Tag Archives: posttraumatic

Septiembre 11: 20 Años Después

Para aquellos de nosotros que vivimos para presenciar ese día, es uno que estará por siempre plasmado en nuestros recuerdos.

Pregúntele a cualquier persona y te dirá exactamente qué estaba haciendo cuando todos pensamos que un avión había chocado accidentalmente con la Torre Norte del World Trade Center, donde estaba cuando el segundo avión chocó con la Torre Sur, con quién estaba cuando como vimos el Pentágono en llamas y nos enteramos de que el vuelo 93 había desaparecido sobre Shanksville, Pensilvania. Algunos de nosotros incluso podemos recordar lo que comimos esa mañana y podemos oler y hasta saborear ese desayuno cuando pensamos en tan fatídico día. Personalmente, yo me encontraba en mi clase de microbiología durante mi segundo año de la escuela de medicina. Todos nos aglomeramos para ver la cobertura noticiosa en nuestra sala de estudiantes y vimos el impacto del segundo avión.

El trauma que experimentamos colectivamente el 11 de septiembre fue de una magnitud sin precedentes. Se trató de una pérdida masiva de vidas… Madres, padres, hermanos, hermanas, hijos, hijas. Pero, más allá, se trató de la pérdida de nuestra seguridad, la pérdida de algunas de nuestras libertades, la pérdida de nuestra tranquilidad y, en general, la pérdida de nuestra inocencia.

Después del 11 de septiembre, en mi entrenamiento como médico en psiquiatría y psiquiatría forense en el Centro Médico San Vincente en el Greenwich Village de la Ciudad Nueva York, le ofrecí tratamiento a sobrevivientes del WTC, familias de víctimas y socorristas. También completé evaluaciones de discapacidades psiquiátricas para el Fondo WTC de la Junta Médica del Departamento de Bomberos de la Ciudad de Nueva York. He visto toda la gama de secuelas psicológicas. Depresión, ansiedad, trastornos por uso de sustancias, trastorno de estrés postraumático. Algunas personas pudieron recuperarse con breves intervenciones terapéuticas. Otras han requerido tratamiento a largo plazo para síntomas que persisten hasta el día de hoy.

Aquellos que continúan experimentando depresión y trastorno de estrés postraumático suelen tener pensamientos perturbadores, flashbacks y pesadillas que los llevan a revivir los eventos de ese fatídico día. Pueden alejarse de los demás y padecer de una gran variedad de sentimientos encontrados: tristeza, culpa, vergüenza, miedo, e ira. Esa ira puede manifestarse de muchas formas. Podría estar dirigida a otros miembros de la familia, al gobierno, a los terroristas, e incluso a si mismos y a sus seres queridos perdidos en el 9/11. La ira puede variar desde una irritabilidad leve hasta arrebatos severos que pueden llevar a un mayor distanciamiento de amigos y familiares.

Los sobrevivientes y las familias de las víctimas pueden culpar – o desplazar su culpa – a varias personas, dependiendo de la percepción propia de su participación en los eventos que condujeron al 11 de septiembre. Pueden culpar al gobierno por no habernos protegido. Pueden desplazar de manera inapropiada la culpa hacia un grupo étnico o religioso que asemeje el perfil general de los terroristas. En el caso de las familias de las víctimas, pueden culpar a sus seres queridos perdidos por haber ido a trabajar ese día. Pueden culparse a sí mismos por no haber impedido que su ser querido fallecido en los ataques saliera por la puerta o por no retrasar su partida. De manera similar, los sobrevivientes pueden culparse a sí mismos por haber ido a trabajar ese día o por no haber hecho lo suficiente para ayudar a un compañero de trabajo a escapar. Pueden tener cierto grado de culpabilidad de sobreviviente. En general, puede haber muchas dudas de “qué hubiese pasado si” y una forma circular de pensar que complica aún más el bienestar psicológico de los sobrevivientes.

Hay un dicho que nos menciona que “El tiempo cura todas las heridas.” Esto no es totalmente correcto. A aquellas personas que se quejan de que el 11 de septiembre sucedió hace 20 años y que ya es hora de superarlo les diría que, si bien se necesita tiempo para sanar, el tiempo de por sí no es el sanador de nuestras heridas. Para algunos de nosotros, la mejoría conlleva más tiempo que para otros. Algunos de nosotros continuaremos lidiando con el peso de la pérdida que sufrimos ese día. Además, parte de esa mejoría es recordar a aquellos a quienes perdimos. Los eventos conmemorativos anuales sirven para esa mejoría para algunos, pero pueden reabrir heridas parcialmente cerradas para otros.

