Updated: Aug 28, 2008
Introduction
Disaster victims and those who love them are vulnerable to considerable emotional turmoil and a variety of symptoms following a traumatic event and the loss of loved ones. This article discusses common reactions to traumatic events and to the loss of loved ones. This article also explores when to seek professional help, ways that loved ones and friends can help victims and their families, and what professionals can do in these situations. In addition, specific assistance for children who have experienced emotional trauma or loss is discussed.
All people experience traumatic events in their lives. All people lose loved ones, 1 in 4 women experience rape or attempted rape during their lifetime, and 1 million children a year are abused or neglected. In 2000, one quarter of a million Americans were raped or sexually assaulted, three quarters of a million were robbed, and half a million were assaulted. Millions of children are bullied in school, 7% of men and 22% of women are assaulted by an intimate partner, and 3 million people a year are involved in car accidents. Most Americans were shocked by the loss of thousands of lives in the terrorist attack on the World Trade Center.
Psychiatric trauma
Freud defined trauma as the experience of having the ego rendered helpless by overstimulation. Winnicot said trauma was pathogenic for children because it catastrophically destroyed the child's illusion of omnipotence and the illusion that his parents would protect him. Trauma establishes a new possibility for the child of what can happen in the world and a preoccupation with danger and vulnerability.
In 1996, Van Der Kolk wrote that posttraumatic stress disorder (PTSD) involves the combination of a conditioned fear response to trauma-related stimuli, altered neurobiological processes leading to increased arousal, and altered cognitive schemata and social apprehension.
Horowitz said that trauma occurs when an individual is faced with an overwhelming and negative experience that is incongruent within existing schema. The individual repeatedly recollects the event in an attempt to integrate it and to accommodate existing cognitive schema with the new information. Meanwhile, numbness and withdrawal arise in an attempt to cope with the pain of memories. In 1993, Lifton discussed how trauma could transform the structure of the self.
Emotional response to disaster
Impact phase: During the first few days, individuals often feel stunned. In the first week, disbelief, numbness, fear, and possibly confusion to the point of disorganization occur.
Crisis phase: After the initial impact has been absorbed, individuals can experience a number of feelings.
Individuals may alternate between denial and intrusive symptoms with hyperarousal.
Persons may experience somatic symptoms (eg, fatigue, dizziness, headaches, nausea) as well as anger, irritability, apathy, and social withdrawal. Individuals may be angry with caregivers who fail to solve problems or who are unable to respond in a fully organized way in the chaos of the crisis.
Resolution phase: Grief, guilt, and depression are often prominent during the first year as individuals continue to cope with their losses.
Reconstruction phase: During this phase, reappraisal, assignment of meaning, and the integration of the event into a new self-concept occur.
Potential outcomes of traumatic events
Traumatic events can lead to a wide variety of emotional reactions. The treating clinician must understand that underneath the individual's reaction is an attempt to cope with the traumatic event. The first 6 symptoms are particularly common. Most individuals have some symptoms following a significant traumatic event. A minority have sufficient symptoms to fulfill the diagnostic criteria for acute stress disorder (ASD) or PTSD.
Relatively common symptoms following traumatic events
Physical reactions - Difficulty sleeping, exaggerated startle response, tension, fatigue, irritability, aches and pains, tachycardia, nausea, change in appetite, change in libido
Interpersonal reactions - Distrust, conflict, withdrawal, work problems, school problems, irritability, decreased intimacy, domineering demeanor, feeling rejected or abandoned; children may become clingy or oppositional
More significant symptoms that call for professional consultation
Severe persistent problematic symptoms - Marked depression (eg, hopelessness, feeling worthless, overwhelmed with worry), marked hyperarousal (eg, panic attacks, rage, extreme irritability, intense agitation), extreme numbness, inability to control emotions even when important to do so, persistent problems in work or school, significant problems in self-care
Exacerbation or reoccurrence of preexisting psychiatric problems
Dissociative symptoms (eg, depersonalization, derealization, fugue, amnesia)
Intrusive reexperiencing - Terrifying memories, persistent nightmares, flashbacks
Acute stress disorder
PTSD (occurs in 10-30% of individuals who are highly exposed to the traumatic event)
Substance abuse
Aggression
In children, aggression, risk taking, sexual acting out
Acute stress disorder
ASD is a diagnosable Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) axis I disorder that includes a number of significant symptoms and often leads to PTSD. The main differences between ASD and PTSD are duration (ASD lasts only briefly) and the presence of several dissociative symptoms in ASD.
In ASD, a person has been exposed to a traumatic event in which both of the following occurred:
Person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury or that involved a threat to the physical integrity of oneself or others.
The person's response involved intense fear, helplessness, or horror.
