Tips to treat the psychological fallout of trauma

From the June ACP-ASIM Observer, copyright © 2002 by the American College of Physicians-American Society of Internal Medicine.

By Phyllis Maguire

PHILADELPHIA—As physicians have become painfully aware, traumatic events like last fall's terrorist and bioterrorist attacks bring not only death and disease, but also psychological problems that take a devastating toll on health care.

While such problems might be widespread, they can be difficult to recognize and treat, said Lt. Col. Charles C. Engel Jr., MD, a psychiatrist and epidemiologist at Bethesda's Uniformed Services University and Walter Reed Army Medical Center in Washington.

Dr. Engel notes that the consequences of traumatic events are likely to be medically unexplained physical symptoms.

"The consequences of traumatic events are likely to be medically unexplained physical symptoms," Dr. Engel explained at a session on the psychological impact of terrorism. "Distress is the key clinical marker that lets you recognize patients at risk for chronic psychological problems."

A major problem, he noted, is that all of your patients may feel distressed in the wake of a traumatic event. What separates patients who effectively handle distress from those with acute or chronic psychological problems, Dr. Engel said, is their ability to function.

Because it is hard to immediately distinguish between those two types of patients, however, it can be difficult to treat those suffering from trauma-related psychological effects. The longer you let those problems go untreated, Dr. Engel added, the more the doctor-patient relationship suffers.

Lessons learned

To get an idea of what to expect from patients who have experienced a trauma, Dr. Engel reviewed data from past events.

Much of experts' insights into the psychological consequences of trauma and terrorism come from physicians' experiences treating military veterans. After the Gulf War, for instance, veterans showed a much higher incidence of unexplained physical symptoms and syndromes such as sleep disturbances, pain, fatigue and memory problems.

Interestingly, Engel said, physicians have observed similar phenomena after both man-made and natural disasters.

Following the Exxon Valdez disaster and the Three Mile Island crisis, for example, many people in those immediate vicinities began complaining of physical symptoms for which causes were never found. And last fall, newspapers reported on "World Trade Center syndrome," a host of respiratory complaints and unexplained ailments that affected people near ground zero of the attacks.

Media reports also help spread psychological distress far from disaster or attack sites. More than 9% of people polled last fall said they believed it was "very or somewhat likely" that they or a family member would be a victim of an anthrax attack, even though they lived far from where the attacks took place.

A collaborative approach

So what can physicians do to help patients? In trying to treat patients' psychological distress, Dr. Engel said, avoid using a biomedical approach that centers narrowly on using tests to find a diagnosis.

The problem with a narrow biomedical approach, he explained, is that it will lead you to tell patients suffering psychological distress that they're well and that they should come back if symptoms return. That damages your credibility with patients and brings them little relief.

Instead, Dr. Engel urged, listen to patients' explanations and symptoms and try a more collaborative model of care. "Treatment needs to focus on behavioral outcomes rather than biomedical indices," Dr. Engel said. "You are trying to heal patients both physically and psychologically, so work together to negotiate goals."

Dr. Engel offered the following tips to treat patients' trauma-related psychological problems:

• "Less is more," he said. When it's clear that you're getting low-yield results from diagnostic tests, don't take a more aggressive approach. You'll only increase the risk of iatrogenic complications.

• Avoid quick labels such as "post-traumatic stress disorder" that can negatively affect patients' view of themselves. Instead, keep a "medically unexplained" diagnosis and adopt a supportive and watchful waiting approach.

• Ask patients to consider consulting a mental health professional early in the process. If patients are willing to go that route, try to refer them to practitioners who have experience treating patients with trauma-related disorders.

• Carefully weigh medication risks against treatment goals. While patients suffering from psychological distress may benefit from NSAIDs, antidepressants and over-the-counter analgesics, they could be harmed by opioids, sedatives, muscle relaxants, antipsychotics and antibiotics. "These medications reduce function," Dr. Engel pointed out, "which is the opposite of what you're trying to accomplish."

• When you do use drugs, put patients on a medication schedule. Do not leave medication use up to their discretion or tell them to take drugs as needed. The same is true for scheduling office visits: Set up a schedule and don't wait until patients feel they need to see you.

• Consider underlying factors that may encourage patients to stay impaired. A patient who is consistently tended by a too-caring spouse or on an indefinite leave from work may not be motivated to get well.

"It comes down to basic primary care, which some people might interpret as hand-holding," Dr. Engel said. "Trust built over time and the physician's commitment are what help patients get well."

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