Managing the Emotional Response

Managing the Emotional Response to Disaster and other Traumatic Events in Primary Care Practice

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About a year ago, our neighbors’ dog was in our front yard, alerting me that something was wrong. The owners, an elderly couple in poor health, were no longer capable of walking the dog and I often did. His appearance told me I better check on them.

There had been a severe thunderstorm which took out the power and communications grid in the Washington area for several days.  I knocked on their door. No response. As I opened the unlocked door, I found him on the floor. He had fallen in the dark and his wife was calling 911 from their landline, not realizing that the emergency communication system was down. Fortunately, he was not seriously injured. But the experience engrained in me the realization that under disaster circumstances the possibility of receiving emergency medical services would depend on how far I could walk and how loudly I could shout for help. It was a lonely, sobering feeling.

Despite extensive planning and preparation for the recent “Superstorm Sandy,” I felt increasing anxiety at the prospect of trying to survive and at the same time wanting to serve others in near freezing darkness. I was wishing for the 100 degree heat and humidity of the summer storm, with its “amenities” of daylight and warm water. The morning after Sandy, although relieved not to be dead, homeless, or even significantly inconvenienced, I was ashamed not to be doing more than to donate blood and money to the American Red Cross. My emotional response of helpless vulnerability challenged me to develop empathy for my patients who endured the same, if not worse, traumatic events that I did. In fact, the after-effects may be magnified, especially for those who have been traumatized before.

It has been estimated that in our lifetime most of us, clinicians as well as our primary care patients will have been exposed personally to at least one life threatening event. [1] Use of primary care services by those exposed to disasters in the immediate aftermath is often for injury or acute illness related to the event, or for exacerbation of chronic conditions because of the disruption of ongoing care. Stress related illness visits increase in the year following a disaster and may manifest as somatic complaints. [2] Emotional response to trauma is normal and survivors can most often help themselves or others; there are many self-help resources available including:

Multiple federal agencies have contributed to the development of Psychological First Aid (PFA), an approach to Anxiety Stress Response (ASR) for use by all first responders, both clinical and non-clinical. PFA consists of the following core actions:

  1. Contact and engagement (in which a relationship is established and immediate needs are assessed).
  2. Safety and comfort (providing information and assistance in coping and grieving tasks).
  3. Practical assistance (helping assess short-term needs and formulation of a plan of action).
  4. Connection with social supports (contacting family and community resources).
  5. Information on stress symptoms and coping (offer basic stress management techniques and discourage maladaptive behaviors).
  6. Linkage with collaborative services (arrange continuing care and referrals).

PFA content is available online as a textbook  (http://www.ptsd.va.gov/professional/manuals/psych-first-aid.asp) or multimedia course granting 6 continuing education credit hours for medicine, nursing, psychology, and social work (http://learn.nctsn.org/course/category.php?id=11), and now as a mobile application for Apple IOS devices (https://mobile.va.gov/app/pfa-mobile). An annotated algorithm for clinicians on the recognition and management of Acute Stress Disorder (ASR/ASD) in the civilian disaster setting is found on pages 16-27 of the current Department of Defense and Veterans Administration Clinical Practice Guideline (CPG) for Post-Traumatic Stress Disorder (PTSD) summary document (http://www.healthquality.va.gov/ptsd/CPG_Summary_FINAL_MgmtofPTSDfinal.pdf). The Veterans Administration National Center for PTSD has recently updated resources for providers responding to traumatic events. (http://www.ptsd.va.gov/professional/trauma/disaster-terrorism/Providers_Disaster.asp).

ASR is a normal response to an abnormal situation and, like many other behavioral conditions, becomes Acute Stress Disorder (ASD) only when the symptoms are persistent and interfere with social function. The probability that an individual with ASR will develop ASD or PTSD varies with the nature of the traumatic event and the population surveyed, but 1 in 4 is a reasonable estimate.[3]

Assuming that the individual is no longer in the traumatic environment, a diagnosis of ASD requires presence of symptoms after 2 to 30 days following the most recent trauma exposure in at least three of the following four categories: dissociation, intrusion, avoidance, and arousal and interfering which significantly impairs their function. Formal diagnosis of Acute Stress Disorder (ASD) by the criteria of the American Psychiatric Association Diagnostic and Statistical Manual (DSM 4th edition, 2000 revision) is generally done by a structured interview with a behavioral health professional.