Either while experiencing or after experiencing the distressing event, the individual exhibits 3 or more of the following dissociative symptoms:
Subjective sense of numbness, detachment, or absence of emotional responsiveness
Reduction in awareness of his or her surroundings (being in a daze)
Derealization
Depersonalization
Dissociative amnesia
The traumatic event is persistently reexperienced in at least 1 of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience. Distress is observed on exposure to reminders of the traumatic event.
The individual displays marked avoidance of stimuli that arouse recollections of the trauma.
Marked symptoms of anxiety or increased arousal (eg, difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness) are observed.
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.
The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.
Signs and symptoms of ASD are as follows:
The individual experienced intense fear, helplessness, or horror in response to exposure to a serious traumatic event that caused or threatened serious harm of injury or violation of bodily integrity. Children may experience disorganized or agitated behavior.
The traumatic event is reexperienced in 1 or more of the following ways:
Distressing recurrent and intrusive recollections of the event (In young children, repetitive play of themes or aspects of the traumatic event may occur.)
Recurrent distressing dreams (In children, their dreams are frightening, but they may not have recognizable content.)
Acting or feeling as if the traumatic event was recurring
Intense psychological distress at exposure to cues that symbolize or resemble an aspect of the traumatic event
Physiological reactivity on exposure to cues that symbolize or resemble an aspect of the traumatic event
Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by 3 (or more) of the following:
Efforts to avoid thoughts, feelings, or conversations associated with the trauma
Efforts to avoid activities, places, or people that arouse recollections of the trauma
Inability to recall an important aspect of the trauma
Markedly diminished interest or participation in significant activities
Feeling of detachment or estrangement from others
Restricted range of affect (eg, unable to have loving feelings)
Sense of a foreshortened future (eg, does not expect to have a career, marriage, children, or a normal life span)
Persistent symptoms of increased arousal (not present before the trauma), as indicated by 2 (or more) of the following:
Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hypervigilance
Exaggerated startle response
Symptoms of reexperiencing the trauma, avoidance, and persistent arousal last more than 1 month.
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Risk factors for ASD and PTSD
Persons who lost a loved one
Individuals who experienced an injury
Persons who witnessed horrendous images
Persons who had dissociation at the time of the event
Those who experience serious depressive symptoms within a week and lasting for a month or more
Individuals with numbness, depersonalization, sense of reliving the trauma, and motor restlessness after the event
Those with preexisting psychiatric problems
Persons with prior trauma
Loss of home or community
Extended exposure to danger
Toxic exposure
Individuals with a lack of social supports or whose social supports were also traumatized and are unable to be adequately emotionally available
Signs the patient needs help
Task-oriented activities are not being performed.
Task-oriented activity is not goal-directed, organized, or effective.
The survivor is overwhelmed by emotion most of the time.
Emotions cannot be modulated when necessary.
The survivor inappropriately blames himself or herself, and the self-blame generalizes to the entire self.
The survivor is isolated and avoids the company of others.
Thoughts or plans of suicide or homicide.
Symptoms of Grief
Stages of bereavement and grief
Persons who have lost someone close or who have had a permanent injury experience grief and bereavement. Observers of the tragedy who did not lose someone are not affected. These stages may occur in any order.
Shocked disbelief
This stage lasts up to 2 weeks
Episodes of deep sighing, lack of strength and appetite, choking, and breathlessness may occur.
The individual may deny the death.
The individual may feel numb and cut off from the world.
Awareness develops
Loss of vitality, physical symptoms of stress, and development of symptoms similar to those of the deceased are possible.
Emotional symptoms include outbursts of weeping; hallucinations; searching; pining; guilt; idealization; loneliness; and anger at doctors, other family members, the deceased, or God.
Bargaining: Individual attempts to strike a deal, or bargain, with God to undo what occurred.
Depression
Depression may occur about 6 months after the trauma.
Loss of interest in the individual's own life and the lives of others occurs.
The individual's life may seem to be without purpose.
Existing personality problems may worsen.
Social isolation is possible.
Resolution
The individual now believes he or she can cope.
Resolution may take 1-2 years.
The individual can begin to enjoy life without feeling disloyal to the deceased.
Mental status
Appearance: Individuals may be disheveled and unclean and show the effects of dehydration and failure to care for themselves.
Affect/mood: The patient may appear sad, anxious, irritable, emotionally labile, apathetic, angry, or calm. Depressive illness occurs in 17-27% of survivors during the first year after a death.
Thought content: The individual may feel helpless, be in a state of disbelief, be confused, have markedly impaired concentration, have lowered self esteem, and likely be driven to search for the deceased.
Perceptions: At this time, the individual may have hallucinations (visual or auditory) that the deceased person is present. Flashbacks, feelings of unreality, numbness, and denial may occur.
