“In order to provide effective care to our patients it is necessary to have clear ideas on how to follow criteria for diagnosis and as a consequence for treatment,” Dr. Corvalan says. “The field at times is confusing; patients do not always follow the diagnostic criteria. The needs of the moment, limitations of recourses, intensity and variety of symptoms, urgency of the situation, etc., all conspire to make the job more difficult.”
Patients with anthrax-related anxiety should be encouraged to “try to function as normally as possible and keep an open communication with peers and those who they look to for information,” Dr. Frank notes. Dr. Allen adds that his patients with anthrax-inspired stress have responded well to breathing, meditation and other relaxation techniques.
Treatment of patients who are severely traumatized and exhibit true PTSD symptoms will vary based on severity of exposure, history of prior PTSD, and existence of comorbidities. A combination of pharmacological and psychosocial therapy is the common first-line treatment.
The selective serotonin reuptake inhibitor (SSRI) sertraline is specifically indicated for treating confirmed PTSD symptoms, and several studies have documented the agent’s effectiveness for this use.14,15 Dr. Frank recommends dosages between 50 and 200 mg/d depending on the patient’s body weight or complaint of side effects (e.g., diarrhea, nausea, or sexual dysfunction). Other SSRIs, as well as tricyclics and MAO inhibitors, are alternatives. Fluoxetine, amitriptyline, phenelzine, and imipramine have all been found more effective than a placebo;16-18 paroxetine also has been shown effective in specific populations.19
THE FOUR STAGES OF COPING WITH DISASTER
Kenneth S. Thompson, MD, a Pittsburgh-based disaster psychiatrist who helped coordinate Oklahoma City’s emergency psychiatry effort after the 1995 bombing, identified four stages that the public works through after a major disaster:
- Mobilization. Rebuilding—or just surviving—is foremost on people’s minds immediately after a traumatic event. Many people either throw themselves headfirst into the recovery and cleanup effort, or assist grieving families that have been hardest hit by the disaster. Others fear for their safety and leave town. Feelings of grief and loss are set aside to focus on the needs of the moment.
- Self-importance. As the media reports on their efforts to put their city—and their lives—back together, people at this stage tend to feel they are part of something. Those who have lost family members and coworkers seem to be coping well at this point, and feel as though they can draw ample moral support from friends and neighbors.
- Abandonment. Once the dust settles and the media coverage dies down, people who lost loved ones are left to confront their grief alone. Those who witnessed the tragedy, or who know someone who was killed or injured in the incident, must confront their demons one on one. It is at this point that PTSD and other psychiatric disorders can set in. Those who did not lose a friend or relative feel a more general sense of loss. Worse still, there may be “a disaster after the disaster,” in which a political official or emergency services officer is charged with some type of wrongdoing or abuse of power. People then feel used and betrayed.
- Acceptance. People begin to seek psychiatric or other help in dealing with the trauma, and begin to come to terms with their loss.
Benzodiazapenes also may be prescribed to manage PTSD symptoms. Patients should be counseled against taking these sedating agents in the daytime, however, as they can lead to fogginess, detachment, and trouble functioning.
Assessing the patient’s available social support also is crucial to PTSD treatment. “Do patients talk to other people about the event?” Dr. Frank asks. “Are they trying to get back to a daily routine? Can they make sense of this experience? Are they incorporating the event into a world view?”
Dr. Thompson, the Pittsburgh disaster psychiatrist, agrees. Psychiatrists should encourage their patients to talk more about their trauma and how fear is affecting their lives. “We don’t discuss with our trauma patients as much as we might what the experience has been like for them,” he says.
Small-group therapy is the most conducive approach to psychotherapy for PTSD, according to Dr. Frank, although individual counseling can work in many cases. Several studies have found group therapy effective,20,21 and 12-step group therapy has shown promise in PTSD patients with comorbid substance abuse disorder.22
Managing fear
Just as people grieve and confront death in stages, Dr. Thompson, who helped coordinate Oklahoma City’s disaster psychiatry effort, has discovered that the public usually employs a similar subconscious process to cope with a traumatic event (Box 4).