Rev. 4/03
Fact Sheet for Mental Health Professionals Working
with Acute Traumatic Stress
John Briere, Ph.D.
Associate Professor of Psychiatry and Director, Psychological Trauma Clinic
Keck School of Medicine, University of Southern California
1. Acute reactions to disasters,
terrorist attacks, and other major traumas are usually short-term -- In many cases they resolve spontaneously over time.
2. Normal acute (e.g. in the first
hours or days) responses to trauma may include:
|
Feelings of horror,
helplessness, fear, or disbelief
Attention and concentration problems
Preoccupation with the traumatic
event
Hypervigilance to danger, including misperception of non-dangerous stimuli as potentially
dangerous
"Survivor guilt" (i.e., guilt about having survived when others did not)
Reduced emotional responses to
the environment ("shutting down" or "going numb")
Feelings of unreality,
depersonalization, or other dissociative phenomena
For some, no significant
psychological difficulties
| | | | | | | |
3. Later (e.g. in subsequent
hours, days, or weeks) reactions often include
some combination of the above acute responses, as well as -- in some cases -- one or more of the following:
 | |
Intrusive thoughts and
recollections of the trauma, nightmares, and occasionally flash-backs
(intrusive sensory reexperiencing of aspects of the trauma) |
| |
Sustained feelings of numbness
or emotional constriction |
| |
Attempts to avoid reminders of the trauma |
| |
Initiation of (or re-involvement in) substance abuse |
| |
Evidence of autonomic hyperarousal, such as muscle tension, jumpiness and heightened startle responses, sleep disturbance, and irritability |
| |
Problems in interpersonal relationships |
| |
Mood swings |
| |
Anxiety |
| |
Depression and self-isolation |
4. Only about 15-25% of all of those exposed to a traumatic event go on to satisfy DSM diagnostic criteria for
PTSD - extreme traumas may produce higher rates for those directly affected, but rarely over 50-70%.
5. In individuals with pre-existing psychological disorders, trauma exposure
occasionally may exacerbate symptomatology or produce a relapse. Potentially exacerbating
or relapsing disorders may include previous PTSD, substance dependency, anxiety, depression, and psychosis.
6. Exposure to a current trauma (e.g., a terrorist attack or disaster) may activate memories of previous traumas (e.g., childhood abuse, rape, or combat). As a result, the individual may experience distress associated with both events.
7. Because many responses to trauma are normal and will recede with time, referral for professional assistance is only indicated if
one or more of the following occur:
| | The individual requests treatment |
| | Symptoms interfere significantly with normal functioning |
| | Major symptoms persist for more than a month or two |
| | Suicidality, aggression, or psychotic symptoms emerge |
8. Current research indicates that single session "psychological
debriefing" of all individuals exposed to a trauma
generally is not helpful. Instead, research indicates that treatment should be offered
only when indicated (see #7), and should involve multiple sessions - ideally several
visits over a 1-2 month period.
9. Effective acute (first hours or days) intervention, when indicated, typically involves:
| | Assessment of suicidality, symptom severity,
psychological disability (e.g., psychosis or severe dissociative states) and possible exacerbation of preexisting disorders |
| | Provision of adequate food, shelter, and safety |
| | Reassurance |
| | Cognitive normalization of the individual's
posttraumatic reactions, and gentle intervention in inappropriate guilt, shame, or
self-blame |
| | To the extent that the individual is comfortable with it, encouragement to seek out support from family, friends, and local resources (e.g., clergy) |
| | When indicated and tolerable to the individual, support for emotional expression and
general processing of the event.
|
10. Effective clinical interventions for lasting posttraumatic stress usually involve:
| | A context of safety and support |
| | Some version of cognitive-behavioral therapy,
often involving imaginal exposure to traumatic memories and cognitive
restructuring, and/or trauma-focused psychodynamic psychotherapy wherein
trauma memories are explicitly addressed. |
11. Although prolonged exposure techniques may be especially helpful for simple/uncomplicated traumatic stress, graduated/titrated exposure may be indicated for posttraumatic stress that is accompanied by affect regulation problems or significant comorbidity
| | Therapeutic exposure activities should not exceed the individual's capacity to tolerate acute distress
|
12. Discussion of the lack of real-world support for the individual's self-blame or guilt may be helpful, but should not involve arguing with the individual or lecturing him/her.
13. Medication may be used as indicated. According to leading trauma-psychopharmacologists, this may involve trials of:
Anxiolytics and hypnotics to reduce anxiety and increase sleep acutely.
Over-reliance on anxiolytic medication is generally discouraged by these authorities, at least beyond initial anxiety management. Prolonged treatment with benzodiazepines in those exposed to a recent trauma has been associated with a higher incidence of PTSD at 6 months
SSRIs (which research indicates have specific efficacy for PTSD, perhaps especially in women) or other antidepressants are often helpful,
usually as an adjunct to therapy.
World Wide Web resources for acute trauma interventions:
