Identifying a traumatic event of an extreme nature, for example, a life-threatening experience, is key to diagnosing PTSD in the presence of comorbidities, Dr. Corvalan says. “Some of the symptoms—such as avoidance, numbing, and increased arousal—are present in other disorders and may have occurred before exposure to the traumatic event.” If they did, he says, PTSD is ruled out.
Gauging the extent of the patient’s exposure to the traumatic event is critical to determining the likelihood of PTSD onset. Dr. Allen, of Oklahoma City, points to studies that show that the closer and longer the patient has been exposed to a catastrophic event, the more likely he or she will develop PTSD.9,10
Julia Frank, MD, associate professor and director of student education and psychiatry at George Washington University in Washington, DC, suggests screening for symptoms that are unique to PTSD as stated in the DSM-IV, such as nightmares, difficulty remembering the traumatic event, and extreme reactions to reminders of the trauma. She also proposes analyzing the past event and the patient’s reaction to it to confirm that it is a source of trauma.
Patients with PTSD symptoms are easily startled by loud or piercing noises. Dr. Shalev says this characteristic sets true PTSD cases apart from other psychopathology, particularly depression. In one study, Israeli combat veterans with PTSD exhibited a more pronounced heart rate and skin conductance when exposed to auditory stimuli than did combat veterans with no PTSD symptoms.11
Drs. Allen and Frank note that patients who have anthrax-related fears and no prior PTSD symptoms are not likely to develop PTSD. They may, however, manifest symptoms of chronic fatigue, fibromyalgia, and generalized anxiety disorder. Patients may be jumpy, intense, or lethargic, with autonomic instability and rapid heart rate. They may feel alienated and mistrustful of the government. A nonspecific stress disorder and mixed anxiety depression are other possible effects.
Who to treat—and how
Psychiatrists nationwide have reported increased patient presentations after the Sept. 11 attacks and throughout the anthrax scare. Studies conducted after the Oklahoma City bombing also suggest that psychiatrists could be seeing more patients in the coming months.12,13 As caseloads increase, so do the questions about who to treat, how, and how to avoid the possibility of overtreatment.
PTSD lessons from Israel, Colombia
While many clinicians in the United States recently received their first taste of post-terror psychiatry, those in more violent parts of the world are well-versed in helping their patients manage fear.
Israel has repeatedly been at war throughout its 53-year history. During “peacetime,” terrorism and senseless violence have been a way of life.
“Sadly, Israel’s citizens and its medical and paramedical communities have accrued extensive experience in dealing with the ongoing threat of war and terrorist attacks and their sequelae,” says Zeev Kaplan, MD, director of the Beer-Sheva Mental Health Center and professor of psychiatry at the Ben Gurion University School of Medicine in Beer-Sheva.
Similarly, Colombia is a country long plagued by terrorist and gang violence. PTSD has been on the rise the past 5 years, according to Javier Leon-Silva, MD, chief of psychiatry at the Fundación Santafe de Bogotá. “There is not a single day without a terrorist attack in the news,” Dr. Leon-Silva notes. In addition, two major natural disasters in the last 20 years—the Armero flood and the earthquake in the coffee region—have resulted in tens of thousands of casualties.
Exposure to terror in Israel is widespread—be it direct, as a victim or witness, or secondary, as a victim’s close friend or relative. Recurrent PTSD, brought on by direct and indirect exposure, is common, Dr. Kaplan says. Holocaust survivors, almost as numerous within Israel’s population as combat veterans, have been especially prone to recurrent PTSD.
Children are particularly susceptible to PTSD. In Israel, someone’s parent, sibling or classmate often is among the casualties of a terrorist attack, Dr. Kaplan notes. In Colombia, “children grow up influenced by stories about family members or friends who have been victims of the consequences of war and terror, and by strict family security measures concerning behavior,” Dr. Leon-Silva adds.
Because of the Middle East’s volatile history, most of Israel’s psychiatric professionals have hands-on experience in treating traumatized patients in both military and civilian settings. Joseph Zohar, MD, chairman of Israel’s Consortium on PTSD, says that most psychiatrists have served at some point in the Israeli Defense Forces.
Further, as both Israel’s medical community and the public have learned more about PTSD and post-terror anxiety, physicians can now identify affected people more rapidly, and can refer them for treatment, Dr. Kaplan says. Civilians and veterans have access to five regional trauma and post trauma centers. Educators are trained to detect behavioral changes in the young, and Israel’s children are followed into adulthood to assess the long-term effects of terrorist events.
Colombia’s psychiatrists are also well-qualified to treat terror-inspired psychiatric illness, Dr. Leon-Silva says. However, most people in the impoverished nation cannot afford needed medicines, and psychiatrists are hard-pressed to reach many disaster or terror victims.
Dr. Zohar urges psychiatrists here to attend seminars and workshops on PTSD and acute stress reaction. He says such seminars in Israel have taught clinicians the long-term effects of exposure to terror and its effect on families, as well as how to help patients manage acute stress reactions.
Dr. Kaplan feels his U.S. counterparts should incorporate a multidisciplinary approach that addresses bio-medical, psychotherapeutic, familial, and social/occupational rehabilitation. He encourages national and local civic leaders to educate the public about terror-related stress.
Dr. Leon-Silva advises U.S. psychiatrists not to be ashamed to reveal their fears after a terrorist atrocity. “Sometimes expressing how the event impacts you will help the patient be more communicative and will more extensively show the patient’s symptoms.”