Terror-related stress: How ready are you to deal with it?

Since September 11, America has carried on under a cloud of fear. Though the cloud is lifting, it will not disappear for months or years. The terrorist attacks on New York City and Washington, DC, the resultant military action in Afghanistan, and the anthrax scare—combined with pervasive, nagging doubts about homeland security and the specter of another possible future terrorist attack—all are straining the nation’s collective emotional well-being.

Psychiatrists in America have reported new cases of terror-inspired acute stress disorder, anxiety, depression, and other illnesses, as well as recurrences of posttraumatic stress disorder (PTSD) in existing patients, in the weeks after the recent attacks and the anthrax scare. What will be the impact on psychiatric practice in the coming months and years?

“We are all at ground zero,” says Kenneth S. Thompson, MD, of Pittsburgh, an experienced disaster psychiatrist. But he and other subspecialists have identified four critical areas in which psychiatrists should be prepared:

1. Identifying how terrorist attacks and scares can exacerbate symptoms in patients now in your practice;
2. Diagnosing PTSD among comorbid conditions present in existing or new patients;
3. Treating—and avoiding over-treatment—of patients with acute stress disorder and PTSD;
4. Managing fear in your communities—in response to the Sept. 11 attacks, to the anthrax scare, or in anticipation of an impending catastrophe.

To bring you this special report, the editors of Current Psychiatry have reviewed the literature and interviewed psychiatrists nationwide and in countries such as Israel and Colombia, where terrorism has been a fact of life for years (see “PTSD lessons from Israel, Colombia,”).

Terror and your patients

Which symptoms are you most likely to see in existing patients subsequent to recent events? In the weeks following the Sept. 11 attacks, psychiatrists reported the most commonly seen symptoms as increased anxiety and worsened depression. Sleep disturbances, agoraphobia, suicidality, and severe reactions among patients with personality disorders also were reported.

Patients with previous PTSD or exposure to trauma face a high risk of new or recurrent PTSD in the wake of Sept. 11 than do those not previously exposed to trauma.¹ War veterans with prior posttraumatic symptoms have been particularly prone to recurrent PTSD after the attacks. James Allen, MD, of the Department of Psychiatry and Behavioral Sciences at the University of Oklahoma Health Sciences Center, calls this the “additive effect”: patients traumatized by military service in Vietnam experience a recurrence after seeing a major disaster or atrocity. Dr. Allen, who was extensively involved with Oklahoma City’s disaster psychiatry effort after the 1995 bombing there, recalls seeing patients who were traumatized in Vietnam suffer a recurrence after the Alfred P. Murrah Building attack, and then another relapse after Sept. 11.

“The Sept. 11 attacks were very similar to the war for them,” says Juan Corvalan, MD, of the PTSD Unit of the St. Louis Veterans Administration Medical Center, referring to the numerous war veterans he treated after the atrocities. “Seeing it on TV triggered many memories.” By early November, however, many who experienced recurrent PTSD had returned to their pre-Sept. 11 mental states.

Craig Katz, MD, director of emergency psychiatry services at New York’s Mount Sinai Medical Center, says that a patient’s psychiatric history is crucial to determining risk for PTSD or other terror-related sequelae:

“You can recognize that a given person is at high risk for PTSD post-trauma, based on any combination of these factors—having a psychiatric history, past trauma, high exposure to the event, psychosocial problems pre-disaster, or lack of supports post-disaster.”

The clinical interview is a vital tool in assessing patients with suspected PTSD or posttraumatic sequelae, says Arieh Shalev, MD, of the department of psychiatry at Hadassah University Hospital in Jerusalem, Israel. “It provides the opportunity to discuss the traumatic event with the patient, and to listen to his or her perceptions of the event and its effects” in order to carefully appraise the patient’s symptoms.²

The guidelines set forth in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) remain the gold standard for confirming a diagnosis of PTSD and discerning long-term posttraumatic sequelae from temporary acute stress disorder (Box 1). The guidelines have proved far from foolproof, however, and the existence of psychiatric comorbidities often clouds the picture.

Box 1

DSM-IV DIAGNOSTIC CRITERIA FOR PTSD

1. Exposure to a traumatic event with both of the following present:
2. The traumatic event is persistently reexperienced in one or more of the following ways:
3. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three or more of the following:
4. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two or more of the following:
5. Duration of symptoms in criteria B, C or D exceeds 1 month.
6. Disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if; Acute: if duration of symptoms is less than 3 months.

Chronic: if symptoms persist 3 months or more.

With delayed onset: if onset of symptoms is at least 6 months after the stressor.

Acute stress disorder, whose symptom pattern is similar to that of PTSD, is distinguished from PTSD because the symptom pattern must occur and resolve within 4 weeks of the traumatic event. If the symptoms persist for more than 1 month and meet the criteria for PTSD, the diagnosis is changed from acute stress disorder to PTSD.

Differential diagnosis of PTSD

Patients with PTSD are more likely to have substantial psychiatric comorbidity than are those without the disorder.³ Possible reasons include suspected self-medication of PTSD symptoms, particularly among patients with substance abuse, and the possible overreporting of symptoms by patients. Psychiatrists should maintain a high level of suspicion for PTSD when managing a new or existing patient with psychopathology.

Citing data from the National Comorbidity Study of the Institute for Social Research at the University of Michigan, Kessler and others in 1995 noted that more than 80 percent of individuals with PTSD meet criteria for at least one other psychiatric diagnosis. Roughly half of PTSD sufferers met criteria for three or more comorbidities.³

Kathleen Brady, MD, professor of psychiatry at the Medical University of South Carolina in Charleston, noted in a 1997 study that affective disorders, other anxiety disorders, somatization, substance abuse, and dissociative disorders are common comorbidities of PTSD.⁵ Dr. Shalev and colleagues in one study found that a history of major depressive disorder may increase the severity of posttraumatic morbidity.⁶ Dr. Brady and others also have found that PTSD patients with a comorbid substance abuse disorder experience severe PTSD symptoms while in a withdrawal state.⁷

Box 2

PTSD often is overlooked in the presence of other psychiatric diagnoses. Meuser et al in 1998 studied 275 patients with schizophrenia and bipolar disorder. As many as 98 percent of patients reported lifetime exposure to at least one traumatic event. The researchers found diagnosable PTSD in 119 (43 %) of the subjects, but only three (2%) had the diagnosis in their charts.⁸

In a later study, Dr. Brady and others cited substantial symptom overlap between PTSD and other psychiatric diagnoses, particularly major depressive disorder. This can contribute to underdiagnosis of PTSD, the researchers found.⁷ (Box 2).