There are no systematic studies of screening for ASD in primary care practice. A 2007 Practitioner’s Guide for the Treatment of Adults with ASD and PTSD suggests Australian GPs screen with a 7 question symptom inventory reproduced at their website. (http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/mh15.pdf). Individuals with ASD are at risk of developing PTSD and should receive follow-up screening for PTSD as well as assessment for danger to self, according to both clinical practice guidelines mentioned above.

A current and thorough review of the management of ASD was conducted by faculty members of the Creighton University School of Medicine and published in the October 1, 2012 issue of American Family Physician. [3] The authors cite several studies that cognitive behavioral therapy (CBT) in ASD is more beneficial than supportive counseling in preventing PTSD, but there is currently no recommendation for CBT to prevent ASD in those who have ASR. The authors present a table of “evidence supported intervention strategies” for primary care which include urging patients to concentrate on their personal and community strengths, teaching stress reduction skills, and informing them of material, social, and behavioral support resources available to them.

Pharmacologic treatment of post-traumatic stress symptoms has not been shown consistently to prevent either ASD or PTSD. Unless symptoms are disabling or a co-occurring condition has been treated effectively with pharmacotherapy, guidelines do not recommend any medication. Prazosin is useful for nightmares after traumatic stress, but it is a potent alpha-adrenergic blocker and patients need to be warned about the risk of syncope.[4] Panic attacks can be treated with sedating selective serotonin reuptake inhibitors like paroxetine or sertraline.[5,6]

 

Charles Sneiderman MD PhD DABFP
Family Physician and Medical Director
Culmore Clinic, Falls Church, VA

Published on January 22, 2013

Biosketch
Charles Sneiderman, MD PhD, retired in 2010 after a 31-year career in medical informatics at the Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health. His work included research and development in telemedicine, distance learning, and medical language and image processing. Since leaving federal service, he has developed a computerized clinical decision support system to assist primary healthcare practices in the recognition and management of post-traumatic stress syndromes with support from the NLM Disaster Information Management Research Center. Dr. Sneiderman received a B.S. with high honors from the University of Maryland in 1969, and M.D. and Ph.D. degrees from Duke University in 1975. He completed residency training in family medicine at the Medical University of South Carolina in 1979. He has authored numerous scientific reports, book chapters, and medical educational media. He was a Clinical Assistant Professor of Family Practice at the Uniformed Services University of the Health Sciences. He maintains certification by the American Board of Family Medicine and has practiced family medicine part-time in the Washington, DC area since 1980. He has assisted wounded warriors with adaptive snowsports since 2005.

References

  1. Freedy JR, Magruder KM, Zoller JS, Hueston WJ, Carek PJ, Brock CD. Traumatic events and mental health in civilian primary care: implications for training and practice. Fam Med. 2010 Mar;42(3):185-92.
  2. Freedy JR, Simpson WM Jr. Disaster-related physical and mental health: a role for the family physician. Am Fam Physician. 2007 Mar 15;75(6):841-6.
  3. Kavan MG, Elsasser GN, Barone EJ. The physician’s role in managing acute stress disorder. Am Fam Physician. 2012 Oct 1;86(7):643-9.
  4. Hudson SM, Whiteside TE, Lorenz RA, Wargo KA. Prazosin for the treatment of nightmares related to posttraumatic stress disorder: a review of the literature. Prim Care Companion CNS Disord. 2012;14(2).
  5. Davidson JR. Pharmacologic treatment of acute and chronic stress following trauma: 2006. J Clin Psychiatry. 2006;67 Suppl 2:34-9.
  6. Sheehan DV, Kamijima K. An evidence-based review of the clinical use of sertraline in mood and anxiety disorders. Int Clin Psychopharmacol. 2009 Mar;24(2):43-60.