Posttraumatic Stress Disorder and 9/11
Peter J. Panzarino Jr., MD, FAPA
Peter J. Panzarino Jr., MD, FAPA
Peter J. Panzarino, Jr., MD, is the former Chairman of the Department of Psychiatry and Mental Health at Cedars-Sinai Medical Center in Los Angeles. He is an Associate Adjunct Professor of Psychiatry at the University of California, Los Angeles.
Leslie J. Schoenfield, MD, PhD
Leslie J. Schoenfield, MD, PhD
Dr. Schoenfield served as associate professor of medicine and consultant in gastroenterology on the faculty of the Mayo Clinic for seven years. He became a professor of medicine in residence at UCLA from 1972 to 1999 (now emeritus). He was the director of gastroenterology at Cedars-Sinai Medical Center in Los Angeles for 25 years, where he received the chief resident's teaching award, the president's award, and the pioneer of medicine award.
The September 11th Trauma
The events of 9-11-01 have caused great consternation, confusion, grief, and sadness throughout our nation. It is probably still too soon to estimate the damage to the nation's collective psyche (functioning mind). In fact, it is possible that symptoms suggesting posttraumatic stress disorder (PTSD) will yet occur in many people across the nation, even miles from the actual physical traumatic events. Of course, the people directly affected by the actual tragedies have had and will still be expected to have a variety of responses to this posttraumatic stress.
In the wake of the September 11th tragedies, the main questions regarding PTSD are:
What is posttraumatic stress disorder (PTSD)?
PTSD, as such, has been a part of organized psychiatry for only the past twenty years. The concept of PTSD, however, has been well known for over a hundred years under a variety of different names. Certainly, Freud thought that traumatic events in childhood had an effect on an individual's subsequent emotional development. Actually, however, it was his contemporary, Pierre Janet, who wrote most brilliantly and eloquently on traumatic stress. In fact, he was really the first person to describe the full syndrome (group of symptoms) of posttraumatic stress disorder.
During World War I, PTSD was called shell shock, and during WW II, it was referred to as combat fatigue. After the Vietnam War, it was often mistakenly called the Post Vietnam Syndrome. Indeed, the understanding and effective treatment of PTSD were actually described in the psychiatric literature well before the Vietnam War. A psychiatrist from Harvard Medical School, Dr. Eric Lindemann at Massachusetts General Hospital in Boston, was the first to report on the systematic management of PTSD. He did this work after the Coconut Grove fire and tragedy in the 1940's.
Posttraumatic stress disorder is defined in terms of the trauma itself and the person's response to the trauma. Trauma occurs when a person has experienced, witnessed, or been confronted with a terrible event that is an actual occurrence. Alternatively, the person may have been threatened with a terrible event, perhaps injury (physical or psychological) or death to themselves or others. Then, the person's response to the event or to the threat involves intense fear, helplessness, and/or horror.
It is important to note, however, that having strong reactions to trauma is normal. What's more, there is a range (spectrum) of expected reactions depending on a person's prior exposure to trauma and even on hereditary (genetic) factors. Most importantly, you should understand that there are efficient and effective treatments for PTSD.
The scope of posttraumatic stress disorder
Sadly, the September 11th tragedy is only the most recent causative (precipitating) event for posttraumatic stress disorder. The scope of the PTSD problem in our society is actually substantial. For example, a current diagnosis of PTSD has been found in 15% of 500,000 men who were Vietnam veterans. Likewise, almost 18% of 10 million women who were victims of physical assault have PTSD. As a matter of fact, eight to 10% of the population will suffer from PTSD at sometime in their lives.
The consequences of PTSD for both the afflicted individual and society are significant. For example, studies have shown that patients with PTSD will have an increased number of suicides and hospitalizations. Also, patients with PTSD will have an increased frequency of alcohol abuse and drug dependency problems. In addition, we know that patients who have been victims of criminal acts subsequently have a much higher utilization of medical services in general. Most significantly, one third of PTSD patients will have related symptoms 10 years after the trauma. The majority of these people will also suffer from other psychiatric, marital, occupational, financial, and health problems.
The symptoms of PTSD
In general, posttraumatic stress disorder can be seen as an overwhelming of the body's normal psychological defenses against stress. Thus, after the trauma, there is abnormal function (dysfunction) of the normal defense systems, which results in certain symptoms. The symptoms are produced in three different ways:
First, symptoms can be produced by re-experiencing the trauma, whereby the individual can have distressing recollections of the trauma. For example, the person may relive the experience as terrible dreams or nightmares or as daytime flashbacks of the event. Furthermore, external cues in the environment may remind the patient of the event. As a result, the psychological distress of the exposure to trauma is reactivated (brought back) by internal thoughts, memories, and even fantasies. Persons also can experience physical reactions to stress, such as sweating and rapid heart rate. (These reactions are similar to the "fight or flight" responses to emergencies described by Dr. Walter Cannon.) The patient's posttraumatic symptoms can be identical to those symptoms experienced when the actual trauma was occurring.
