The Royal New Zealand College of General Practitioners

Stress Symptoms after Traumatic Events

Sept 2010

• Many people will experience symptoms of psychological distress after the recent earthquake. This is part of a normal and healthy stress response to a traumatic event. 

• Patients can be reassured that this is a normal response and that symptoms will generally decrease over time without the need for psychological or medical intervention.

• Medication is not appropriate in this initial period, with the exception of a short term (up to 7 days) course of benzodiazepines to normalise sleep patterns if indicated. Use with caution in people with history of substance abuse.

• Normalising supportive approaches are more helpful than debriefing or re-living the experience, which may do more harm than good.

• Post Traumatic Stress Disorder may be diagnosed only when symptoms last >1 month and cause clinically significant distress and impairments in social, occupational, or other important areas of functioning. PTSD SHOULD NOT be diagnosed <1 month after a traumatic event.

• Refer those with severe symptoms to the GP Mental Health Liaison Team. Phone advice available from Cerina Altenburg 353-9893. Appointments can be offered within 48 hours (fax referrals to 353 9945).

Stress Symptoms after Traumatic Events

Many people will experience symptoms of psychological distress after the recent earthquake. This is part of a normal and healthy stress response to a traumatic event.  It does not mean the person has post traumatic stress disorder (PTSD) or is developing PTSD. Most people recover without the need for psychological or medical intervention.

Symptoms

Normal responses include re-experiencing (flashbacks); bad dreams and frightening thoughts; avoidant symptoms such as staying away from reminders (the room where the earthquake was experienced for example – this may be a particular issue with children); feelings such as emotional numbing and dissociation, losing interest in activities and feeling worried and guilty; hyper-arousal symptoms – being easily startled, feeling on edge, sleeping problems, irritability.

In very young children symptoms can include secondary enuresis - bedwetting when they’ve already learnt how to use the toilet; regression in developing speech; acting out the scary event during playtime; and being unusually clingy with a parent or other adult.

Older children and teens usually show symptoms similar to those seen in adults. They may also display disruptive, disrespectful, or destructive behaviors.

Resilience factors that may reduce the risk of ongoing symptoms include seeking out support from other people such as friends and family; feeling good about one’s own actions in the face of danger; having a coping strategy, or a way of getting through the bad event and learning from it; and being able to act and respond effectively despite feeling fear.

Management

Patients can be reassured that these symptoms are normal, they will generally decrease over time, and the majority of people will not experience post traumatic stress disorder.

Medication is not appropriate in this initial period, with the exception of a short term (up to 7 days) course of benzodiazepines to normalise sleep patterns, if indicated. Use with caution in people with a history of substance abuse.

There is little evidence from randomised controlled trials for intervention of initial stress symptoms. Psychological ‘debriefing’ (i.e. making people go over the events in graphic detail and drawing emotional response from this) was once a widely used and popular form of intervention. Psychological debriefing is now cautioned against as it is ineffective and revisiting events may compound the trauma [Cochrane]. There is some evidence for trauma focused Cognitive Behaviour Therapy (CBT) for more severe acute reactions, if this service is available [Cochrane].

Those with severe symptoms can be referred to the GP Mental Health Liaison Team (contact Cerina Altenburg 353-9893). The team is available for phone advice and can offer an appointment within 48 hours. Fax referrals to 353 9945.

Pragmatic Approaches to Initial Management

• It may be helpful for people not to be on their own during this time if at all possible – consider phoning your elderly patients who live alone.
• Encourage people to seek support from friends, family and local community – discussing the distress with others who shared the event and who are known to the patient seems more helpful than discussing with strangers.
• It is important to allow people to work through their experience of the earthquake at their own pace. For many people it will be enough just to discuss and make sense of the event with friends, neighbours, and family. For others, keeping busy doing other activities may be more useful than discussion. It is best not to push people to discuss what happened if they do not want to. If someone does want to talk it through then let them do this.
• Reinforce positive aspects of the patient’s behaviour in the emergency – people will often feel guilty that they didn’t react as well as they would have liked to.
• Facilitate, where possible, assistance relating to loss of employment and insurance claims – longer time to resolution of these issues is related to ongoing symptoms
• Relaxation and anger control skills may be useful – the CALM website from the University of Auckland has some helpful material on self help strategies for patients: www.calm.ac.nz
• Provide sleep hygiene information

The Anxiety Disorders Unit Advice for Concerned Parents:

• Be supportive and reassuring, children may need to be held.
• Your child’s fears are genuine to them, this may include worries they may be separated from their parents and needing them close. Talk this through with them.
• Listen to your child’s fears and explanations about what happened.
• Return to some sense of normalcy, such as playing with friends, going back to school.
• Regular routines are important such as mealtimes and bedtimes. If children are demonstrating aggression or anger then use a nurturing but firm approach, pointing out their behaviour is not acceptable.
• Explain what you know about the disaster. You may need to do this more than once. Children may want to re-enact or draw pictures about the earthquake, this is ok.

Those vulnerable to more severe symptoms include those:

• With a history of mental illness
• Who have experienced previous trauma
• Who have seen people killed or hurt
• Having little or no social support
• Who have other stressors such as work, or compensation claims

Post Traumatic Stress Disorders (PTSD)

PTSD SHOULD NOT be diagnosed less than one month after a traumatic event. PTSD may be diagnosed only when symptoms last longer than one month and cause clinically significant distress and impairments in social, occupational, or other important areas of functioning.

Within the next few weeks more detailed information about evidence for management and a pathway for patients who may have developed PTSD will be provided.