Judgment/insight: Confusion in combination with preoccupation with those they have lost may impair individuals' judgment and insight.
Suicide: Suicidal thoughts occur in as many as 54% of survivors and may continue up to 6 months after the death.
Homicide: Thoughts or plans of homicide.
Physical complaints from grief
Loss of appetite
Changes in weight
Trouble going to sleep or staying asleep
Fatigue
Chest pain
Headache
Palpitations
Hair loss
Gastrointestinal distress
Complicated/traumatic grief
Traumatic grief is an example of a complicated grief reaction that occurs following the traumatic death of someone close.
Traumatic grief may occur when the death results from war, disasters, accidents, suicide, or homicide.
In traumatic bereavement, the individual is preoccupied with images of the traumatic event, rather than of the person who is deceased as in normal bereavement. Moreover, the individual has difficulty passing through the mourning process and moving on with his or her life.
The individual needs treatment for both trauma and grief. The individual also needs help in remembering an intact representation of the person who is deceased and not be filled with images of the person being killed. If no body is present following the death, placing a picture of the individual in nondegradable plastic in the coffin can be helpful.
Differential Diagnosis
Posttraumatic Stress Disorder
Exacerbation of preexisting mental condition
Brief psychotic episode
Substance abuse
Adjustment reaction
Anxiety Disorders
Depression (See Medscape's Depression Resource Center.)
Dissociative Disorders
Basic Principles of Intervention After Emotional Trauma
Reduce stress by all possible means.
Ensure that survivors have a safe environment.
Promote contact with loved ones and other sources of support (eg, religious organizations).
Support self-esteem. Help the individual to understand that their reaction to the trauma is a normal reaction to an abnormal situation, not a sign of weakness or psychopathology.
Help the person to focus on immediate needs, such as rest, food, shelter, social supports, or sense of community (some feel cut off and detached).
Promote coping mechanisms.
Help individuals to reframe any destructive cognitions, such as he or she acted terribly and is a terrible person or is weak for being so distraught, life is hopeless or worthless, or the world is totally unsafe.
Administer medication (eg, propranolol, alpha-agonists, benzodiazepines, nonactivating selective serotonin reuptake inhibitors [SSRIs]), if needed, to decrease arousal.
Avoid increasing stress.
Avoid prompting discussion of issues that cannot be resolved.
Avoid abreaction in groups and the resulting contagion effect.
Respect defenses, and do not force reality on persons who cannot handle it yet.
Debriefing may be harmful.
Share the experience with persons who want to talk about it, and avoid pressuring those who do not want to talk about it.
Identify persons at high risk: Screen for physical causes of psychiatric problems (eg, dehydration, head trauma, infection, metabolic abnormality, toxins).
Have faith in the normal healing processes.
Promote support networks.
Patient Education
Helping adults who are grieving
Be available, and do not allow a grieving person to become isolated.
Take action (eg, call, send a card, give hugs, help with practical matters).
Be available after others get back to their own lives.
Be a good listener, but do not give advice.
Do not be afraid to talk about the loss.
Talk about the person who died by name.
Do not minimize the loss; avoid clichés and easy answers.
Be patient with the bereaved; there are no shortcuts.
Encourage the bereaved to care for themselves.
Remember significant days and memories.
Do not try to distract the bereaved from grief through forced cheerfulness.
Helping children who are grieving or traumatized
Reassure children of their safety and the safety of their loved ones (as much as possible); tell them that such things are very rare, that people are there to take care of them, and that they will always be loved.
Be emotionally available to children despite personal loss (or fears).
Give children more time than usual.
Encourage them to share their feelings, to talk at weekly family meetings, and to use drawings and puppets to express their feelings.
Let them know it is all right to talk about unpleasant feelings (including sadness and anger) and listen to them. (Sharing personal feelings of sadness with them is all right as well.)
Check to see if children feel that they somehow caused the death or disaster or if they have other misunderstandings, and reassure them or correct the misunderstanding. Do not assume children are fine just because they are not saying anything.
Understand that children probably know more than you think.
Ask what the child knows and what questions the child has.
Monitor and limit TV watching after a disaster lest it flood them or desensitize them to violence.
When they watch TV, watch it with them and discuss the events.
Share only the details they can deal with. Do not overload them with facts. Be honest.
Encourage action, such as sending letters to victims, to keep them from feeling helpless.
Understand that regression, fear, sleep problems, and anger toward remaining family members are common after a loss or trauma.
Do not force children to go to the funeral if they do not want to, but help them create a ritual.
Maintain as normal a schedule as possible.
Eat balanced meals on time, drink fluids, sleep, relax, exercise, and avoid alcohol and caffeine.
Get help if serious signs appear and last more than a couple of weeks.
