This article originally appeared in the January 2002 issue of the Harvard Mental Health Letter and is provided courtesy of Harvard Health Publications.

Disaster and Trauma

The attacks of September 11 ended the lives of more than 5,000 people and transformed the lives of many more. Most directly affected were the tens of thousands of witnesses, rescue workers, and grieving family members and friends. Millions more read and heard the news and saw the images displayed repeatedly on television. This catastrophe has had a more devastating impact than a natural disaster or major accident, because we know that it was meant to sow terror and we have good reasons to fear that something like it may happen again. Even people not directly touched may feel temporarily shaken and helpless. This sad and anxious time is also a time for thinking about the psychological effects of trauma and how to cope with the emotional disorders that can follow.

Shock, anger, grief, and fear are normal reactions to such a devastating event. Almost all of us have lost something, if only some confidence in the future. Surveys conducted in the weeks after the attacks indicated a rise in the number of people—even among those not close to the scenes of the disaster—who felt depressed, had trouble sleeping, or couldn’t concentrate. Fatigue, headaches, indigestion, nightmares, and intrusive images were common among the bereaved, witnesses, and relief workers. The number of new prescriptions for sleeping pills rose by a reported 28% and the number of new prescriptions for antidepressants by 17% in the New York area.

A person’s immediate response to a disaster, no matter how extreme, is not an emotional disorder or a sign of mental illness. People who were far from the sites of the attack and even most who were nearby can expect to recover quickly. They should resume their normal lives as soon as possible, coming to terms with regret and concentrating on the future, keeping faith in their own capacities and getting help if necessary. Most symptoms of this kind go away in a week or two, and just being with others at community gatherings, religious services, and other meetings can be an important source of solace. Physical activity and other distractions often provide relief, and techniques such as meditation, breathing exercises, and muscle relaxation may help.

For most of the more immediate victims, thinking about the experience and discussing it may be better than suppressing the memories and images. Many will need listeners, even as they tell their stories repeatedly. The benefit of formal crisis counseling is disputed. One method—critical stress incident debriefing—was originally developed to help firefighters cope with their experiences but is now used more widely. A counselor in an informal setting encourages trauma survivors to recall the event and discuss their feelings in the immediate aftermath. Some studies have found these sessions to be helpful, but others suggest that they may actually do harm. What is clear is that no one should be forcefully persuaded to talk about the experience.

Post-traumatic stress disorder
While most people are recovering their balance and resuming their routines, a few will have lasting symptoms, including persistent severe depression and anxiety. And some will develop a chronic condition that is complex, pervasive, and difficult to treat—the lingering wound (the original meaning of “trauma”) from an overwhelming assault on the emotions. According to the American Psychiatric Association’s definition, post-traumatic stress disorder (PTSD) results from experiencing an event that involves a threat of death or serious injury or a threat to physical integrity. The experience causes intense fear, horror, and feelings of helplessness. A diagnosis of PTSD is made only after the symptoms have lasted at least a month. They may appear immediately but occasionally emerge after a long delay—sometimes even years later. These symptoms are:

1. Reexperiencing: Victims may relive the traumatic event in the form of intrusive memories, nightmares, and flashbacks (feeling or acting as though the experience is recurring). They may be upset when they are exposed to anything—an emotion, sensation, place, or person—that recalls or resembles some aspect of the experience. Even remote reminders can provoke intense physical stress reactions.
   
   
2. Avoidance: Victims often try to avoid the thoughts and feelings they had at the time of the trauma and all people, places, and activities that bring the experience to mind. In the process, their lives become restricted and their emotions numbed. They may be unable to recall all or part of the experience. They lose interest in everyday activities and feel estranged from others. They may suffer from a sense of futility and expect to die before their time. It is as though their feelings are no longer fully real to them and the ordinary business of life no longer matters.
   
   
3. Heightened arousal: Victims may be irritable or subject to angry outbursts. Their sleep is troubled and their concentration is poor. They are jumpy (an exaggerated startle response) and constantly on guard (hypervigilant), as though they are still being threatened.

Few people will have all of these symptoms. A diagnosis of post-traumatic stress disorder formally requires at least one in the first group, three in the second, and two in the third. The symptoms may seem to be a strange mixture, even superficially incompatible in some ways, but there is a common theme—the traumatic event is controlling emotional life. The victim refers everything to it, constantly responding to that past experience as though it were present, unable to adapt to new circumstances and take advantage of new opportunities.