Box 3

WATCH FOR SIGNS OF PTSD IN CHILDREN

Children also have been experiencing stress disorders since Sept. 11, says Arshad Husain, MD, professor and chief of child and adolescent psychiatry and director of the International Center for Psychosocial Trauma at the University of Missouri-Columbia. Such disorders manifest as sleep disturbances, anxiety, hyperarousal/hyperactivity, and nightmares.

Young children regress and cling to their parents, and are frightened of the dark or noises, Dr, Husain notes. Those who are toilet-trained can suddenly wet the bed, become neurotic, and demand attention. School-age children are more fearful; they may not want to go to school, their schoolwork may decline, and they may have trouble paying attention. Dr. Husain suggests discussing the trauma and devising a plan of action with them in case the trauma recurs.

The media’s role in reporting on the aftermath of the attacks—and triggering traumatic reactions as an unintended consequence—cannot be overlooked. Two recent studies performed after the Oklahoma City bombing suggest that television reports of that atrocity precipitated PTSD symptoms in middle-school children 7 weeks after the bombing,²³ and in geographically distant sixth-graders 2 years after the attack.¹² It was not clear whether any of these students had prior PTSD or other psychopathology.

Psychiatric education in the schools is especially crucial in light of the school violence that has occurred in America in recent years. Dr. Husain believes that the children who commit violence are victims of abuse. If teachers early on can identify children who show evidence of stress disorders, they can refer them to trained psychiatrists, catching those who need help before tragedies occur. “It is the psychiatric equivalent of CPR,” Dr. Husain says.

Dr. Brady recommends that psychiatrists and primary care physicians routinely screen patients for exposure to traumatic events. Ask patients specifically about their reaction to such events and encourage them to talk about it. Patients often feel either guilty or embarrassed about the traumatic event, or do not believe it affects their presenting complaints, she notes. Other approaches may be needed to identify the risk of PTSD in children (Box 3).

Identifying a traumatic event of an extreme nature, for example, a life-threatening experience, is key to diagnosing PTSD in the presence of comorbidities, Dr. Corvalan says. “Some of the symptoms—such as avoidance, numbing, and increased arousal—are present in other disorders and may have occurred before exposure to the traumatic event.” If they did, he says, PTSD is ruled out.

Gauging the extent of the patient’s exposure to the traumatic event is critical to determining the likelihood of PTSD onset. Dr. Allen, of Oklahoma City, points to studies that show that the closer and longer the patient has been exposed to a catastrophic event, the more likely he or she will develop PTSD.^9,10

Julia Frank, MD, associate professor and director of student education and psychiatry at George Washington University in Washington, DC, suggests screening for symptoms that are unique to PTSD as stated in the DSM-IV, such as nightmares, difficulty remembering the traumatic event, and extreme reactions to reminders of the trauma. She also proposes analyzing the past event and the patient’s reaction to it to confirm that it is a source of trauma.

Patients with PTSD symptoms are easily startled by loud or piercing noises. Dr. Shalev says this characteristic sets true PTSD cases apart from other psychopathology, particularly depression. In one study, Israeli combat veterans with PTSD exhibited a more pronounced heart rate and skin conductance when exposed to auditory stimuli than did combat veterans with no PTSD symptoms.¹¹

Drs. Allen and Frank note that patients who have anthrax-related fears and no prior PTSD symptoms are not likely to develop PTSD. They may, however, manifest symptoms of chronic fatigue, fibromyalgia, and generalized anxiety disorder. Patients may be jumpy, intense, or lethargic, with autonomic instability and rapid heart rate. They may feel alienated and mistrustful of the government. A nonspecific stress disorder and mixed anxiety depression are other possible effects.

Who to treat—and how

Psychiatrists nationwide have reported increased patient presentations after the Sept. 11 attacks and throughout the anthrax scare. Studies conducted after the Oklahoma City bombing also suggest that psychiatrists could be seeing more patients in the coming months.^12,13 As caseloads increase, so do the questions about who to treat, how, and how to avoid the possibility of overtreatment.

“In order to provide effective care to our patients it is necessary to have clear ideas on how to follow criteria for diagnosis and as a consequence for treatment,” Dr. Corvalan says. “The field at times is confusing; patients do not always follow the diagnostic criteria. The needs of the moment, limitations of recourses, intensity and variety of symptoms, urgency of the situation, etc., all conspire to make the job more difficult.”

Patients with anthrax-related anxiety should be encouraged to “try to function as normally as possible and keep an open communication with peers and those who they look to for information,” Dr. Frank notes. Dr. Allen adds that his patients with anthrax-inspired stress have responded well to breathing, meditation and other relaxation techniques.

Treatment of patients who are severely traumatized and exhibit true PTSD symptoms will vary based on severity of exposure, history of prior PTSD, and existence of comorbidities. A combination of pharmacological and psychosocial therapy is the common first-line treatment.

The selective serotonin reuptake inhibitor (SSRI) sertraline is specifically indicated for treating confirmed PTSD symptoms, and several studies have documented the agent’s effectiveness for this use.^14,15 Dr. Frank recommends dosages between 50 and 200 mg/d depending on the patient’s body weight or complaint of side effects (e.g., diarrhea, nausea, or sexual dysfunction). Other SSRIs, as well as tricyclics and MAO inhibitors, are alternatives. Fluoxetine, amitriptyline, phenelzine, and imipramine have all been found more effective than a placebo;^16-18 paroxetine also has been shown effective in specific populations.¹⁹

Box 4

Benzodiazapenes also may be prescribed to manage PTSD symptoms. Patients should be counseled against taking these sedating agents in the daytime, however, as they can lead to fogginess, detachment, and trouble functioning.

Assessing the patient’s available social support also is crucial to PTSD treatment. “Do patients talk to other people about the event?” Dr. Frank asks. “Are they trying to get back to a daily routine? Can they make sense of this experience? Are they incorporating the event into a world view?”

Dr. Thompson, the Pittsburgh disaster psychiatrist, agrees. Psychiatrists should encourage their patients to talk more about their trauma and how fear is affecting their lives. “We don’t discuss with our trauma patients as much as we might what the experience has been like for them,” he says.

