First aid for emotional trauma

Content provided by the Faculty of the Harvard Medical School

First aid for emotional trauma

When and how must we act to prevent lasting damage?

A great deal is known about first aid for physical wounds but much less — despite advances since the mid-1980s — about how to prevent the injuries that come from memories of traumatic experience. One popular method, critical incident stress debriefing, may be ineffective or worse. Cognitive behavioral therapy shows some promise, and there are experimental drugs that raise difficult questions. It is fortunate that, in the end, most people can cope with traumatic experiences if left to their own devices.

Many symptoms can result from traumatic events — experiences that involve a threat of death or serious injury and evoke fear, helplessness, or horror. Apart from depression and complicated grief, the main effect is post-traumatic stress disorder (PTSD). It lasts for at least a month and has three kinds of symptoms:

Reliving the experience in nightmares, intrusive memories, flashbacks, and physical reactions to anything that serves as a reminder of the experience.

Efforts to avoid people, places, activities, feelings, and thoughts that bring the experience to mind; loss of interest in everyday activities; feelings of emotional numbness and estrangement; inability to recall aspects of the experience.

Heightened arousal or vigilance, as indicated by irritability, angry outbursts, insomnia, poor concentration, and a tendency to be easily startled and constantly on guard.

What all these symptoms have in common is an inability to shake off the ruling influence of the traumatic experience.

Who needs prevention?

Those most at risk for PTSD include people who have suffered traumatic incidents in the past; children; rescue workers; people with physical injuries; people with poor social support; and those with a family or individual history of anxiety, depression, or a personality disorder. Traumatic events that result from intentional actions present a greater risk than impersonal disasters.

Other risk factors appear during and soon after the experience. Bad omens include regarding your reactions as a sign of weakness, believing (correctly or not) that others are not responding sympathetically or helpfully, fearing that it will happen again, fearing that you will break down if you think too much about it, ruminating about why it happened to you and not to someone else, how it could have been prevented, or how someone can be blamed or punished for it.

Acute stress disorder, a diagnosis introduced by the American Psychiatric Association in 1980, refers to a reaction that begins two days to a month after the traumatic event and lasts for days to weeks. Except for the timing, its symptoms resemble PTSD, with the addition of dissociation: partial amnesia, feeling as if you are somewhere else or it is happening to someone else, being in a daze or barely conscious of the surroundings, experiencing a slowing of time or a sense that the world is unreal.

Early intervention

Loss of control — helplessness — is one of the prime signs of trauma and sources of post-traumatic stress disorder. So doing anything at all rather than concentrating on one's own misery reduces the chance of devel­oping the disorder. A person's attitude toward the symptoms is all-important. That's why it helps to educate people about the experience. They should be told that their reactions are usually normal, and the symptoms will probably go away within two or three months. If not, they may want to seek treatment for chronic post-traumatic stress disorder. But often all they need is sympathetic listening, reassurance, and comforting along with practical help. Because soothing the body can quiet the mind, reducing physical stress responses with exercise, breath training, yoga, meditation, or muscle relaxation may help.

Critical incident stress debriefing

A practice originated by commanders of battlefield troops in the two world wars was applied in the 1980s to fire fighters, police officers, and emergency medical technicians and later extended to include immediate survivors of traumatic experiences. Critical incident stress debriefing is conducted in groups or individually in a single session lasting several hours within a few days after the event. Participants tell the story of the traumatic experience and discuss their thoughts and feelings about it with a counselor who emphasizes that their reactions are normal. It's often part of a more extensive stress management program.

Controlled trials have not shown debriefing to be effective. In some studies it even seemed to make natural recovery from stress reactions more difficult. Possibly people who are told to probe their feelings about the experience at such an early stage feel overwhelmed and misinterpret later symptoms as more serious than they are. Often, at least in the immediate aftermath, they need to avoid thinking about the experience or to be alone with their thoughts. It's generally agreed that, despite its military origins, no one should be pressured or ordered to participate in critical incident stress debriefing.

Altering the memory

Drugs can soothe early traumatic stress symptoms. Benzodiazepines are used for anxiety and insomnia, and, if necessary, antipsychotic or anticonvulsant drugs for severe agitation or angry outbursts. Later, selective serotonin reuptake inhibitors (SSRIs) help relieve some symptoms of chronic PTSD. But none of these drugs prevents the disorder.