According to a nationwide survey, more than 50% of people in this country have undergone an experience that is potentially traumatic—chiefly a natural disaster, a life-threatening accident, or seeing another person badly injured or killed. Other surveys have found a lifetime PTSD rate of 8% in the United States and a current rate (previous year) of 1-3%, although it is difficult to separate pure PTSD from other mental disorders, such as mood or personality disorders. Mass destruction that affects a whole community, like the September attacks, is an especially potent source of PTSD. The disorder is common after airplane crashes and major fires, and the risk is especially high if the cause of the trauma is a deliberate assault rather than an accident or natural disaster.

Both circumstances and individual personality determine who is likely to develop PTSD. Most at risk, obviously, are those most directly exposed—people who are seriously injured or narrowly escape death, police officers, firefighters, healthcare and emergency rescue workers who are on the scene immediately afterward, and anyone who has lost a husband, wife, parent, child, co-worker, or close friend. Women are twice as vulnerable as men, and children are at even higher risk. According to one recent study, as many as 30% of children exposed to a trauma may develop symptoms of PTSD. Another powerful risk factor is previous traumatic experience—especially child abuse and chronic severe stress such as long periods of combat.

The risk is higher for people who lack social support—someone to commiserate with, help they can count on from family, friends, and the community. Anyone who has a psychiatric disorder or a family history of psychiatric disorders is also vulnerable. In a situation like the present one, people with paranoid or other delusional tendencies are especially likely to suffer, but the trauma can worsen almost any existing symptoms, including anxiety, depression, personality problems, and addictions to alcohol and other drugs. It is often difficult to tell which of the symptoms are independent of the trauma and which are caused by it.

Chronic PTSD is especially common among people who suffer an acute stress reaction that lasts several days to a month. Although this response may include a number of PTSD symptoms, its distinguishing feature is dissociation. Victims feel detached and disconnected from others and from their own feelings. They are barely conscious of their surroundings. They suffer from a sense of unreality (depersonalization or derealization) and sometimes amnesia as well. Numbing or loss of awareness may provide some immediate shelter, but this response quickly loses any usefulness it may have, making it difficult to assimilate the memories and recover from the effects of the trauma. About 50% of people with acute stress reactions return to normal within three months, but an estimated 25% develop PTSD.

Physiology of stress
Reactions to stress involve the body as well as the mind. An automatic stress response is normal whenever an emergency disrupts or severely tests adaptive capacity. As the body mobilizes to confront the crisis, the adrenal hormones cortisol and adrenaline (epinephrine) begin to circulate, responding to signals passed through the pituitary gland from the hypothalamus, deep in the brain. The chemical messengers dopamine and norepinephrine are released in the sympathetic nervous system. Muscles tense and heart rate, blood pressure, and respiratory rate rise.

Both during a trauma like September 11 and when they recall it, people who develop PTSD show higher arousal levels than other survivors of the same catastrophe—more activity in the sympathetic nervous system, higher levels of adrenaline, and a greater rise in heart rate and blood pressure. But they have lower than average levels of cortisol, which supplies a feedback mechanism that turns off the alarm when the emergency is over. As soon as it reaches a certain level in the blood, the brain receives a signal and delivers a reply: turn down the sympathetic system and suppress the secretion of adrenaline. One theory about the origin of PTSD is that trauma makes some people hypersensitive to cortisol. In response, the adrenal glands stop releasing the hormone, and it never reaches a level high enough to curb the emergency response.

Meanwhile, the mind is undergoing changes. The sympathetic nervous system activates the amygdala, a brain region that coordinates responses to fear and anger, storing emotionally significant memories that are needed for survival. These memories in turn can influence later physical reactions. The form of the memories may also be affected. If the alarm is never completely turned off, the experience is not assimilated normally and may return as nightmares and other intrusive experiences.

The physiology of depression, another long-term effect of severe stress, is different; for example, depressed people tend to have a high rather than a low level of cortisol. Whether a person develops PTSD or other symptoms after a traumatic experience depends on individual differences we know too little about. Psychiatric researchers are trying to gain a better understanding of these vulnerabilities in order to develop more effective treatments.

Overcoming trauma
The aftereffects of trauma demand both intellectual and emotional resolution. While minds are calmed and bodies soothed, sufferers may want an explanation or a response from others that helps them make sense of the experience. For some, the first few days and weeks are a critical time in which an acute stress reaction may be prevented from turning into chronic PTSD. Physical comfort—massage, hugging—may mean a great deal to them. They can be educated about stress responses and helped to manage their anxiety. Psychotherapy or counseling may also be helpful.