Small-group therapy is the most conducive approach to psychotherapy for PTSD, according to Dr. Frank, although individual counseling can work in many cases. Several studies have found group therapy effective,^20,21 and 12-step group therapy has shown promise in PTSD patients with comorbid substance abuse disorder.²²

Managing fear

Just as people grieve and confront death in stages, Dr. Thompson, who helped coordinate Oklahoma City’s disaster psychiatry effort, has discovered that the public usually employs a similar subconscious process to cope with a traumatic event (Box 4).

But Americans have had no time to recover. As U.S. troops seek justice in Afghanistan, back home people grapple with the threat of anthrax contamination and the prospect of another terrorist attack. The ominously enhanced presence of security at airports, major bridges, sporting and entertainment events, and in other aspects of everyday life, has further fueled the sensation that all is not right.

“The September 11 tragedy brings trauma home,” adds Arshad Husain, MD, professor and chief of child and adolescent psychiatry and director of the International Center for Psychosocial Trauma at the University of Missouri-Columbia. “The anthrax scare and the Nov. 12 plane crash of American Airlines Flight 587 only further remind people of their vulnerability and fears. If the anthrax scare were an accident, people would have been relieved. Since the plane crash was ruled an accident, it has offered people a chance to feel more in control. Accidents can be fixed with better maintenance. Terrorism cannot.”

Dr. Katz of New York City and other disaster psychiatrists are urging their colleagues to help manage public fear by reaching out through community efforts.

Dr. Katz is president of the volunteer group Disaster Psychiatry Outreach, which helped coordinate the city’s post-Sept. 11 trauma psychiatry effort. Visitors waiting at New York’s Family Assistance Center, a referral and help center for people who lost family and friends in the World Trade Center attack, were approached by Dr. Katz and other colleagues to let them know that psychiatric services were available if needed. By doing this, he says, Disaster Psychiatry Outreach clinicians have identified, treated, and referred scores of patients with terror-related stress who otherwise would have gone untreated.

Joseph Dorzab, MD, of the Holt-Krock Clinic in Fort Smith, Ark., also has offered his services. Members of his clinic’s psychiatry department have made several TV appearances, and have given and coordinated area lectures. Working with the local mental health association, the department also is starting a community forum called Mental Health Mondays, an open discussion group with coffee and cookies at a local coffee shop.

In Pittsburgh, Dr. Thompson is encouraging psychiatrists to educate their communities about how traumatic events affect the public. He proposes:

• Staging community meetings to brief religious and other leaders on how to manage traumatized people;
• Informing local news editors about the nature of psychiatric disorders;
• Instructing school administrators about detecting signs of distress in children;
• Contacting local government officials to offer input in devising the town’s emergency response plan.

Psychiatrists also can educate themselves about managing public trauma, thanks to scores of studies that have been done in recent years following major man-made and natural disasters, from Mount St. Helens and Hurricane Andrew, to Chernobyl and the Yom Kippur War. Dr. Thompson urges psychiatrists to seek out the papers of prominent leaders in trauma-related psychiatry, mentioning studies by Carol North, MD, Betty Pfefferbaum, MD, and Robert Ursano, MD, as examples. Other sources include the Web sites of the American Psychiatric Association and National Center for PTSD. (See Related Resources.)

In the end, psychiatrists have been well primed for dealing with public disaster—just by treating individual patients whose psychiatric disorders emanated from everyday life, Dr. Thompson says. “Psychiatrists know more about trauma than they recognize.”

Related resources

• National Center for PTSD Web site
• National Institute of Mental Health:
• Linenthal EJ. The Unfinished Bombing: Oklahoma City in American Memory. Oxford University Press, 2001.
• Norwood AE, Ursano RJ, Fullerton CS. Disaster psychiatry: principles of practice. Psychiatr Q. 2000; 71(3):207-226.
• American Psychiatric Association Web site:
• The Psychiatric Training Manual for Teachers and Mental Health Professionals

Drug brand names

• Amitriptyline • Elavil
• Bupropion • Wellbutrin
• Fluoxetine • Prozac
• Imipramine • Tofranil
• Paroxetine • Paxil
• Phenelzine • Nardil
• Sertraline • Zoloft

Since September 11, America has carried on under a cloud of fear. Though the cloud is lifting, it will not disappear for months or years. The terrorist attacks on New York City and Washington, DC, the resultant military action in Afghanistan, and the anthrax scare—combined with pervasive, nagging doubts about homeland security and the specter of another possible future terrorist attack—all are straining the nation’s collective emotional well-being.

Psychiatrists in America have reported new cases of terror-inspired acute stress disorder, anxiety, depression, and other illnesses, as well as recurrences of posttraumatic stress disorder (PTSD) in existing patients, in the weeks after the recent attacks and the anthrax scare. What will be the impact on psychiatric practice in the coming months and years?

“We are all at ground zero,” says Kenneth S. Thompson, MD, of Pittsburgh, an experienced disaster psychiatrist. But he and other subspecialists have identified four critical areas in which psychiatrists should be prepared:

1. Identifying how terrorist attacks and scares can exacerbate symptoms in patients now in your practice;
2. Diagnosing PTSD among comorbid conditions present in existing or new patients;
3. Treating—and avoiding over-treatment—of patients with acute stress disorder and PTSD;
4. Managing fear in your communities—in response to the Sept. 11 attacks, to the anthrax scare, or in anticipation of an impending catastrophe.

To bring you this special report, the editors of Current Psychiatry have reviewed the literature and interviewed psychiatrists nationwide and in countries such as Israel and Colombia, where terrorism has been a fact of life for years (see “PTSD lessons from Israel, Colombia,”).

Terror and your patients

Which symptoms are you most likely to see in existing patients subsequent to recent events? In the weeks following the Sept. 11 attacks, psychiatrists reported the most commonly seen symptoms as increased anxiety and worsened depression. Sleep disturbances, agoraphobia, suicidality, and severe reactions among patients with personality disorders also were reported.

