported. in which psychiatrists should be prepared: Patients with previous PTSD or exposure to trauma face 1. Identifying how terrorist attacks and scares can exacer- a high risk of new or recurrent PTSD in the wake of Sept. 11 bate symptoms in patients now in your practice; than do those not previously exposed to trauma.1 War veter- 2. Diagnosing PTSD among comorbid conditions present ans with prior posttraumatic symptoms have been particular- in existing or new patients; ly prone to recurrent PTSD after the attacks. James Allen, 3. Treating—and avoiding over-treatment—of patients MD, of the Department of Psychiatry and Behavioral with acute stress disorder and PTSD; Sciences at the University of Oklahoma Health Sciences VOL. 1, NO. 1/JANUARY 2002 29 Terror-related stress Box 1 DSM-IV DIAGNOSTIC CRITERIA FOR PTSD Center, calls this the “additive effect”: patients traumatized by A. Exposure to a traumatic event with both of the following military service in Vietnam experi- present: 1. The patient experienced, witnessed, or was confronted with ence a recurrence after seeing a an event or events that involved actual or threatened death or major disaster or atrocity. Dr. serious injury, or a threat to the physical integrity of self or Allen, who was extensively others. involved with Oklahoma City’s 2. The patient’s response involved intense fear, helplessness, or disaster psychiatry effort after the horror. In children, this may by expressed by disorganized or agitated behavior. 1995 bombing there, recalls seeing patients who were trau- B. The traumatic event is persistently reexperienced in one or more of matized in Vietnam suffer a recurrence after the Alfred P. the following ways: Murrah Building attack, and then another relapse after 1. Recurrent and intrusive recollections of the event (e.g., images, Sept. 11. thoughts or perceptions). Children may express themes or aspects “The Sept. 11 attacks were very similar to the war for of the trauma in repetitive play. them,” says Juan Corvalan, MD, of the PTSD Unit of the 2. Recurrent nightmares of the event. Children may have frightening dreams without recognizable content. St. Louis Veterans Administration Medical Center, refer- 3. A sense of reliving the trauma: illusions, flashbacks or hallucinations ring to the numerous war veterans he treated after the in adults, or trauma-specific reenactment in children. atrocities. “Seeing it on TV triggered many memories.” 4. Intense psychological distress or extreme physiological reaction to By early November, however, many who experienced internal or external cues that symbolize or resemble an aspect of the recurrent PTSD had returned to their pre-Sept. 11 men- traumatic event. C. Persistent avoidance of stimuli associated with the trauma and tal states. numbing of general responsiveness (not present before the trauma), Craig Katz, MD, director of emergency psychiatry as indicated by three or more of the following: services at New York’s Mount Sinai Medical Center, 1. Efforts to avoid thoughts, feelings, or conversations associated with says that a patient’s psychiatric history is crucial to the trauma; determining risk for PTSD or other terror-related 2. Efforts to avoid activities, places or people that arouse recollections sequelae: of the trauma; 3. Inability to recall an important aspect of the trauma; “You can recognize that a given person is at high 4. Markedly diminished interest or participation in significant activities; risk for PTSD post-trauma, based on any combination 5. Feeling of detachment or estrangement from others; of these factors—having a psychiatric history, past 6. Restricted range of affect (e.g., unable to have loving feelings); trauma, high exposure to the event, psychosocial prob- 7. Sense of a foreshortened future. lems pre-disaster, or lack of supports post-disaster.” D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two or more of the following: The clinical interview is a vital tool in assessing 1. Difficulty falling or staying asleep; patients with suspected PTSD or posttraumatic 2. Irritability or outbursts of anger; sequelae, says Arieh Shalev, MD, of the department of 3. Difficulty concentrating; psychiatry at Hadassah University Hospital in 4. Hypervigilance; Jerusalem, Israel. “It provides the opportunity to dis- 5. Exaggerated startle response. cuss the traumatic event with the patient, and to lis- E. Duration of symptoms in criteria B, C or D exceeds 1 month. F. Disturbance causes clinically significant distress or impairment in ten to his or her perceptions of the event and its social, occupational, or other important areas of functioning. effects” in order to carefully appraise the patient’s Specify if; Acute: if duration of symptoms is less than 3 months. symptoms.2 Chronic: if symptoms persist 3 months or more. The guidelines set forth in the Diagnostic and With delayed onset: if onset of symptoms is at least 6 months after the Statistical Manual for Mental Disorders, Fourth stressor. Acute stress disorder, whose symptom pattern is similar to that of Edition (DSM-IV) remain the gold standard for PTSD, is distinguished from PTSD because the symptom pattern must confirming a diagnosis of PTSD and discerning occur and resolve within 4 weeks of the traumatic event. If the symp- long-term posttraumatic sequelae from temporary toms persist for more than 1 month and meet the criteria for PTSD, the acute stress disorder (Box 1). The guidelines have diagnosis is changed from acute stress disorder to PTSD. 30 VOL. 1, NO. 1/JANUARY 2002 Currentp SYCHIATRY Currentp SYCHIATRY proved far from foolproof, howev- Box 2 er, and the existence of psychiatric PTSD and comorbidities: Overlapping symptoms comorbidities often clouds the picture. Disorder Symptoms that overlap with PTSD Extreme response to stressor. Stressor is not necessarily Differential diagnosis Adjustment disorder extreme in nature (e.g., spouse leaving, being fired), and the response might not meet criteria for PTSD.4 of PTSD Patients with PTSD are Diminished interest, restricted range of affect, sleep Depression 5 more likely to have substantial difficulties, or poor concentration. psychiatric comorbidity than are Inability to recall important information about past trauma, 3 sense of detachment from oneself, derealization, nightmares, those without the disorder. Dissociative disorders Possible reasons include suspect- flashbacks, startle responses, or lack of affective response (e.g., onset of dissociative fugue may be tied to past trauma).4 ed self-medication of PTSD 5 symptoms, particularly among Generalized anxiety Irritability, hypervigilance, or increased startle reflex. patients with substance abuse, Obsessive-compulsive Recurrent intrusive thoughts (not related to trauma in 4 and the possible overreporting disorder obsessive-compulsive disorder). of symptoms by patients. Heart palpitations or increased heart rate, sense of Panic attacks 4 Psychiatrists should maintain a detachment, nausea or abdominal distress. Illusions, hallucinations, or other perceptual disturbances high level of suspicion for PTSD Psychosis when managing a new or existing (may be confused with flashbacks in PTSD).4 patient with psychopathology. Substance abuse Hallucinations, illusions, diminished
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