BASIC PRINCIPLES OF INTERVENTION AFTER EMOTIONAL TRAUMA	Section 5 of 10
Author Information Introduction Symptoms Of Grief Differential Diagnosis Basic Principles Of Intervention After Emotional Trauma Patient Education Care Of Rescue Workers Therapeutic Interventions Medication Bibliography

• Reduce stress by all possible means.
  • Ensure that survivors have a safe environment.

  • Promote contact with loved ones and other sources of support (eg, religious organizations).

  • Support self-esteem. Help the individual to understand that their reaction to the trauma is a normal reaction to an abnormal situation, not a sign of weakness or psychopathology.

  • Help the person to focus on immediate needs, such as rest, food, shelter, social supports, or sense of community (some feel cut off and detached).

  • Promote coping mechanisms.

  • Help individuals to reframe any destructive cognitions, such as he or she acted terribly and is a terrible person or is weak for being so distraught, life is hopeless or worthless, or the world is totally unsafe.

  • Administer medication (eg, propranolol, alpha-agonists, benzodiazepines, nonactivating selective serotonin reuptake inhibitors [SSRIs]), if needed, to decrease arousal.

• Avoid increasing stress.
  • Avoid prompting discussion of issues that cannot be resolved.

  • Avoid abreaction in groups and the resulting contagion effect.

  • Respect defenses, and do not force reality on persons who cannot handle it yet.

  • Debriefing may be harmful.

• Share the experience with persons who want to talk about it, and avoid pressuring those who do not want to talk about it.

• Identify persons at high risk: Screen for physical causes of psychiatric problems (eg, dehydration, head trauma, infection, metabolic abnormality, toxins).

• Have faith in the normal healing processes.

• Promote support networks.

	PATIENT EDUCATION	Section 6 of 10
Author Information Introduction Symptoms Of Grief Differential Diagnosis Basic Principles Of Intervention After Emotional Trauma Patient Education Care Of Rescue Workers Therapeutic Interventions Medication Bibliography

Helping adults who are grieving

Be available, and do not allow a grieving person to become isolated.

• Take action (eg, call, send a card, give hugs, help with practical matters).

• Be available after others get back to their own lives.

• Be a good listener, but do not give advice.

• Do not be afraid to talk about the loss.

• Talk about the person who died by name.

• Do not minimize the loss; avoid clichés and easy answers.

• Be patient with the bereaved; there are no shortcuts.

• Encourage the bereaved to care for themselves.

• Remember significant days and memories.

• Do not try to distract the bereaved from grief through forced cheerfulness.

Helping children who are grieving or traumatized

• Reassure children of their safety and the safety of their loved ones (as much as possible); tell them that such things are very rare, that people are there to take care of them, and that they will always be loved.

• Be emotionally available to children despite personal loss (or fears).
  • Give children more time than usual.

  • Encourage them to share their feelings, to talk at weekly family meetings, and to use drawings and puppets to express their feelings.

  • Let them know it is all right to talk about unpleasant feelings (including sadness and anger) and listen to them. (Sharing personal feelings of sadness with them is all right as well.)

• Check to see if children feel that they somehow caused the death or disaster or if they have other misunderstandings, and reassure them or correct the misunderstanding. Do not assume children are fine just because they are not saying anything.

• Understand that children probably know more than you think.
  • Ask what the child knows and what questions the child has.

  • Monitor and limit TV watching after a disaster lest it flood them or desensitize them to violence.

  • When they watch TV, watch it with them and discuss the events.

  • Share only the details they can deal with. Do not overload them with facts. Be honest.

• Encourage action, such as sending letters to victims, to keep them from feeling helpless.

• Understand that regression, fear, sleep problems, and anger toward remaining family members are common after a loss or trauma.

• Do not force children to go to the funeral if they do not want to, but help them create a ritual.

• Maintain as normal a schedule as possible.

• Eat balanced meals on time, drink fluids, sleep, relax, exercise, and avoid alcohol and caffeine.

• Get help if serious signs appear and last more than a couple of weeks.
  • Extended depression and loss of interest in activities and events

  • Inability to sleep, loss of appetite, or prolonged fear of being alone

  • Extended period of marked regression

  • Excessive imitation of the deceased or repeated statements about wanting to join the deceased

  • Withdrawal from friends

  • Serious drop in school performance or refusal to go to school

  • Persistent fears

  • Persistent irritability and being easily startled

  • Behavior problems

  • Physical complaints

	THERAPEUTIC INTERVENTIONS	Section 8 of 10
Author Information Introduction Symptoms Of Grief Differential Diagnosis Basic Principles Of Intervention After Emotional Trauma Patient Education Care Of Rescue Workers Therapeutic Interventions Medication Bibliography

Debriefing

Critical incident stress debriefing is one of the most common interventions thought of following a traumatic event. (Caution: Critical incident stress debriefing has not been shown to reduce the later development of depression, anxiety, or PTSD, and it may harm individuals by increasing their arousal and overwhelming their defenses.)