Patients with previous PTSD or exposure to trauma face a high risk of new or recurrent PTSD in the wake of Sept. 11 than do those not previously exposed to trauma.¹ War veterans with prior posttraumatic symptoms have been particularly prone to recurrent PTSD after the attacks. James Allen, MD, of the Department of Psychiatry and Behavioral Sciences at the University of Oklahoma Health Sciences Center, calls this the “additive effect”: patients traumatized by military service in Vietnam experience a recurrence after seeing a major disaster or atrocity. Dr. Allen, who was extensively involved with Oklahoma City’s disaster psychiatry effort after the 1995 bombing there, recalls seeing patients who were traumatized in Vietnam suffer a recurrence after the Alfred P. Murrah Building attack, and then another relapse after Sept. 11.

“The Sept. 11 attacks were very similar to the war for them,” says Juan Corvalan, MD, of the PTSD Unit of the St. Louis Veterans Administration Medical Center, referring to the numerous war veterans he treated after the atrocities. “Seeing it on TV triggered many memories.” By early November, however, many who experienced recurrent PTSD had returned to their pre-Sept. 11 mental states.

Craig Katz, MD, director of emergency psychiatry services at New York’s Mount Sinai Medical Center, says that a patient’s psychiatric history is crucial to determining risk for PTSD or other terror-related sequelae:

“You can recognize that a given person is at high risk for PTSD post-trauma, based on any combination of these factors—having a psychiatric history, past trauma, high exposure to the event, psychosocial problems pre-disaster, or lack of supports post-disaster.”

The clinical interview is a vital tool in assessing patients with suspected PTSD or posttraumatic sequelae, says Arieh Shalev, MD, of the department of psychiatry at Hadassah University Hospital in Jerusalem, Israel. “It provides the opportunity to discuss the traumatic event with the patient, and to listen to his or her perceptions of the event and its effects” in order to carefully appraise the patient’s symptoms.²

The guidelines set forth in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) remain the gold standard for confirming a diagnosis of PTSD and discerning long-term posttraumatic sequelae from temporary acute stress disorder (Box 1). The guidelines have proved far from foolproof, however, and the existence of psychiatric comorbidities often clouds the picture.

Box 1

DSM-IV DIAGNOSTIC CRITERIA FOR PTSD

1. Exposure to a traumatic event with both of the following present:
2. The traumatic event is persistently reexperienced in one or more of the following ways:
3. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three or more of the following:
4. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two or more of the following:
5. Duration of symptoms in criteria B, C or D exceeds 1 month.
6. Disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if; Acute: if duration of symptoms is less than 3 months.

Chronic: if symptoms persist 3 months or more.

With delayed onset: if onset of symptoms is at least 6 months after the stressor.

Acute stress disorder, whose symptom pattern is similar to that of PTSD, is distinguished from PTSD because the symptom pattern must occur and resolve within 4 weeks of the traumatic event. If the symptoms persist for more than 1 month and meet the criteria for PTSD, the diagnosis is changed from acute stress disorder to PTSD.

Differential diagnosis of PTSD

Patients with PTSD are more likely to have substantial psychiatric comorbidity than are those without the disorder.³ Possible reasons include suspected self-medication of PTSD symptoms, particularly among patients with substance abuse, and the possible overreporting of symptoms by patients. Psychiatrists should maintain a high level of suspicion for PTSD when managing a new or existing patient with psychopathology.

Citing data from the National Comorbidity Study of the Institute for Social Research at the University of Michigan, Kessler and others in 1995 noted that more than 80 percent of individuals with PTSD meet criteria for at least one other psychiatric diagnosis. Roughly half of PTSD sufferers met criteria for three or more comorbidities.³

Kathleen Brady, MD, professor of psychiatry at the Medical University of South Carolina in Charleston, noted in a 1997 study that affective disorders, other anxiety disorders, somatization, substance abuse, and dissociative disorders are common comorbidities of PTSD.⁵ Dr. Shalev and colleagues in one study found that a history of major depressive disorder may increase the severity of posttraumatic morbidity.⁶ Dr. Brady and others also have found that PTSD patients with a comorbid substance abuse disorder experience severe PTSD symptoms while in a withdrawal state.⁷

Box 2

PTSD often is overlooked in the presence of other psychiatric diagnoses. Meuser et al in 1998 studied 275 patients with schizophrenia and bipolar disorder. As many as 98 percent of patients reported lifetime exposure to at least one traumatic event. The researchers found diagnosable PTSD in 119 (43 %) of the subjects, but only three (2%) had the diagnosis in their charts.⁸

In a later study, Dr. Brady and others cited substantial symptom overlap between PTSD and other psychiatric diagnoses, particularly major depressive disorder. This can contribute to underdiagnosis of PTSD, the researchers found.⁷ (Box 2).

Box 3

WATCH FOR SIGNS OF PTSD IN CHILDREN

Children also have been experiencing stress disorders since Sept. 11, says Arshad Husain, MD, professor and chief of child and adolescent psychiatry and director of the International Center for Psychosocial Trauma at the University of Missouri-Columbia. Such disorders manifest as sleep disturbances, anxiety, hyperarousal/hyperactivity, and nightmares.

Young children regress and cling to their parents, and are frightened of the dark or noises, Dr, Husain notes. Those who are toilet-trained can suddenly wet the bed, become neurotic, and demand attention. School-age children are more fearful; they may not want to go to school, their schoolwork may decline, and they may have trouble paying attention. Dr. Husain suggests discussing the trauma and devising a plan of action with them in case the trauma recurs.

The media’s role in reporting on the aftermath of the attacks—and triggering traumatic reactions as an unintended consequence—cannot be overlooked. Two recent studies performed after the Oklahoma City bombing suggest that television reports of that atrocity precipitated PTSD symptoms in middle-school children 7 weeks after the bombing,²³ and in geographically distant sixth-graders 2 years after the attack.¹² It was not clear whether any of these students had prior PTSD or other psychopathology.

Psychiatric education in the schools is especially crucial in light of the school violence that has occurred in America in recent years. Dr. Husain believes that the children who commit violence are victims of abuse. If teachers early on can identify children who show evidence of stress disorders, they can refer them to trained psychiatrists, catching those who need help before tragedies occur. “It is the psychiatric equivalent of CPR,” Dr. Husain says.

Dr. Brady recommends that psychiatrists and primary care physicians routinely screen patients for exposure to traumatic events. Ask patients specifically about their reaction to such events and encourage them to talk about it. Patients often feel either guilty or embarrassed about the traumatic event, or do not believe it affects their presenting complaints, she notes. Other approaches may be needed to identify the risk of PTSD in children (Box 3).