People with PTSD need to regain the capacity to think and talk about the experience without unwanted intrusions, and exercise control over their feelings without avoidance and emotional numbing. If the treatment succeeds, they will be calm when they want to be and vigilant only when they have to be.

The most popular and well-studied treatments for PTSD are behavioral and cognitive. Exposure with systematic desensitization can reduce the fear of cues that evoke memories of the trauma. Patients review the experience under controlled conditions, gradually approaching its most disturbing aspects, until the memories no longer cause serious distress. In cognitive therapy, the techniques of reframing and reinterpretation are used to change unrealistic assumptions and probe automatic thoughts that provoke inappropriate fear, guilt, and other disturbing emotions. Training in problem solving and assertiveness may also be helpful.

Many people with PTSD make good use of group therapy or mutual support groups. They give meaning to their experience by telling their stories and listening to other victims whose similar experiences promote understanding and sympathy. By helping others, group participants come to feel more capable of helping themselves. They are reassured when they see others recover, and they tolerate their feelings better when many people are available to offer comfort.

Drugs are prescribed for trauma victims to relieve severe symptoms quickly, and in the longer term, to help them make use of psychotherapy. For the immediate treatment of restlessness and anxiety, beta-blockers like propranolol (Inderal) and benzodiazepines such as clonazepam (Klonopin) are often helpful. The most effective medications for the long haul (they take several weeks to begin working) are antidepressants, especially selective serotonin reuptake inhibitors (SSRIs) like sertraline (Zoloft) and fluoxetine (Prozac). (See Harvard Mental Health Letter, October and November 2000.) These drugs not only relieve depression but also improve sleep, suppress intrusive images, and calm explosive anger. Some of these symptoms can also be treated with mood stabilizers like lithium or anticonvulsants such as carbamazepine (Tegretol).

Systematic desensitization, cognitive therapy, and problem-solving training have all been found better than no treatment and in some studies more effective than simple counseling. In one study, cognitive-behavioral therapy was found to prevent the acute stress reaction from developing into PTSD. The rate of PTSD in patients given counseling alone was 83%, compared with 33% among those who had cognitive-behavioral therapy.

A 1998 review of 41 controlled studies of PTSD treatment found that psychotherapy was more effective than drugs alone, although SSRIs had some advantage in the treatment of depression related to trauma. Behavior therapy was particularly helpful, with results that persisted, according to follow-up studies, at least 3 1/2 months after the end of treatment. There were few rigorous studies of group therapy.

The International Society for Traumatic Stress Studies has recently issued guidelines for the treatment of PTSD based on the tabulated opinions of more than 100 experts. Their collective conclusion is that psychotherapy should be continued at least once a week for three months after improvement, with booster sessions at longer intervals after that. The methods most often recommended are exposure with desensitization, cognitive therapy, and anxiety management (including muscle relaxation, meditation, and breathing exercises). Among drug treatments for PTSD, the experts prefer SSRIs and the newer antidepressants nefazodone (Serzone) and venlafaxine (Effexor).

Researchers at Dartmouth are conducting a nationwide study on the psychotherapy of PTSD among women in the military. More than 400 women at 12 sites will be assigned at random for ten weeks to either exposure with desensitization or a “present-centered” therapy (not further described). For six months afterward, they will be evaluated for depression, anxiety, and post-traumatic symptoms. The events of September 11, too, will stimulate research that provides new insight into ways of neutralizing the effects of traumatic stress.

Resources
National Center for Post-Traumatic Stress Disorder
VA Medical and Regional Office Center (116D)
215 North Main Street
White River Junction, VT 05009
Telephone: 802-296-5132
Web: http://www.ncptsd.org

Anxiety Disorders Association of America
11900 Parklawn Drive, Suite 100
Rockville, Maryland 20852
Telephone: 301-231-9350
Web: http://www.adaa.org

For Further Reading
Yehuda, R. “Psychoneuroendocrinology of Post-Traumatic Stress Disorder,” Psychoneuroendocrinology (June 1998): Vol. 21, No. 2, pp. 359–79.

Ursano, R.J. et al. “Psychiatric Dimensions of Disaster: Patient Care, Community Consultation, and Preventive Medicine,” Harvard Review of Psychiatry (November–December 1995): Vol. 3, No. 4, pp. 196–209.

Hembree, E.A. and Foa, E.B. “Posttraumatic Stress Disorder: Psychological Factors and Psychosocial Interventions,” Journal of Clinical Psychiatry (2000): Vol. 61, Suppl. 7, pp. 33–39.

Foa, E.B. et al., eds. Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies, New York: Guilford Press, 2000.