The Column
Views and expertise from leading children, youth and family professionals

Communities and Crisis
by Glenn C. Davis M.D.
Dean, College of Human Medicine, Michigan State University, and
Director, American Board of Psychiatry and Neurology

What can social and health care professionals do when entire communities are affected by crises and cataclysmic events, like the war in Iraq and the September 11th terrorist attacks?

The advent of the diagnosis of posttraumatic stress disorder (PTSD) in 1980, which evolved from work with Vietnam veterans, raised professional and public awareness about the serious impact and long-term consequences of stress and trauma in people’s lives. Since that time, health care professionals have been adept at diagnosing PTSD in individuals; but they may not be as prepared to respond to community-wide stress created by events like the recent crisis in Iraq or the September 11th terrorist attacks. Fortunately, recent scientific work on PTSD and other consequences of exposure to life-threatening stress provides community professionals and practicing physicians with tools to understand and help patients and community members.

The psychological reactions to events such as the terrorist attacks on the World Trade Center and the Pentagon are not substantially different from reactions to other violent assaults, such as rape, natural disasters like tornadoes, or the unexpected loss of a loved one. Nevertheless, given the scale of such crises, the potential for extensive public health consequences is profound. Crises like these have motivated health care workers, physicians and community-based professionals to consider the exposure to traumatic and life-threatening events in their own patients and clients.

It is important to recognize that such exposure is not uncommon. In one study of adults aged 21-30 years old, 40% had experienced at least one life-threatening event. And, of those exposed to such events, a significant portion will suffer from long-term symptoms.

It is also important to note that certain individuals are at greater risk for developing or maintaining serious symptoms. Women develop PTSD at a higher rate than men (although men are at higher risk of experiencing life-threatening events). Individuals with a history of depression or anxiety disorders are also at higher risk for PTSD. The type of event also plays a role in whether an individual will develop PTSD. The highest rates and chronicity of PTSD occur in individuals personally exposed to violence, including assault and rape. Of those who suffer from serious symptoms and have PTSD, about 50% must deal with symptoms lasting more than a year—and in many cases far longer.

Given the frequency of exposure to life-threatening events, it is important that health care professionals ask their patients about such exposure. Many individuals do not link current physical or emotional symptoms to current or past events. Patients with stress syndromes tend to discuss somatic symptoms rather than explore recent life events. An event such as a rape may have profound consequences that are not clearly (i.e., physically) visible, such as social withdrawal and persistent fear. Such symptoms in turn lead to social impairments, such as leaving the labor market, or going on public assistance.

It is often difficult to separate normal reactions to loss, stress and other trauma from the longer-term syndromes requiring professional attention. Any individual experiencing significant (or increasing) symptoms for more than a month should be referred to a mental health professional. Another rule of thumb would be to refer anyone developing significant avoidance symptoms, such as reluctance to leave the home or the avoiding of places or people that are reminders of the trauma.

Crises and cataclysmic events will have the most effect upon those directly impacted, i.e., those who lost loved ones or employment, but will also affect vulnerable individuals, such as those with a prior history of depression or panic attacks. Recent events like the Iraq crisis and September 11th should serve as a reminder to physicians, mental health workers and other professionals to be at a heightened state of awareness for PTSD as they work with children, families and communities.

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