Identifying a traumatic event of an extreme nature, for example, a life-threatening experience, is key to diagnosing PTSD in the presence of comorbidities, Dr. Corvalan says. “Some of the symptoms—such as avoidance, numbing, and increased arousal—are present in other disorders and may have occurred before exposure to the traumatic event.” If they did, he says, PTSD is ruled out.

Gauging the extent of the patient’s exposure to the traumatic event is critical to determining the likelihood of PTSD onset. Dr. Allen, of Oklahoma City, points to studies that show that the closer and longer the patient has been exposed to a catastrophic event, the more likely he or she will develop PTSD.^9,10

Julia Frank, MD, associate professor and director of student education and psychiatry at George Washington University in Washington, DC, suggests screening for symptoms that are unique to PTSD as stated in the DSM-IV, such as nightmares, difficulty remembering the traumatic event, and extreme reactions to reminders of the trauma. She also proposes analyzing the past event and the patient’s reaction to it to confirm that it is a source of trauma.

Patients with PTSD symptoms are easily startled by loud or piercing noises. Dr. Shalev says this characteristic sets true PTSD cases apart from other psychopathology, particularly depression. In one study, Israeli combat veterans with PTSD exhibited a more pronounced heart rate and skin conductance when exposed to auditory stimuli than did combat veterans with no PTSD symptoms.¹¹

Drs. Allen and Frank note that patients who have anthrax-related fears and no prior PTSD symptoms are not likely to develop PTSD. They may, however, manifest symptoms of chronic fatigue, fibromyalgia, and generalized anxiety disorder. Patients may be jumpy, intense, or lethargic, with autonomic instability and rapid heart rate. They may feel alienated and mistrustful of the government. A nonspecific stress disorder and mixed anxiety depression are other possible effects.

Who to treat—and how

Psychiatrists nationwide have reported increased patient presentations after the Sept. 11 attacks and throughout the anthrax scare. Studies conducted after the Oklahoma City bombing also suggest that psychiatrists could be seeing more patients in the coming months.^12,13 As caseloads increase, so do the questions about who to treat, how, and how to avoid the possibility of overtreatment.

“In order to provide effective care to our patients it is necessary to have clear ideas on how to follow criteria for diagnosis and as a consequence for treatment,” Dr. Corvalan says. “The field at times is confusing; patients do not always follow the diagnostic criteria. The needs of the moment, limitations of recourses, intensity and variety of symptoms, urgency of the situation, etc., all conspire to make the job more difficult.”

Patients with anthrax-related anxiety should be encouraged to “try to function as normally as possible and keep an open communication with peers and those who they look to for information,” Dr. Frank notes. Dr. Allen adds that his patients with anthrax-inspired stress have responded well to breathing, meditation and other relaxation techniques.

Treatment of patients who are severely traumatized and exhibit true PTSD symptoms will vary based on severity of exposure, history of prior PTSD, and existence of comorbidities. A combination of pharmacological and psychosocial therapy is the common first-line treatment.

The selective serotonin reuptake inhibitor (SSRI) sertraline is specifically indicated for treating confirmed PTSD symptoms, and several studies have documented the agent’s effectiveness for this use.^14,15 Dr. Frank recommends dosages between 50 and 200 mg/d depending on the patient’s body weight or complaint of side effects (e.g., diarrhea, nausea, or sexual dysfunction). Other SSRIs, as well as tricyclics and MAO inhibitors, are alternatives. Fluoxetine, amitriptyline, phenelzine, and imipramine have all been found more effective than a placebo;^16-18 paroxetine also has been shown effective in specific populations.¹⁹

Box 4

Benzodiazapenes also may be prescribed to manage PTSD symptoms. Patients should be counseled against taking these sedating agents in the daytime, however, as they can lead to fogginess, detachment, and trouble functioning.

Assessing the patient’s available social support also is crucial to PTSD treatment. “Do patients talk to other people about the event?” Dr. Frank asks. “Are they trying to get back to a daily routine? Can they make sense of this experience? Are they incorporating the event into a world view?”

Dr. Thompson, the Pittsburgh disaster psychiatrist, agrees. Psychiatrists should encourage their patients to talk more about their trauma and how fear is affecting their lives. “We don’t discuss with our trauma patients as much as we might what the experience has been like for them,” he says.

Small-group therapy is the most conducive approach to psychotherapy for PTSD, according to Dr. Frank, although individual counseling can work in many cases. Several studies have found group therapy effective,^20,21 and 12-step group therapy has shown promise in PTSD patients with comorbid substance abuse disorder.²²

Managing fear

Just as people grieve and confront death in stages, Dr. Thompson, who helped coordinate Oklahoma City’s disaster psychiatry effort, has discovered that the public usually employs a similar subconscious process to cope with a traumatic event (Box 4).

But Americans have had no time to recover. As U.S. troops seek justice in Afghanistan, back home people grapple with the threat of anthrax contamination and the prospect of another terrorist attack. The ominously enhanced presence of security at airports, major bridges, sporting and entertainment events, and in other aspects of everyday life, has further fueled the sensation that all is not right.

“The September 11 tragedy brings trauma home,” adds Arshad Husain, MD, professor and chief of child and adolescent psychiatry and director of the International Center for Psychosocial Trauma at the University of Missouri-Columbia. “The anthrax scare and the Nov. 12 plane crash of American Airlines Flight 587 only further remind people of their vulnerability and fears. If the anthrax scare were an accident, people would have been relieved. Since the plane crash was ruled an accident, it has offered people a chance to feel more in control. Accidents can be fixed with better maintenance. Terrorism cannot.”

Dr. Katz of New York City and other disaster psychiatrists are urging their colleagues to help manage public fear by reaching out through community efforts.

Dr. Katz is president of the volunteer group Disaster Psychiatry Outreach, which helped coordinate the city’s post-Sept. 11 trauma psychiatry effort. Visitors waiting at New York’s Family Assistance Center, a referral and help center for people who lost family and friends in the World Trade Center attack, were approached by Dr. Katz and other colleagues to let them know that psychiatric services were available if needed. By doing this, he says, Disaster Psychiatry Outreach clinicians have identified, treated, and referred scores of patients with terror-related stress who otherwise would have gone untreated.