The second way that symptoms are produced is by persistent avoidance. The avoidance refers to the person's efforts to avoid trauma-related thoughts or feelings and activities or situations that may trigger memories of the trauma. This so-called psychogenic (emotionally caused) amnesia (loss of memory) for the event can lead to a variety of reactions. For example, the patient may develop a diminished interest in activities that used to give pleasure, detachment from other people, restricted range of feelings, and a sad affect that leads to the view that the future will be shortened.
The third way that symptoms are produced is by an increased state of arousal of the affected person. These arousal symptoms include sleep disturbances, irritability, outbursts of anger, difficulty concentrating, increased vigilance, and an exaggerated startle response when shocked.
The initial approach and diagnosis of PTSD
Anyone can normally have any combination of the above-described symptoms during the first month after a significant trauma. If, however, the duration of these symptoms is more than one month and causes significant distress, or the symptoms impair the person's ability to function, then the diagnosis of PTSD can be made. In addition, if the duration of symptoms is more than three months, a diagnosis of chronic (long duration) PTSD is made. In some cases, oddly enough, the onset of symptoms is not until six months after the stressful events. This situation is referred to as delayed onset of PTSD, for which the outcome (prognosis) is often worse.
Research has shown that an immediate reduction of symptoms can be harmful in terms of the long-term outcome and persistent psychological illness. In other words, allowing an early peaking of the symptoms of depression and other PTSD problems is appropriate and preferable. Therefore, many of the treatments that psychiatrists have adopted are under the category (rubric) of what is referred to as stress debriefing (reviewing) of the critical incident (traumatic event). That is, we meet with the victims as soon as possible after the traumatic event. The purpose of the meeting is to discuss (debrief) the traumatic event in detail primarily with those most involved, and secondarily with those individuals who are involved at some distance. The specific goal is not to push the trauma away, but to get the people to talk about all aspects of the trauma and how it is affecting them.
Clinicians need to inquire very quickly about all aspects of the trauma and the person's response to it. This information will lead to a more rapid, specific diagnosis. We have found that with early management (intervention) techniques, we are able to reduce the number of patients who go on to develop full-blown acute (early) posttraumatic stress disorder and chronic (long duration) posttraumatic stress disorder. The question then is, once PTSD has been diagnosed, what are the most successful ways to treat it?
The tools to treat PTSD
The basic tools for the treatment of posttraumatic stress disorder are:
Various clinicians and clinics have their own methods for treating PTSD. A survey of PTSD experts, however, seems to conclude that for milder acute (early) PTSD, stress debriefing and early individual psychotherapy are especially important. For more severe acute PTSD, medication, critical incident stress debriefing, and group and individual psychotherapy should be started in combination. For mild, chronic PTSD in children, adolescents, and geriatric (senior) patients, the treatment is psychotherapy. For milder, chronic PTSD in adults, combination treatment is again used with stress debriefing, medications, and group and individual psychotherapy.
The types of psychotherapy
The next question is, what kind of psychotherapy should be used for PTSD? Some people will have a history of previous severe trauma in childhood, such as sexual or physical abuse. These people may be particularly sensitive (vulnerable) if they are re-traumatized by the therapy itself. That is to say, with review and discussion of the traumatic event, they may develop a more severe and perhaps chronic (long duration) variant of PTSD. So, for these patients, longer-term psychodynamic psychotherapy is usually indicated. In psychodynamic psychotherapy, there is a focus on past traumas and how they are rekindled by the present experiences. For most suffers of PTSD, however, a combination of cognitive and behavioral strategies (psychotherapy) that focus on the symptoms would usually be recommended.
For example, intrusive (unwelcome) thoughts, flashbacks, panic, and avoidance (actions to avoid emotional pain) are best treated by exposure therapy, anxiety management, and cognitive therapy (see below). Exposure therapy consists of education about common reactions to trauma, breathing retraining, (such as breath counting and deep breathing), and repeated exposure to the past trauma in graduated doses. As a result of exposure therapy, the traumatic issue or event can be remembered without the anxiety or panic resulting.
