COMMENTARY

Coping With Disaster: The Mental Health Effects of Trauma

Jeffrey A. Lieberman, MD; Yuval Neria, PhD

Disclosures

September 06, 2011

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Disasters and Mental Health: Introduction

Jeffrey A. Lieberman, MD: Hello. I am Dr. Jeffrey Lieberman, Professor and Chairman of Psychiatry at Columbia University. I am here with my colleague, Dr. Yuval Neria, who is Professor of Clinical and Medical Psychology at Columbia University. We are here today on behalf of Medscape to discuss the issue of emotional trauma and its consequences on the mental health of the population, particularly on the occasion of the 10th anniversary of the 9/11 disaster.

Yuval, the phenomenon of emotional trauma and its consequences on mental functioning is nothing new. It has been present and has affected humankind throughout history. It was relatively frequent and commonly described in the context of warfare and military combat. We have heard it described by many previous terms, such as "combat neurosis," "shellshock," or "battle fatigue."

In the 21st century, however, emotional trauma has taken on a whole new meaning, and it has become understood by the medical profession in a way that it had not before. As a consequence, we are seeing increasing attention paid by healthcare professionals to the emotional consequences of disasters or traumatic events. We see in our military servicemen increased rates of different mental disorders, the most common of which is post-traumatic stress disorder (PTSD). Is this something that is occurring more frequently now or is it just that in the past, it has not been recognized and taken seriously?

Yuval Neria, PhD: I think it is the latter. Emotional trauma, especially the pathological reaction to trauma, is more recognized now. Detection and assessment are better, and to a certain extent, we have better treatments for emotional trauma. Maladaptive responses to trauma have been with us for many years and are not limited to combat events or disasters. Traumatic events are very frequent, such as sexual abuse, physical abuse, and car accidents. Among us are many trauma survivors who are undernoticed and should be noticed.

Dr. Lieberman: Is trauma basically an extreme form of stress, or is there something unique about what we are calling trauma from disasters or from extreme life events?

Dr. Neria: Traumatic events are a combination of the event itself (the objective dimensions of the event) together with an emotional response. For an event to become traumatic, very stressful, or extremely stressful, it should result in an extreme emotional response (especially at the beginning), such as horror or fear, and a deep sense of vulnerability.

Dr. Lieberman: What ultimately characterizes it as pathologic and potentially raises it to the level of a psychiatric or mental syndrome is the fact that the response is out of proportion to the precipitant or it lasts too long and begins to affect the person adversely and impair their functioning.

Dr. Neria: Right. It is usually both. We are talking about an atypical reaction initially, especially with respect to the stress that the person feels, the anxiety, the fearful response, and the idea that something is a severe threat to their integrity. The second step is a range of symptoms, starting with repetition of the experience itself combined with anxiety, nightmares, flashbacks, hypervigilance, and a combination of anxiety-related symptoms together with hyperarousal.

Dr. Lieberman: These emotional consequences can also lead to complications in behavior, such as substance abuse, violence, and potentially, to self-harmful behavior or suicide.

Dr. Neria: Right. It is a very important point that the results of a traumatic event can be PTSD symptoms but are not limited to PTSD. The symptoms are very frequently accompanied by the need to decrease anxiety by all sorts of behaviors. Some people will use drugs, cigarettes, or marijuana more often. Some people might display the more severe behaviors of drug abuse or alcohol, mostly to reduce unbearable levels of anxiety. Humans easily feel that they are losing control over their minds, thus they seek ways to reduce their anxiety.

Dr. Lieberman: Right. These are basically complications resulting in large part from misguided attempts by individuals to try and quell or alleviate their distress.

Dr. Neria: Exactly.

What Was Unique About 9/11?

Dr. Lieberman: Based on what you have said, can we regard the emotional trauma as something that can occur in the context of events in everyday life but also collectively in the context of some type of disaster, or in the case of war, combat experience?

Dr. Neria: Right. Some traumatic events occur nationally or in large communities like natural disasters like Hurricane Katrina or other hurricanes -- the Japan tsunami was a good example of how natural disasters can become national disasters. The events of 9/11 were very unique in the history of this country and globally, in which you know a very well-coordinated malicious attack was made on strategic targets -- 2 buildings in the cities of New York and Washington were attacked simultaneously, which resulted in an immense emotional response in the population. Later on, this response can be regarded at least partially as a normal reaction for many, but for some (a significant minority) these events were followed by elevated levels of anxiety and depression.