An experimental approach to PTSD prevention is based on the well-known fact that extreme stress makes memories more difficult to eradicate. Under the influence of stress hormones, the brain indelibly registers experiences so that we will know what to avoid in the future. But in acute stress reactions and PTSD, this natural survival mechanism can overshoot its mark, linking the memory and the intense emotion too tightly, pervasively, and permanently. Anything that weakens the link might be a useful treatment.

Propranolol (Inderal), a drug prescribed for blood pressure control and performance anxiety (stage fright), suppresses symptoms of anxiety by blocking nerve receptors for the stress hormones epinephrine and norepinephrine. Investigators gave propranolol for 10 days to people who came to an emergency room after a traffic accident. They found that three months later, these patients were less likely than average to have symptoms of post-traumatic stress disorder. Other drugs with similar effects are also being explored. But some fear that such drugs might suppress normal and desirable feelings of regret, guilt, and responsibility.

Cognitive behavioral therapy

Cognitive and behavioral approaches are a proven treatment for chronic PTSD (lasting more than three months), and there is also evidence that they can be useful for patients with acute stress disorder and early-stage PTSD — or for anyone who has symptoms suggesting a rocky road to recovery.

The treatment, which requires five to 15 weekly sessions, usually begins weeks after the traumatic event. Here are its main features:

Imaginal exposure. Patients relive the traumatic experience under guidance. They are asked to recount the events repeatedly, making a consecutive narrative out of what they may have previously experienced only as fragmented sensory experiences and intense emotions. Later they may listen to a tape of their account and discuss their thoughts and feelings. Doing this repeatedly (as opposed to the one-shot approach of critical incident stress debriefing) is supposed to facilitate distinguishing the past from the present and lifting the burden of traumatic memories.

In vivo exposure. Patients eliminate conditioned fear responses by con­front­ing trauma-related objects and situations in real life (the meaning of "in vivo"). The goal is for patients to become habituated so that they no longer have to avoid the stimuli. A similar technique is used in the treatment of phobias.

Cognitive restructuring. With the aid of challenging questions, patients learn to recognize automatic thoughts that provoke fear and anger. They put irrational beliefs to the test and reinterpret the experience to gain new perspectives on it.

Stress inoculation training. Although not strictly part of cognitive behavioral therapy, this technique is often added. The training may include muscle relaxation, breathing exercises, and ways to manage or reduce anxiety and anger.

Evaluating therapy

In controlled studies, trauma-focused cognitive therapy has been found to speed the recovery of vulnerable people from early post-traumatic symptoms. But there is conflicting evidence on which parts of the treatment are decisive or whether all of them are needed. The dropout rate is high, so it is important to learn more about which patients will benefit and how to help them stay in treatment.

Cognitive and behavioral approaches have been tested mostly with victims of crimes and industrial or traffic accidents. It's not clear how well these methods would work in other situations (including large-scale disasters) or for people with additional disorders like alcoholism or depression. Some think the technique requires too much training, although experts have found that counselors in a rape crisis center can use it effectively after participating in a five-day workshop.

Resilience

Acute stress reactions and PTSD itself usually fade without treatment. After the World Trade Center attack in September 2001, many trauma counselors were dispatched to New York City, but most of them found that they attracted little business. In October and November 2001, researchers reported that 7.5% of adults living in Manhattan below 110th St. had PTSD. But by February of 2002, the proportion was down to 1.7%.

Most people have suffered or will suffer a traumatic experience at some time in their lives, but few ever develop PTSD. Stress responses after a personal or communal disaster are normal, and even the most intense reactions are not necessarily pathological. Most people cope with disaster as they cope with grief. Attempting to make a diagnosis and intervene shortly after a trauma may lead to mistaking a transient reaction for a more serious disorder. Even dissociation can serve as a protective mechanism, especially if it occurs only during the trauma and doesn't persist. People are not necessarily in denial if they do not seek professional help.

Victims of PTSD may center their lives around a trauma in undesirable ways, but others believe they have learned from a traumatic experience and found new meaning in their lives. Bouncing back — resilience — is the rule rather than the exception, emotionally as well as physically. Psychological first aid can make the process a little quicker and easier.

Last updated:	September 05, 2008