Joseph Dorzab, MD, of the Holt-Krock Clinic in Fort Smith, Ark., also has offered his services. Members of his clinic’s psychiatry department have made several TV appearances, and have given and coordinated area lectures. Working with the local mental health association, the department also is starting a community forum called Mental Health Mondays, an open discussion group with coffee and cookies at a local coffee shop.

In Pittsburgh, Dr. Thompson is encouraging psychiatrists to educate their communities about how traumatic events affect the public. He proposes:

• Staging community meetings to brief religious and other leaders on how to manage traumatized people;
• Informing local news editors about the nature of psychiatric disorders;
• Instructing school administrators about detecting signs of distress in children;
• Contacting local government officials to offer input in devising the town’s emergency response plan.

Psychiatrists also can educate themselves about managing public trauma, thanks to scores of studies that have been done in recent years following major man-made and natural disasters, from Mount St. Helens and Hurricane Andrew, to Chernobyl and the Yom Kippur War. Dr. Thompson urges psychiatrists to seek out the papers of prominent leaders in trauma-related psychiatry, mentioning studies by Carol North, MD, Betty Pfefferbaum, MD, and Robert Ursano, MD, as examples. Other sources include the Web sites of the American Psychiatric Association and National Center for PTSD. (See Related Resources.)

In the end, psychiatrists have been well primed for dealing with public disaster—just by treating individual patients whose psychiatric disorders emanated from everyday life, Dr. Thompson says. “Psychiatrists know more about trauma than they recognize.”

Related resources

• National Center for PTSD Web site
• National Institute of Mental Health:
• Linenthal EJ. The Unfinished Bombing: Oklahoma City in American Memory. Oxford University Press, 2001.
• Norwood AE, Ursano RJ, Fullerton CS. Disaster psychiatry: principles of practice. Psychiatr Q. 2000; 71(3):207-226.
• American Psychiatric Association Web site:
• The Psychiatric Training Manual for Teachers and Mental Health Professionals

Drug brand names

• Amitriptyline • Elavil
• Bupropion • Wellbutrin
• Fluoxetine • Prozac
• Imipramine • Tofranil
• Paroxetine • Paxil
• Phenelzine • Nardil
• Sertraline • Zoloft

Since September 11, America has carried on under a cloud of fear. Though the cloud is lifting, it will not disappear for months or years. The terrorist attacks on New York City and Washington, DC, the resultant military action in Afghanistan, and the anthrax scare—combined with pervasive, nagging doubts about homeland security and the specter of another possible future terrorist attack—all are straining the nation’s collective emotional well-being.

Psychiatrists in America have reported new cases of terror-inspired acute stress disorder, anxiety, depression, and other illnesses, as well as recurrences of posttraumatic stress disorder (PTSD) in existing patients, in the weeks after the recent attacks and the anthrax scare. What will be the impact on psychiatric practice in the coming months and years?

“We are all at ground zero,” says Kenneth S. Thompson, MD, of Pittsburgh, an experienced disaster psychiatrist. But he and other subspecialists have identified four critical areas in which psychiatrists should be prepared:

1. Identifying how terrorist attacks and scares can exacerbate symptoms in patients now in your practice;
2. Diagnosing PTSD among comorbid conditions present in existing or new patients;
3. Treating—and avoiding over-treatment—of patients with acute stress disorder and PTSD;
4. Managing fear in your communities—in response to the Sept. 11 attacks, to the anthrax scare, or in anticipation of an impending catastrophe.

To bring you this special report, the editors of Current Psychiatry have reviewed the literature and interviewed psychiatrists nationwide and in countries such as Israel and Colombia, where terrorism has been a fact of life for years (see “PTSD lessons from Israel, Colombia,”).

Terror and your patients

Which symptoms are you most likely to see in existing patients subsequent to recent events? In the weeks following the Sept. 11 attacks, psychiatrists reported the most commonly seen symptoms as increased anxiety and worsened depression. Sleep disturbances, agoraphobia, suicidality, and severe reactions among patients with personality disorders also were reported.

Patients with previous PTSD or exposure to trauma face a high risk of new or recurrent PTSD in the wake of Sept. 11 than do those not previously exposed to trauma.¹ War veterans with prior posttraumatic symptoms have been particularly prone to recurrent PTSD after the attacks. James Allen, MD, of the Department of Psychiatry and Behavioral Sciences at the University of Oklahoma Health Sciences Center, calls this the “additive effect”: patients traumatized by military service in Vietnam experience a recurrence after seeing a major disaster or atrocity. Dr. Allen, who was extensively involved with Oklahoma City’s disaster psychiatry effort after the 1995 bombing there, recalls seeing patients who were traumatized in Vietnam suffer a recurrence after the Alfred P. Murrah Building attack, and then another relapse after Sept. 11.

“The Sept. 11 attacks were very similar to the war for them,” says Juan Corvalan, MD, of the PTSD Unit of the St. Louis Veterans Administration Medical Center, referring to the numerous war veterans he treated after the atrocities. “Seeing it on TV triggered many memories.” By early November, however, many who experienced recurrent PTSD had returned to their pre-Sept. 11 mental states.

Craig Katz, MD, director of emergency psychiatry services at New York’s Mount Sinai Medical Center, says that a patient’s psychiatric history is crucial to determining risk for PTSD or other terror-related sequelae:

“You can recognize that a given person is at high risk for PTSD post-trauma, based on any combination of these factors—having a psychiatric history, past trauma, high exposure to the event, psychosocial problems pre-disaster, or lack of supports post-disaster.”

The clinical interview is a vital tool in assessing patients with suspected PTSD or posttraumatic sequelae, says Arieh Shalev, MD, of the department of psychiatry at Hadassah University Hospital in Jerusalem, Israel. “It provides the opportunity to discuss the traumatic event with the patient, and to listen to his or her perceptions of the event and its effects” in order to carefully appraise the patient’s symptoms.²

The guidelines set forth in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) remain the gold standard for confirming a diagnosis of PTSD and discerning long-term posttraumatic sequelae from temporary acute stress disorder (Box 1). The guidelines have proved far from foolproof, however, and the existence of psychiatric comorbidities often clouds the picture.

Box 1

DSM-IV DIAGNOSTIC CRITERIA FOR PTSD

1. Exposure to a traumatic event with both of the following present:
2. The traumatic event is persistently reexperienced in one or more of the following ways:
3. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three or more of the following:
4. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two or more of the following:
5. Duration of symptoms in criteria B, C or D exceeds 1 month.
6. Disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if; Acute: if duration of symptoms is less than 3 months.