Dr. Lieberman: It was a historically traumatic event in the sense that it was a disaster. It was a violent attack, and it also had political overtones in terms of warfare and hostile intentions towards this country. You were here in New York in the aftermath of 9/11, you experienced what it was like, and you have also done research on the effects of 9/11 in the survivors and in people who were in New York. What was your personal experience, what has your research found about those who suffered from these consequences, and what have the enduring effects been?

Dr. Neria: Before we go there, I would like to make another comment on 9/11. The 9/11 attacks were the biggest terrorist attacks in history, and we need to remember that the goal of terrorism is psychological warfare, more so than battlefield type of warfare.

Dr. Lieberman: It is more to scare people than to harm them.

Dr. Neria: It really is about inflicting fear and terror, and for reducing a sense of security and safety. This is why discussion on the mental health effects of 9/11 is very much in place and meaningful. With respect to my role, I joined the Columbia University Department of Psychiatry right after 9/11. I was already a PTSD expert in Israel when 9/11 happened, and when I was staying in the United States on a sabbatical, I was offered the opportunity to join a very young and motivated team of clinicians and researchers at Columbia University to conduct all sorts of studies and projects related to 9/11. Primarily what we have done is very intensive funding and grant seeking to train clinicians. We have trained hundreds of clinicians.

Dr. Lieberman: You trained clinicians to be able to treat individuals who may be suffering from the consequences of 9/11?

Dr. Neria: Yes, especially PTSD and complicated grief. For evidence-based treatment of disaster-related psychopathology, we have trained hundreds of clinicians in New York City to provide and to deliver those types of therapies. This was in the early days after 9/11 when we were not sure whether those attacks were a one-time event or might be recurrent, so we thought developing a group of clinicians in the city would be very important.

Risk Factors for PTSD

Dr. Neria: Shortly afterward, we moved on to conducting seminal studies on the responses in New York City, and we have obtained National Institutes of Mental Health funding to conduct the only study in low-income immigrant populations in the city. We thought of conducting such a study because we knew that these are the main risk factors known at the time for PTSD.

Dr. Lieberman: Do you mean lower socioeconomic status and being an immigrant are risk factors for PTSD?

Dr. Neria: Yes, being an immigrant, or having lower levels of social support.

Dr. Lieberman: Interesting. What did you find?

Dr. Neria: As you know Hispanic patients more than anybody else are at a greater risk for PTSD. We were looking at categorizing the cause of PTSD over time in those communities. We already knew (and this was 2 or 3 years after 9/11) that in the general population, the maladaptive responses are quite diminished over time. It was a great phenomenon that a big city like New York was able to rebound, recover, and rebuild in a way that surprised me.

Dr. Lieberman: The city was quite resilient.

Dr. Neria: It was very resilient, very energetic, and able to deal globally with fears and stress, but we knew that we needed to zoom in on certain populations in whom the risk was higher, and there was a great need to understand prevalence and risk factors for disaster-related disorders, especially (but not only) PTSD. We looked at depression, generalized anxiety disorder (GAD), and complicated grief among the bereaved. We offered a lot of insight to the literature about causes of PTSD, the relationship between PTSD and depression, and with GAD. It was a fascinating time.

Dr. Lieberman: Are you saying that although a huge population in the New York metropolitan area was affected by the disaster because of its physical proximity, that over time the initial shock and emotional distress that 9/11 occasioned subsided and people adapted and recovered well? However, in a small proportion of people, there were persistent symptoms and distress?

Dr. Neria: Exactly. Those subpopulations or subgroups were either exposed to the trauma in a more severe way, for example, the bereaved who lost family members in 9/11, or the firefighters who rushed to the World Trade Center sites. They were disadvantaged populations who had minimal resources to address stress to start with. These are populations that we feel are very important to look at, and maybe to develop services for them.

Dr. Lieberman: Apart from socioeconomic status and immigrant status, what are the other primary risk factors that emerged?

Dr. Neria: The severity of exposure is coming up as the main predictor for long-term morbidity, usually combined with level of social support.

Dr. Lieberman: How about pre-existing mental illness, a history of mental illness?