Cognitive therapy involves separating the intrusive thoughts from the associated anxiety that they produce. Additionally, it involves changing the sequence of thought patterns that occurs whenever the patient is exposed to the traumatic stimulus. Cognitive therapy also helps patients that have avoidance because with this therapy, these patients no longer need to avoid situations or places that may be reminders of the trauma. You see, cognitive therapy seriously diminishes the power of these reminders to cause severe reactions. What is more, patients can work on these issues outside of the doctor's office by using audiotapes and/or videotapes and by keeping a journal.
In addition, stress inoculation training, a variant of exposure therapy, can be used for the management of anxiety. This therapy includes relaxation. It also involves carefully monitoring the patient's thoughts that follow from thinking about the traumatic event. Then, when thoughts of the trauma do occur, the patient uses a script that was created in therapy to attempt to change their thoughts that follow thinking about the trauma. At first, the patients may even need to imagine themselves as someone else (role playing) to bring about this change in their thought pattern. But then, the role-playing gradually becomes the reality.
Other types of therapy that are useful for anxiety are visualization techniques and confidence builders, such as positive self-talk and social skills training. In visualization techniques, patients train themselves to recall and visualize a particularly peaceful or pleasant place or situation whenever thoughts of the trauma occur.
Other avoidance symptoms, referred to as numbing, include emotional unresponsiveness, detachment from others, and loss of interest in life's pleasures. For the treatment of numbing, most experts recommend the cognitive therapies, psychodynamic psychotherapy, and peer group support. In fact, numbing symptoms are among the most difficult symptoms to treat. For these symptoms, peer group support is extremely important.
In terms of medications, all types of PTSD symptoms, except sleep disturbance, will respond to the selective serotonin reuptake inhibitors (SSRIs) and other related drugs. The only drug with an approved (by the Food and Drug Administration, FDA) indication for posttraumatic stress disorder at this time is the SSRI, sertraline (Zoloft). If the patient also suffers from bipolar disorder (manic depressive), a mood stabilizer, such as lithium or divalproex sodium (Depakote), should be added. For sleep disturbance, trazodone (Desyrel), temazepam (Restoryl), zaleplon (Sonata) zolpidem (Ambien), are often recommended.
Results of treatment and the follow-up
Most people suffering from a posttraumatic syndrome should expect a good response to treatment within 3 months, as long as they do not have another severe psychiatric illness, substance abuse, depressive disorder, bipolar disorder (manic depressive), or other maladaptive personality disorders, such as antisocial personality disorder.
After the initial 3 months of treatment, acute PTSD can be treated with group or individual psychotherapy booster sessions every 2 to 4 weeks. Chronic PTSD patients should be seen regularly for at least six months with booster sessions. However, a small percentage of patients with PTSD, especially those with another associated psychiatric disorder, remain quite symptomatic for longer periods of time. For acute PTSD, the duration for continuing medication before considering tapering is 6 to 12 months. For chronic PTSD with a good response, we can consider tapering medication at 1 to 2 years. However, patients with chronic PTSD with residual symptoms need to continue treatment for at least 2 years.
Summary and conclusions
There are events that occur to us as children or adults that are so overwhelming and inherently frightening that they cause transient (temporary), and in some cases, permanent changes in our physical and psychological responses to stress. Thankfully, most of us have a relatively non-traumatic childhood and do not suffer many traumas as adults. However, when there is a significant traumatic event, everyone can expect to be temporarily overwhelmed and develop at least some of the symptoms of posttraumatic stress disorder.
Others, however, may be more biologically (inherently or genetically) vulnerable, have a history of more trauma, or are more directly and/or deeply affected by the trauma. Still, these people usually will have transient (temporary) symptoms of posttraumatic stress syndrome that can be managed and treated effectively. In fact, in many cases, PTSD can be cured. The treatment includes early management (intervention), supportive critical incident stress debriefing, group and peer rapport, targeted psychotherapy (for most patients, exposure therapy, anxiety reduction, and cognitive therapy), and medications, especially SSRI's, such as sertraline.
Nevertheless, there is another small percentage of people who develop a more chronic (long duration) PTSD. Some of them may also develop other associated psychiatric disturbances that complicate the clinical picture of PTSD and make their full recovery more challenging. Finally, it is somewhat comforting to know that the various methods of treatment are highly effective and that there are trained clinicians experienced at handling the difficult problems of posttraumatic stress. But, of course, we hope that we will never have to experience a repeat of the traumatic tragedy of September 11th.
Medically reviewed by Marina Katz, MD; American Board of Psychiatry & Neurology
Medically Reviewed by a Doctor on 10/19/2015