Paris Terror Attacks: How to Deal With Psychological Trauma

Aude Lecrubier

December 03, 2015

PARIS ― In the immediate aftermath of the Paris terror attacks, healthcare providers in France were faced with the challenge of identifying individuals with psychological injuries and providing timely, optimal treatment.

Medscape Medical News asked psychological trauma experts Louis Jehel, MD, head of psychiatry at l'Hôpital Pierre-Zobda-Quitman, and Louis Crocq, MD, PhD, a psychiatrist for France's armed forces, honorary associate professor at René Descartes University in Paris, and cofounder of France's national Cellule d'Urgence Médico-Psychologique (CUMP) network, how clinicians can best serve a psychologically traumatized population.

Medscape: In the immediate aftermath of a terrorist attack, which individuals have the greatest need for psychological assessment/intervention?

Dr Louis Jehel

Dr Louis Jehel: When a terrorist attack occurs, the situation requires immediate attention to psychological health and well-being. One has to be able to carry out triage and identify those individuals most seriously affected. It is not those who ask for the most help who necessarily need it most. Those who are suffering most sometimes tend to turn in on themselves and adopt avoidance behavior.

At the first triage level, we have to question people to determine the extent of their exposure to the traumatic event.

There are those who were directly exposed to the event, in particular, those who were physically wounded, but there were also those who were exposed to a potential mortal danger, close to the site of the attacks, and who believed their lives may have been in danger.

Secondly, we have to find out how those exposed behaved at the time, quite apart from their reactions of fear and fright. We have to look for what we call the symptoms of dissociation, the symptoms of shock and the state of disorganization which could have been present in the immediate phase but which could in fact persist afterwards and manifest as concentration and memory problems, etc. These are the people who require the most attention and specialist care.

Differing Stress Reactions

Dr Crocq details the typical reactions of the victims within the first 24 hours following a collective trauma.

Dr Louis Crocq

"In the immediate phase, the subjects can experience eustress, which literally means beneficial stress symptoms. Stress motivates them, they help others, they are relatively lucid, and they calm down in a few hours. But when stress is too intense and an individual is not prepared, then overstress occurs. There are four types of overstress, which include the following:

Paralysis: Individuals do not understand what is happening to them, they are petrified and incapable of communicating with others.

Uncoordinated agitation: Individuals gesticulate, shout, etc.

Panic flight: Individuals run away in a state of panic and can potentially place themselves in danger.

Automatic action: Individuals appear to be normal but when asked what they did during the event, they have no recollection.

Medscape: Apart from those exposed to the traumatic events directly, are there others individuals who are at particular risk?

Dr Jehel: Yes, in particular, I'm thinking of parents with a child in the risk area. Until they received confirmation that their child was safe, they themselves felt in danger because their offspring was threatened by a potential mortal danger.

Some people are also not directly affected. But the violence of the event, the deaths, the warlike language used, and the traumatic images shown in the media could reopen old wounds. These individuals can then be destabilized and present with posttraumatic symptoms linked to previous traumatic events in their lives. They can experience nightmares again or, for example, relive an attack which they suffered years ago.

One of the problems is that these people don't always feel it is legitimate for them to speak out. In a more formal process, physicians should question patients about what personal memories the most recent trauma evokes.

Treatment: From the First Hours to the First Days

When the psychological trauma emergency units (CUMP) reach the site, they begin by defusing.

The role of defusing is to allow those who feel the need to talk to do so (immediate verbalization), to comfort them, to tell them that they are safe, to give them information.

"The presence of the emergency services by the side of the patient reassures them, removes the feeling of imminent death. It is particularly important to establish physical contact with the patient, such as placing a hand on their arm and asking them their name. They must be brought back to the land of the living.

"In most cases, the patient will be able to put words to what they have been through and felt, to be able to establish a semblance of order," said Dr Crocq.

"The following day or 3 days after the events, these persons are offered a debriefing, a postimmediate psychotherapeutic assessment.

"We realize that certain victims experience peritraumatic dissociation. They are unable to think about anything other than the event, unable to go back to their daily occupations. New symptoms can also appear: startle responses, specific phobias, fear of falling asleep, repeated nightmares, and daytime recollections of the event. These are signs of posttraumatic stress disorder. There can even be a personality change, with the person becoming timid, frightened, irritable, unable to get along with those around them," Dr Crocq said.

Medscape: How important is the so-called "emotional ventilation" following such an event?

Dr Jehel: Verbalization or emotional ventilation will make it possible to re-express and identify the emotions that the victims experienced and which they may still be experiencing. However, it's not so much talking which is beneficial but more about talking to someone who knows how to make good use of what they are told. The various levels of suffering must be identified in order to help healing. Simply letting people talk about their traumatic events, giving details of what they went through, can sometimes serve to make things worse, in particular, in the case of overstress. The interviews must also be kept short to avoid wounds, especially if the physician has not received specialized training.

Medscape: What does collective treatment consist of?

Dr Jehel: First of all, I must point out that given the scale of the event, we had to make do with the resources available. Having said that, group interventions are only really of use for psychological debriefing strategies if applied to groups which already existed before the event (family, health professionals, etc). All the international literature confirms this.

With respect to the immediate phase, it is possible to create a group of individuals who had been through the events in order to identify the focal points of their suffering and slightly reduce the symptoms of their pain, but these are support groups, with quite another perspective.

Medscape: When do nightmares become a clinical concern?

Dr Jehel: In the first few days, nightmares are usual and are an adaptation and defense mechanism. Not sleeping because of nightmares helps reduce the impact of the memory trace of the event. It is important to respect this lack of sleep and avoid prescribing sleeping pills in the first few days. However, if the nightmares persist for more than 3 days, steps must be taken to avoid exhaustion.

Medscape: Should sleeping pills be prescribed?

Dr Jehel: If drugs are prescribed, one must be careful to avoid or at least minimize the use benzodiazepines and similar medications because they disrupt memorization and contribute to making the traumatic impact of an event more complex. There are no formal recommendations concerning which drugs are effective in reducing the traumatic impact. If a benzodiazepine is prescribed, the quantities must be limited because they have an amnesic effect which will disrupt the psychological work and any psychotherapy which may be in progress.

CUMP: From Creation to Present Day

Twenty years after it was first created, CUMP played a major role in treating the victims of the Paris terrorist attacks.

Established in 1995, the organization's aim is to treat the "psychologically wounded in a state of overstress, the shocked, the exhausted" in the event of collective disasters.

CUMP functions as a network.

"On Friday, November 13, the CUMP of the Ile de France region came to help the Paris CUMP, and were then themselves relieved in the early hours of the morning by the CUMP from the provinces," said Dr Crocq.

Last year, the regional health agencies were entrusted with the organization of medicopsychological emergency treatment, and the Establishment for the Preparation for and Response to Health Emergencies was charged with the task of coordinating the network of regional consultant psychiatrists.

This national network is composed of seven permanent medicopsychological emergency units in Paris, Nord, Meurthe-et-Moselle, Rhône, Bouches-du-Rhône, Haute Garonne, and Loire-Atlantique, and a departmental consultant psychiatrist for each of the other 89 metropolitan France départements and the four overseas départements.


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