Classically, critical incident stress debriefing has 7 stages, including (1) introduction (purpose of the session), (2) describing the traumatic event, (3) appraisal of the event, (4) exploring the participants' emotional reactions during and after the event, (5) discussion of the normal nature of symptoms after traumatic events, (6) outlining ways of dealing with further consequences of the event, and (7) discussion of the session and practical conclusions.

Research does not support the effectiveness of critical stress debriefing in the prevention of PTSD, depression, or anxiety, and, if performed poorly, debriefing can even be harmful. It can increase arousal and overwhelm the survivor's defenses. Operational debriefing, which focuses on normalizing emotional response, informing of services available, and providing general support, is safer. In engaging in a 1- to 2-session intervention following a traumatic event, a number of guidelines help avoid harm and maximize the chance of benefit for some individuals.

• Provide trained individuals to perform the intervention.

• Avoid ventilating feelings at high levels; this can lead to contagion and flooding, rather than calming and helping cope with feelings.

• Do not pressure individuals to talk about things they do not want to; respect their defenses, including denial.

• Critical tasks to cover include the following:
  • Psychoeducation to help patients see that the feelings they are having are not a sign of weakness or mental illness but a normal reaction to a very disturbing situation.

  • Discuss ways of improving coping skills, including getting adequate rest, recreation, food, and fluids.

  • Avoid excessive exposure to media coverage of the traumatic incident.

  • Discuss common cognitive distortions, such as survivor guilt and fears that the world is totally unsafe.

  • Explain the signs and symptoms indicating that someone should get professional help.

Cognitive behavior therapy

While 70% of those receiving supportive therapy or no therapy develop PTSD, cognitive behavior therapy (CBT) used shortly after a trauma has been shown to reduce the rate of PTSD development to 10-20%. Individuals are aided by the following:

• Seeing that people are concerned about them

• Learning about the range of normal responses to trauma and hearing that their emotional reactions are normal responses to an abnormal event (rather than a sign of weakness or pathology)

• Being reminded to take care of concrete needs (eg, food, fluids, rest)

• Cognitive restructuring (changing destructive schema, such as “having fun is a betrayal of the injured,” “the world is totally unsafe," “I am responsible for the disaster,” or “life is without meaning,” to more constructive ones)

• Learning relaxation techniques

• Undergoing exposure to avoided situations either via guided imagery and imagination or in vivo

Resources permitting, current data suggest that a 4- to 5-session course of CBT should be offered to those at high risk for developing PTSD. CBT should be performed by someone trained in the technique. Severe, relatively common destructive cognitions may arise after a traumatic event and need to be addressed.

On the left side of the Table below are malignant schemata that an individual may have after a traumatic event. On the right side are more constructive schemata that a clinician can suggest for consideration by the individual.

Cognitive Interventions

Malignant Schemata	Constructive Schemata
Life has no meaning.	Right now it is hard to make sense of what happened.
I can't go on.	What happened is very painful. It is hard but will get easier in time.
I behaved terribly.	I was frightened and unsure what to do and made some bad choices.
The world is unsafe.	Disasters are rare. Many things can be done to protect my safety.
I'm losing my mind.	Feeling confused and overwhelmed after a traumatic experience is common.
It was my fault it happened.	What was done to me was a crime.

Brief school intervention

Intervention lasts 1-2 hours and uses 4 therapists per class. A teacher is present, and parents are informed.

• Introduce the therapists, and ask students to guess why they have come to the classroom.

• Explain that therapists have come to talk about the disaster, and encourage students to share what they know for 10-30 minutes; validate correct information, and be calm.

• Have children draw while therapists circulate, and ask students to tell them about their drawings.

• Reassure students that their symptoms are normal and will ease; that people have different symptoms; that disasters are rare; and that teachers, parents, and counselors are available to help them.

• Having students do a second drawing in which they depict a future and a positive state of the world is very important. The first picture is likely to focus on the trauma, their loss, and its effect on them. They now need to do a second picture that shows healing and restoration of normal life.