Chronic: if symptoms persist 3 months or more.

With delayed onset: if onset of symptoms is at least 6 months after the stressor.

Acute stress disorder, whose symptom pattern is similar to that of PTSD, is distinguished from PTSD because the symptom pattern must occur and resolve within 4 weeks of the traumatic event. If the symptoms persist for more than 1 month and meet the criteria for PTSD, the diagnosis is changed from acute stress disorder to PTSD.

Differential diagnosis of PTSD

Patients with PTSD are more likely to have substantial psychiatric comorbidity than are those without the disorder.³ Possible reasons include suspected self-medication of PTSD symptoms, particularly among patients with substance abuse, and the possible overreporting of symptoms by patients. Psychiatrists should maintain a high level of suspicion for PTSD when managing a new or existing patient with psychopathology.

Citing data from the National Comorbidity Study of the Institute for Social Research at the University of Michigan, Kessler and others in 1995 noted that more than 80 percent of individuals with PTSD meet criteria for at least one other psychiatric diagnosis. Roughly half of PTSD sufferers met criteria for three or more comorbidities.³

Kathleen Brady, MD, professor of psychiatry at the Medical University of South Carolina in Charleston, noted in a 1997 study that affective disorders, other anxiety disorders, somatization, substance abuse, and dissociative disorders are common comorbidities of PTSD.⁵ Dr. Shalev and colleagues in one study found that a history of major depressive disorder may increase the severity of posttraumatic morbidity.⁶ Dr. Brady and others also have found that PTSD patients with a comorbid substance abuse disorder experience severe PTSD symptoms while in a withdrawal state.⁷

Box 2

PTSD often is overlooked in the presence of other psychiatric diagnoses. Meuser et al in 1998 studied 275 patients with schizophrenia and bipolar disorder. As many as 98 percent of patients reported lifetime exposure to at least one traumatic event. The researchers found diagnosable PTSD in 119 (43 %) of the subjects, but only three (2%) had the diagnosis in their charts.⁸

In a later study, Dr. Brady and others cited substantial symptom overlap between PTSD and other psychiatric diagnoses, particularly major depressive disorder. This can contribute to underdiagnosis of PTSD, the researchers found.⁷ (Box 2).

Box 3

WATCH FOR SIGNS OF PTSD IN CHILDREN

Children also have been experiencing stress disorders since Sept. 11, says Arshad Husain, MD, professor and chief of child and adolescent psychiatry and director of the International Center for Psychosocial Trauma at the University of Missouri-Columbia. Such disorders manifest as sleep disturbances, anxiety, hyperarousal/hyperactivity, and nightmares.

Young children regress and cling to their parents, and are frightened of the dark or noises, Dr, Husain notes. Those who are toilet-trained can suddenly wet the bed, become neurotic, and demand attention. School-age children are more fearful; they may not want to go to school, their schoolwork may decline, and they may have trouble paying attention. Dr. Husain suggests discussing the trauma and devising a plan of action with them in case the trauma recurs.

The media’s role in reporting on the aftermath of the attacks—and triggering traumatic reactions as an unintended consequence—cannot be overlooked. Two recent studies performed after the Oklahoma City bombing suggest that television reports of that atrocity precipitated PTSD symptoms in middle-school children 7 weeks after the bombing,²³ and in geographically distant sixth-graders 2 years after the attack.¹² It was not clear whether any of these students had prior PTSD or other psychopathology.

Psychiatric education in the schools is especially crucial in light of the school violence that has occurred in America in recent years. Dr. Husain believes that the children who commit violence are victims of abuse. If teachers early on can identify children who show evidence of stress disorders, they can refer them to trained psychiatrists, catching those who need help before tragedies occur. “It is the psychiatric equivalent of CPR,” Dr. Husain says.

Dr. Brady recommends that psychiatrists and primary care physicians routinely screen patients for exposure to traumatic events. Ask patients specifically about their reaction to such events and encourage them to talk about it. Patients often feel either guilty or embarrassed about the traumatic event, or do not believe it affects their presenting complaints, she notes. Other approaches may be needed to identify the risk of PTSD in children (Box 3).

Identifying a traumatic event of an extreme nature, for example, a life-threatening experience, is key to diagnosing PTSD in the presence of comorbidities, Dr. Corvalan says. “Some of the symptoms—such as avoidance, numbing, and increased arousal—are present in other disorders and may have occurred before exposure to the traumatic event.” If they did, he says, PTSD is ruled out.

Gauging the extent of the patient’s exposure to the traumatic event is critical to determining the likelihood of PTSD onset. Dr. Allen, of Oklahoma City, points to studies that show that the closer and longer the patient has been exposed to a catastrophic event, the more likely he or she will develop PTSD.^9,10

Julia Frank, MD, associate professor and director of student education and psychiatry at George Washington University in Washington, DC, suggests screening for symptoms that are unique to PTSD as stated in the DSM-IV, such as nightmares, difficulty remembering the traumatic event, and extreme reactions to reminders of the trauma. She also proposes analyzing the past event and the patient’s reaction to it to confirm that it is a source of trauma.

Patients with PTSD symptoms are easily startled by loud or piercing noises. Dr. Shalev says this characteristic sets true PTSD cases apart from other psychopathology, particularly depression. In one study, Israeli combat veterans with PTSD exhibited a more pronounced heart rate and skin conductance when exposed to auditory stimuli than did combat veterans with no PTSD symptoms.¹¹

Drs. Allen and Frank note that patients who have anthrax-related fears and no prior PTSD symptoms are not likely to develop PTSD. They may, however, manifest symptoms of chronic fatigue, fibromyalgia, and generalized anxiety disorder. Patients may be jumpy, intense, or lethargic, with autonomic instability and rapid heart rate. They may feel alienated and mistrustful of the government. A nonspecific stress disorder and mixed anxiety depression are other possible effects.

Who to treat—and how

Psychiatrists nationwide have reported increased patient presentations after the Sept. 11 attacks and throughout the anthrax scare. Studies conducted after the Oklahoma City bombing also suggest that psychiatrists could be seeing more patients in the coming months.^12,13 As caseloads increase, so do the questions about who to treat, how, and how to avoid the possibility of overtreatment.

