Since September 11, America has carried on under a cloud of fear. Though the cloud is lifting, it will not disappear for months or years. The terrorist attacks on New York City and Washington, DC, the resultant military action in Afghanistan, and the anthrax scare—combined with pervasive, nagging doubts about homeland security and the specter of another possible future terrorist attack—all are straining the nation’s collective emotional well-being.
Psychiatrists in America have reported new cases of terror-inspired acute stress disorder, anxiety, depression, and other illnesses, as well as recurrences of posttraumatic stress disorder (PTSD) in existing patients, in the weeks after the recent attacks and the anthrax scare. What will be the impact on psychiatric practice in the coming months and years?
“We are all at ground zero,” says Kenneth S. Thompson, MD, of Pittsburgh, an experienced disaster psychiatrist. But he and other subspecialists have identified four critical areas in which psychiatrists should be prepared:
- Identifying how terrorist attacks and scares can exacerbate symptoms in patients now in your practice;
- Diagnosing PTSD among comorbid conditions present in existing or new patients;
- Treating—and avoiding over-treatment—of patients with acute stress disorder and PTSD;
- Managing fear in your communities—in response to the Sept. 11 attacks, to the anthrax scare, or in anticipation of an impending catastrophe.
To bring you this special report, the editors of Current Psychiatry have reviewed the literature and interviewed psychiatrists nationwide and in countries such as Israel and Colombia, where terrorism has been a fact of life for years (see “PTSD lessons from Israel, Colombia,”).
Terror and your patients
Which symptoms are you most likely to see in existing patients subsequent to recent events? In the weeks following the Sept. 11 attacks, psychiatrists reported the most commonly seen symptoms as increased anxiety and worsened depression. Sleep disturbances, agoraphobia, suicidality, and severe reactions among patients with personality disorders also were reported.
Patients with previous PTSD or exposure to trauma face a high risk of new or recurrent PTSD in the wake of Sept. 11 than do those not previously exposed to trauma.1 War veterans with prior posttraumatic symptoms have been particularly prone to recurrent PTSD after the attacks. James Allen, MD, of the Department of Psychiatry and Behavioral Sciences at the University of Oklahoma Health Sciences Center, calls this the “additive effect”: patients traumatized by military service in Vietnam experience a recurrence after seeing a major disaster or atrocity. Dr. Allen, who was extensively involved with Oklahoma City’s disaster psychiatry effort after the 1995 bombing there, recalls seeing patients who were traumatized in Vietnam suffer a recurrence after the Alfred P. Murrah Building attack, and then another relapse after Sept. 11.
“The Sept. 11 attacks were very similar to the war for them,” says Juan Corvalan, MD, of the PTSD Unit of the St. Louis Veterans Administration Medical Center, referring to the numerous war veterans he treated after the atrocities. “Seeing it on TV triggered many memories.” By early November, however, many who experienced recurrent PTSD had returned to their pre-Sept. 11 mental states.
Craig Katz, MD, director of emergency psychiatry services at New York’s Mount Sinai Medical Center, says that a patient’s psychiatric history is crucial to determining risk for PTSD or other terror-related sequelae:
“You can recognize that a given person is at high risk for PTSD post-trauma, based on any combination of these factors—having a psychiatric history, past trauma, high exposure to the event, psychosocial problems pre-disaster, or lack of supports post-disaster.”
The clinical interview is a vital tool in assessing patients with suspected PTSD or posttraumatic sequelae, says Arieh Shalev, MD, of the department of psychiatry at Hadassah University Hospital in Jerusalem, Israel. “It provides the opportunity to discuss the traumatic event with the patient, and to listen to his or her perceptions of the event and its effects” in order to carefully appraise the patient’s symptoms.2
The guidelines set forth in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) remain the gold standard for confirming a diagnosis of PTSD and discerning long-term posttraumatic sequelae from temporary acute stress disorder (Box 1). The guidelines have proved far from foolproof, however, and the existence of psychiatric comorbidities often clouds the picture.
DSM-IV DIAGNOSTIC CRITERIA FOR PTSD
- Exposure to a traumatic event with both of the following present:
- The traumatic event is persistently reexperienced in one or more of the following ways:
- Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three or more of the following:
- Persistent symptoms of increased arousal (not present before the trauma), as indicated by two or more of the following:
- Duration of symptoms in criteria B, C or D exceeds 1 month.
- Disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if; Acute: if duration of symptoms is less than 3 months.
Chronic: if symptoms persist 3 months or more.
With delayed onset: if onset of symptoms is at least 6 months after the stressor.
Acute stress disorder, whose symptom pattern is similar to that of PTSD, is distinguished from PTSD because the symptom pattern must occur and resolve within 4 weeks of the traumatic event. If the symptoms persist for more than 1 month and meet the criteria for PTSD, the diagnosis is changed from acute stress disorder to PTSD.