• Thank the students and the teachers, and redirect their attention to learning.

	MEDICATION	Section 9 of 10
Author Information Introduction Symptoms Of Grief Differential Diagnosis Basic Principles Of Intervention After Emotional Trauma Patient Education Care Of Rescue Workers Therapeutic Interventions Medication Bibliography

Theoretically, the use of medications to decrease arousal, such as propranolol, benzodiazepines, and alpha-agonists, may reduce the future development of PTSD. Diphenhydramine may be helpful for sleep. If these agents are inadequate, valproic acid may be useful. Atypical antipsychotics may also be necessary.

Propranolol may limit hyperarousal and, thereby, decrease the possibility of PTSD development. SSRIs can be helpful in dealing with anxiety, depression, and avoidance. Benzodiazepines may limit hyperarousal and, perhaps, decrease the possibility of PTSD development. Continuous administration may interfere with grieving and readaptation because they interfere with learning. Longer-acting agents are particularly beneficial when medication is administered at the emergency site.

No controlled studies are available to evaluate the efficacy of antihistamines in separation anxiety disorder; however, possible adverse effects include a decrease in sleep latency and awakenings in mid sleep.

Drug Category: Beta-adrenergic blocking agents - These agents inhibit chronotropic, inotropic, and vasodilatory responses to beta-adrenergic stimulation.

Drug Name	Propranolol (Inderal)- May be useful for the treatment of hyperarousal.
Adult Dose	10-120 mg PO tid
Pediatric Dose	0.6 mg/kg/d PO initially; may gradually increase; not to exceed 2.5 mg/kg/d PO in divided doses
Contraindications	Documented hypersensitivity; uncompensated CHF; bradycardia; cardiogenic shock; A-V conduction abnormalities; asthma
Interactions	Coadministration with aluminum salts, barbiturates, NSAIDs, penicillins, calcium salts, cholestyramine, and rifampin may decrease effects; calcium channel blockers, cimetidine, loop diuretics, and MAOIs may increase toxicity; increases levels of neuroleptics (eg, chlorpromazine, thioridazine); may increase effects of hydralazine, haloperidol, and benzodiazepines
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in diabetes (ie, may cause hypoglycemia or hyperglycemia and mask signs of hypoglycemia) and hyperthyroidism; beta-adrenergic blockade may decrease signs of acute hypoglycemia and hyperthyroidism; abrupt withdrawal may exacerbate symptoms of hyperthyroidism, including thyroid storm; adverse effects include depression, decreased energy, and possibly decreased mental acuity

Drug Category: Selective serotonin reuptake inhibitors (SSRIs) – First-line agent for managing anxiety, depression, avoidance behavior, and intrusive recollections. Antidepressant agents chemically unrelated to tricyclic, tetracyclic, or other available antidepressants. SSRIs inhibit CNS neuronal uptake of serotonin (5HT). SSRIs may also have a weak effect on norepinephrine and dopamine neuronal reuptake.

Drug Name	Citalopram (Celexa)- Enhances serotonin activity due to selective reuptake inhibition at the neuronal membrane. Least-activating of the SSRIs; is particularly useful in ASD. Incidence of adverse effects (especially sexual) is less than with other SSRIs.
Adult Dose	20-60 mg/d PO
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; concurrent MAOI therapy or use of another serotonergic agent (another SSRI or tryptophan)
Interactions	May be potentiated by azole antifungals, omeprazole, and macrolides; serotonin syndrome may be induced by buspirone, tramadol, MAOIs, and nefazodone; serotonin syndrome (ie, myoclonus, rigidity, confusion, nausea, hyperthermia, autonomic instability, coma, eventual death) occurs with simultaneous use of other serotonergic agents (eg, anorectic agents, tramadol, buspirone, trazodone, clomipramine, nefazodone, tryptophan), discontinue other serotonergic agents at least 2 wk prior to SSRIs
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in cirrhosis, suicidal tendencies, SIADH, DM, and breastfeeding; common adverse effects include sexual dysfunction and headache The Medicines and Healthcare products Regulatory Agency (MHRA) in the UK and the US Food and Drug Administration (FDA) have issued an advisory to treating physicians to use appropriate caution when considering using selective serotonin-reuptake inhibitor antidepressants in the pediatric population; the advisory reported the occurrence of suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients; nonetheless, the FDA has asked for additional studies to be performed, because suicidality occurs in both treated patients and untreated patients with major depression and, thus, could not at this point be linked to drug treatment

Drug Category: Benzodiazepines - These agents bind to a specific benzodiazepine receptor on the GABA receptor complex, thereby increasing GABA affinity for its receptor. They also increase the frequency of chlorine channel opening in response to GABA binding. GABA receptors are chlorine channels that mediate postsynaptic inhibition, resulting in postsynaptic neuron hyperpolarization. The final result is a sedative-hypnotic and anxiolytic effect.