“In order to provide effective care to our patients it is necessary to have clear ideas on how to follow criteria for diagnosis and as a consequence for treatment,” Dr. Corvalan says. “The field at times is confusing; patients do not always follow the diagnostic criteria. The needs of the moment, limitations of recourses, intensity and variety of symptoms, urgency of the situation, etc., all conspire to make the job more difficult.”

Patients with anthrax-related anxiety should be encouraged to “try to function as normally as possible and keep an open communication with peers and those who they look to for information,” Dr. Frank notes. Dr. Allen adds that his patients with anthrax-inspired stress have responded well to breathing, meditation and other relaxation techniques.

Treatment of patients who are severely traumatized and exhibit true PTSD symptoms will vary based on severity of exposure, history of prior PTSD, and existence of comorbidities. A combination of pharmacological and psychosocial therapy is the common first-line treatment.

The selective serotonin reuptake inhibitor (SSRI) sertraline is specifically indicated for treating confirmed PTSD symptoms, and several studies have documented the agent’s effectiveness for this use.^14,15 Dr. Frank recommends dosages between 50 and 200 mg/d depending on the patient’s body weight or complaint of side effects (e.g., diarrhea, nausea, or sexual dysfunction). Other SSRIs, as well as tricyclics and MAO inhibitors, are alternatives. Fluoxetine, amitriptyline, phenelzine, and imipramine have all been found more effective than a placebo;^16-18 paroxetine also has been shown effective in specific populations.¹⁹

Box 4

Benzodiazapenes also may be prescribed to manage PTSD symptoms. Patients should be counseled against taking these sedating agents in the daytime, however, as they can lead to fogginess, detachment, and trouble functioning.

Assessing the patient’s available social support also is crucial to PTSD treatment. “Do patients talk to other people about the event?” Dr. Frank asks. “Are they trying to get back to a daily routine? Can they make sense of this experience? Are they incorporating the event into a world view?”

Dr. Thompson, the Pittsburgh disaster psychiatrist, agrees. Psychiatrists should encourage their patients to talk more about their trauma and how fear is affecting their lives. “We don’t discuss with our trauma patients as much as we might what the experience has been like for them,” he says.

Small-group therapy is the most conducive approach to psychotherapy for PTSD, according to Dr. Frank, although individual counseling can work in many cases. Several studies have found group therapy effective,^20,21 and 12-step group therapy has shown promise in PTSD patients with comorbid substance abuse disorder.²²

Managing fear

Just as people grieve and confront death in stages, Dr. Thompson, who helped coordinate Oklahoma City’s disaster psychiatry effort, has discovered that the public usually employs a similar subconscious process to cope with a traumatic event (Box 4).

But Americans have had no time to recover. As U.S. troops seek justice in Afghanistan, back home people grapple with the threat of anthrax contamination and the prospect of another terrorist attack. The ominously enhanced presence of security at airports, major bridges, sporting and entertainment events, and in other aspects of everyday life, has further fueled the sensation that all is not right.

“The September 11 tragedy brings trauma home,” adds Arshad Husain, MD, professor and chief of child and adolescent psychiatry and director of the International Center for Psychosocial Trauma at the University of Missouri-Columbia. “The anthrax scare and the Nov. 12 plane crash of American Airlines Flight 587 only further remind people of their vulnerability and fears. If the anthrax scare were an accident, people would have been relieved. Since the plane crash was ruled an accident, it has offered people a chance to feel more in control. Accidents can be fixed with better maintenance. Terrorism cannot.”

Dr. Katz of New York City and other disaster psychiatrists are urging their colleagues to help manage public fear by reaching out through community efforts.

Dr. Katz is president of the volunteer group Disaster Psychiatry Outreach, which helped coordinate the city’s post-Sept. 11 trauma psychiatry effort. Visitors waiting at New York’s Family Assistance Center, a referral and help center for people who lost family and friends in the World Trade Center attack, were approached by Dr. Katz and other colleagues to let them know that psychiatric services were available if needed. By doing this, he says, Disaster Psychiatry Outreach clinicians have identified, treated, and referred scores of patients with terror-related stress who otherwise would have gone untreated.

Joseph Dorzab, MD, of the Holt-Krock Clinic in Fort Smith, Ark., also has offered his services. Members of his clinic’s psychiatry department have made several TV appearances, and have given and coordinated area lectures. Working with the local mental health association, the department also is starting a community forum called Mental Health Mondays, an open discussion group with coffee and cookies at a local coffee shop.

In Pittsburgh, Dr. Thompson is encouraging psychiatrists to educate their communities about how traumatic events affect the public. He proposes:

• Staging community meetings to brief religious and other leaders on how to manage traumatized people;
• Informing local news editors about the nature of psychiatric disorders;
• Instructing school administrators about detecting signs of distress in children;
• Contacting local government officials to offer input in devising the town’s emergency response plan.

Psychiatrists also can educate themselves about managing public trauma, thanks to scores of studies that have been done in recent years following major man-made and natural disasters, from Mount St. Helens and Hurricane Andrew, to Chernobyl and the Yom Kippur War. Dr. Thompson urges psychiatrists to seek out the papers of prominent leaders in trauma-related psychiatry, mentioning studies by Carol North, MD, Betty Pfefferbaum, MD, and Robert Ursano, MD, as examples. Other sources include the Web sites of the American Psychiatric Association and National Center for PTSD. (See Related Resources.)

In the end, psychiatrists have been well primed for dealing with public disaster—just by treating individual patients whose psychiatric disorders emanated from everyday life, Dr. Thompson says. “Psychiatrists know more about trauma than they recognize.”

Related resources

• National Center for PTSD Web site
• National Institute of Mental Health:
• Linenthal EJ. The Unfinished Bombing: Oklahoma City in American Memory. Oxford University Press, 2001.
• Norwood AE, Ursano RJ, Fullerton CS. Disaster psychiatry: principles of practice. Psychiatr Q. 2000; 71(3):207-226.
• American Psychiatric Association Web site:
• The Psychiatric Training Manual for Teachers and Mental Health Professionals

Drug brand names

• Amitriptyline • Elavil
• Bupropion • Wellbutrin
• Fluoxetine • Prozac
• Imipramine • Tofranil
• Paroxetine • Paxil
• Phenelzine • Nardil
• Sertraline • Zoloft