Extended depression and loss of interest in activities and events
Inability to sleep, loss of appetite, or prolonged fear of being alone
Extended period of marked regression
Excessive imitation of the deceased or repeated statements about wanting to join the deceased
Withdrawal from friends
Serious drop in school performance or refusal to go to school
Persistent fears
Persistent irritability and being easily startled
Behavior problems
Physical complaints
Online resources
The following are useful Web sites for patient and family education:
Duke University Health Services, Bereavement, Coping After a Traumatic Death
The University of Iowa, Coping with Death, Grief, and Loss
Helpguide.org, Coping with Grief and Loss: Guide to Grieving and Bereavement
Connect for Kids, Help with Healing, on the Web
For other patient education resources, visit eMedicine's Mental Health and Behavior Center. Also, see eMedicine's patient education articles Grief and Bereavement and Post-traumatic Stress Disorder (PTSD).
Care of Rescue Workers
Rescue workers may develop the same symptoms, including those of PTSD, as victims. As many as 1 in 3 rescue workers develop PTSD.
Encourage staying in touch with family and friends.
Be sure that rescue workers get rest, food, exercise, and relaxation.
Encourage understanding of survival guilt.
Explain how chaos and confusion inevitably leads to upset between individuals and groups that are participating in the rescue effort.
Develop a buddy system, and encourage support of coworkers.
Encourage workers to defuse after troubling incidents and following each shift.
After the rescue operation, workers should take a few days to decompress and attend a debriefing.
Do not overwhelm children with talk of experiences as a rescue worker; ask about their activities.
Therapeutic Interventions
Debriefing1,2,3,4,5
Critical incident stress debriefing is one of the most common interventions thought of following a traumatic event. (Caution: Critical incident stress debriefing has not been shown to reduce the later development of depression, anxiety, or PTSD, and it may harm individuals by increasing their arousal and overwhelming their defenses.)
Classically, critical incident stress debriefing has 7 stages, including (1) introduction (purpose of the session), (2) describing the traumatic event, (3) appraisal of the event, (4) exploring the participants' emotional reactions during and after the event, (5) discussion of the normal nature of symptoms after traumatic events, (6) outlining ways of dealing with further consequences of the event, and (7) discussion of the session and practical conclusions.
Research does not support the effectiveness of critical stress debriefing in the prevention of PTSD, depression, or anxiety, and, if performed poorly, debriefing can even be harmful. It can increase arousal and overwhelm the survivor's defenses. Operational debriefing, which focuses on normalizing emotional response, informing of services available, and providing general support, is safer. In engaging in a 1- to 2-session intervention following a traumatic event, a number of guidelines help avoid harm and maximize the chance of benefit for some individuals.
Provide trained individuals to perform the intervention.
Avoid ventilating feelings at high levels; this can lead to contagion and flooding, rather than calming and helping cope with feelings.
Do not pressure individuals to talk about things they do not want to; respect their defenses, including denial.
Critical tasks to cover include the following:
Psychoeducation to help patients see that the feelings they are having are not a sign of weakness or mental illness but a normal reaction to a very disturbing situation.
Discuss ways of improving coping skills, including getting adequate rest, recreation, food, and fluids.
Avoid excessive exposure to media coverage of the traumatic incident.
Discuss common cognitive distortions, such as survivor guilt and fears that the world is totally unsafe.
Explain the signs and symptoms indicating that someone should get professional help.
Cognitive behavior therapy6,7,8,9,10,11
While 70% of those receiving supportive therapy or no therapy develop PTSD, cognitive behavior therapy (CBT) used shortly after a trauma has been shown to reduce the rate of PTSD development to 10-20%. Moreover, patients who received CBT and CBT/hypnosis reported less re-experiencing and less avoidance symptoms than patients who received supportive counseling. Individuals are aided by the following:
Seeing that people are concerned about them
Learning about the range of normal responses to trauma and hearing that their emotional reactions are normal responses to an abnormal event (rather than a sign of weakness or pathology)
Being reminded to take care of concrete needs (eg, food, fluids, rest)
Cognitive restructuring (changing destructive schema, such as "having fun is a betrayal of the injured," "the world is totally unsafe," "I am responsible for the disaster," or "life is without meaning," to more constructive ones)
Learning relaxation techniques
Undergoing exposure to avoided situations either via guided imagery and imagination or in vivo
Resources permitting, current data suggest that a 4- to 5-session course of CBT should be offered to those at high risk for developing PTSD. CBT should be performed by someone trained in the technique. Severe, relatively common destructive cognitions may arise after a traumatic event and need to be addressed.
On the left side of the Table below are malignant schemata that an individual may have after a traumatic event. On the right side are more constructive schemata that a clinician can suggest for consideration by the individual.
Cognitive Interventions
http://emedicine.medscape.com/article/295003-overview
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