Drug Name	Clonazepam (Klonopin)- Suppresses muscle contractions by facilitating inhibitory GABA neurotransmission and other inhibitory transmitters.
Adult Dose	Not to exceed 1.5 mg/d PO divided tid initially; may gradually increase by 0.5 mg q3d as warranted; not to exceed 20 mg/d Based on equivalence doses of other benzodiazepines, such as 1 mg of clonazepam for 1-2 mg PO of alprazolam
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; severe liver disease; acute narrow-angle glaucoma
Interactions	Phenytoin, carbamazepine, and barbiturates may reduce effects; coadministration of CNS depressants increase toxicity
Pregnancy	D - Unsafe in pregnancy
Precautions	Caution in chronic respiratory disease or impaired renal function; withdrawal symptoms can result from abrupt discontinuation; other precautions include history of drug and alcohol abuse; monitor blood counts and liver function tests

Drug Name	Lorazepam (Ativan)- Sedative-hypnotic with short onset of effects and relatively long half-life. By increasing the action of GABA, which is a major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including limbic and reticular formation. Important to monitor patient's blood pressure after administering dose and to adjust dose as necessary.
Adult Dose	1-10 mg/d PO divided bid/tid; adjust dose to response (ie, same dose used in acute treatment of severe withdrawal)
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; preexisting CNS depression; hypotension; narrow-angle glaucoma; breastfeeding
Interactions	Toxicity of benzodiazepines in CNS increases when used concurrently with alcohol, phenothiazines, barbiturates, and MAOIs; oral contraceptives enhance metabolism, thus higher lorazepam doses may be required
Pregnancy	D - Unsafe in pregnancy
Precautions	Caution in renal or hepatic impairment, myasthenia gravis, limited pulmonary reserve, organic brain syndrome, or Parkinson disease

Drug Category: Alpha-adrenergic agonists - Centrally acting alpha2-adrenergic agonists, clonidine and guanfacine have been used to treat children with attention deficit hyperactivity disorder (ADHD). Inhibition of norepinephrine release in the brain may be its mechanism of action.

Drug Name	Clonidine (Catapres)- Frequently given to children but not approved by FDA for any psychiatric uses in children. Available in tabs or transdermal skin patches. Affects the alpha1-, alpha2-, and alpha3-adrenergic receptors.
Adult Dose	0.05 mg PO qd initially; may increase by 0.05 mg q3-4d until dose reaches 0.1-0.3 mg/d PO divided tid
Pediatric Dose	Limited data suggest: 0.15-0.3 mg/d PO divided tid
Contraindications	Documented hypersensitivity; cardiovascular disease; depressive symptoms
Interactions	Concurrent CNS depressants may increase effects; tricyclic antidepressants may decrease levels; sudden death reported in patients taking clonidine with methylphenidate at bedtime
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in cerebrovascular disease, coronary insufficiency, sinus node dysfunction, and renal impairment; check ECG before use and after dose increases; common adverse effects include drowsiness, depression, dry mouth, dysphoria, and photophobia; less common adverse effects are headache, abdominal pain, nosebleeds, irritability, decreased glucose tolerance, and exacerbation of existing arrhythmias

Drug Name	Guanfacine (Tenex)- Action similar to clonidine but has a longer half-life and less sedation. More selective alpha-agonist. Not recommended for children <12 y. Effects alpha2-adrenergic receptors only.
Adult Dose	0.5 mg PO qd initially; may increase by 0.5 mg q3d until desired effect reached; typical dose is 1-3 mg/d PO divided bid/tid
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	Increases effect of other hypotensive agents; tricyclic antidepressants may decrease hypotensive effects
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Caution in hepatic impairment, severe coronary insufficiency, and recent myocardial infarction; check ECG before use and after dose increases; drowsiness is less of a problem than with clonidine but is present; may cause depression, dysphoria, photophobia, and dry mouth; less common adverse effects are headache, abdominal pain, nosebleeds, irritability, decreased glucose tolerance, and exacerbation of existing arrhythmias

Drug category: Antihistamines, sedating - Older, sedating antihistamines (eg, diphenhydramine) are often prescribed as sedatives because of their CNS depressive properties.