Dr. Neria: Right. It has consistently shown up in our model in ways to predict post-9/11 psychopathology. Depression, especially pre-9/11 depression, is coming up as a very strong predictor.

Dr. Lieberman: As somebody who lived in Israel, served in the Israeli military, and studied trauma in Israel, coming to New York, how did this seem to you? Was it similar to what you have seen in the post-terror reactions in Israel, or was this unique because of the magnitude and scale of the 9/11 event?

Dr. Neria: This is a very interesting question. I believe that each society has its resources and habits when a massive traumatic event occurs. In Israel, what I have seen over time is the wish to ignore or neglect the sense that human beings are vulnerable and perhaps weak at times, or there is a great sense of active coping and maintaining the ethos of fighting it and moving forward. New Yorkers were more reflective, and it took them more time to absorb the surprise, the feeling of vulnerability, the degree of loss, and economic and physical damage in the city. Processing this took more time and, in a way, went deeper because it was so new and unfamiliar for most of the people.

What Treatments Work Best?

Dr. Lieberman: I see. In the aftermath, there was a big effect on a large number of people, then over time it dissipated, and there were a smaller number of people who had persistent problems. What in the way of treatment could be provided to them and how well did it work?

Dr. Neria: A great effort was made, since 9/11, to sort out the available treatments and compare them and to come up with conclusions about which treatments were more effective. For PTSD, the consensus is that psychotherapy (especially cognitive-behavioral therapy) is more useful and more effective than medication treatment. It has been shown time after time that healing from the effects of trauma requires some sort of processing, talking it over, and dealing emotionally with the stress in a very focused way. Medication (such as selective serotonin reuptake inhibitors) combined with psychotherapy, especially when depressive symptoms interfere with the natural course of feeling, low self-esteem, guilt, and sleep problems, was found to be quite effective but overall less effective than psychotherapy. For complicated grief, bereavement, and processes that are enduring, complex, and unremitting, there is quite a bit of progress now with a number of evidence-based treatments developed by a Columbia professor, Dr. Katherine Shear and her colleagues. We have much to offer now, but there is a lot yet to study and to figure out, especially in terms of integrating new compounds into psychotherapy.

Dr. Lieberman: Are mental healthcare providers and psychiatrists trained to the point that we have a workforce that can minister to the population in the event of such a disaster occurring again?

Dr. Neria: It is a little bit unknown. New York City is in a better place than many other major metropolitan areas because having endured 9/11, we have developed more consciousness and hopefully more understanding of the city's needs. The idea that trauma treatment should be focused and evidence-based is relatively new. I can't tell you for sure whether the entire professional community of psychologists, psychiatrists, and social workers are ready if another disaster happens. I hope they are, and I hope there would be more educational opportunities to provide therapies with evidence-based knowledge.

Dr. Lieberman: There is also an emerging awareness of the fact that the rapidity of providing the treatment is important -- the sooner that it can be provided, rather than allowing the effects and the memories to consolidate, is important.

Dr. Neria: That is a very important point for a number of reasons. When the disorder is chronic and unremitting, it is usually combined with comorbidities such as substance abuse, drug abuse, depression, and sometimes psychotic symptoms, especially in chronic PTSD patients. You need to intervene earlier rather than later. How early or how soon after the exposure is yet to be defined. It is important to wait a couple of weeks before you provide somebody with a full course of treatment. The most important piece of knowledge that we have after 9/11 is that for people with initial symptomatology, most of it will be remitted over time, so we don't want to prescribe medication or to assign stigmatic labels to patients prematurely.

Dr. Lieberman: It sounds as though in psychiatric medicine and mental healthcare, we have come to recognize the potential consequences of emotional trauma and begun to recognize who is affected and what the risk factors are, and we have begun to develop treatment. But there is a lot more to be done in terms of research and further understanding about the underlying pathophysiology, and who are the most vulnerable to being affected, and then developing better treatments that are effective, but at this point it is still fairly limited.

We all hope and pray that we never have to face another disaster like 9/11, but emotional trauma will be part of the vicissitudes of daily life for many people, particularly those who are most vulnerable. Psychiatrists and mental healthcare providers will have to be knowledgeable about how to recognize and treat emotional trauma. Thank you very much.

Dr. Neria: You are welcome.

Dr. Lieberman: I want to also thank our viewing audience for tuning in and listening to this, and on behalf of Medscape I'd like to say thank you and have a good day.

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