¡Recuerda el 11 de septiembre y Recuerda siempre cuidar de ti y de tus seres queridos!

9/11: Twenty Years Later

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For those of us who lived to experience that day, 9/11 is one that will forever be embedded in our memories.

Ask anyone and they will tell you exactly what they were doing when we all thought it was an accident that a plane had hit the North Tower of the World Trade Center, where they were when the second plane hit the South Tower, and who was with them as we saw the Pentagon on fire and found out about flight 93 going down near Shanksville, Pennsylvania. Some of us may even remember what we were eating that morning and can even smell and taste that breakfast when we think of that day. Personally, I was in my microbiology class during my second year of medical school. We all huddled to watch the news coverage in our student lounge and saw the second plane hit.

The trauma that we collectively experienced on 9/11 was unprecedented in magnitude. It was about massive loss of life… Mothers, fathers, sisters, brothers, daughters, sons. But it was also about the loss of security, the loss of some of our freedoms, the loss of trust, and, overall, the loss of our innocence.

In the aftermath of 9/11, as a psychiatry resident and forensic psychiatry fellow at St Vincent’s Medical Center in New York City’s Greenwich Village, I treated WTC survivors, victims’ families, and first responders. I also completed evaluations of psychiatric disabilities for the NYC Fire Department Medical Board’s WTC Fund. I have seen the whole gamut of psychological sequelae. Depression, anxiety, substance use disorders, post-traumatic stress disorder (PTSD), and beyond. Some individuals were able to recover with brief therapeutic interventions. Others have required long-term treatment for persistent symptoms to this day.

Those who continue to experience depression and PTSD may have disturbing thoughts, flashbacks and nightmares that lead them to relive the events of that fateful day. They may estrange themselves from others and experience a myriad of feelings: sadness, guilt, shame, fear, and anger. That anger can manifest itself in many ways. It could be directed at other family members, the government, the terrorists, and even themselves and their lost loved ones. It could range from mild irritability to severe outbursts that can lead to further estrangement from friends and family members.

Survivors and families of victims may place — or displace – their blame at several targets, depending on their perception of their involvement in the events leading to and on 9/11. They may blame the government for not having protected us. They may inappropriately displace blame towards an ethnic or religious group that fits the general profile of the terrorists. For families of victims, they may blame their lost loved ones for having gone to work on that day or for not getting out. They may blame themselves for not having stopped their lost loved one from going out the door or for not delaying their departure. Similarly, survivors may blame themselves for having gone to work that day or for not having done enough to help a co-worker escape. They may have a degree of survivor’s guilt. Overall, there may be a lot of “what ifs” and a circular way of thinking that can further complicate the survivors’ psychological wellness.

The old adage tells us that “Time heals all wounds.” This is not entirely accurate. To those people who say 9/11 was 20 years ago and that it is time to put it behind us, I would tell them that while it does take time to heal, time itself is not a healer. For some of us, healing takes longer than for others. Some of us will continue to deal with the burden of the loss that we sustained on that day. Part of that healing process may include remembering those whom we lost. While annual commemorative events serve towards that healing for some, the same memorials may reopen partially closed wounds for others.

Remember 9/11 and Remember to take care of yourself and your loved ones!

Be Smart. Be Safe. Be Healthy. Be Strong.

Until next time!

Dr. Felix

Emotional Impact of the Separation of Children and Parents at the US Border

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On June 20, 2018, the American Psychiatric Association (of which I am an Assembly Member) and 17 other mental health organizations joined forces in a letter to the Departments of Justice, of Homeland Security and of Health and Human Services, urging the administration of President Donald Trump to end its policy of separation of children from their parents at the United States border.

The letter states that “children are dependent on their parents for safety and support. Any forced separation is highly stressful for children and can cause lifelong trauma, as well as an increased risk of other mental illnesses, such as depression, anxiety, and posttraumatic stress disorder (PTSD). In addition, the longer that children and parents are separated, the greater the reported symptoms of anxiety and depression for the children.”¹

The separation and detention of minors is a human rights crisis

The United Nations Convention on the Rights of the Child emphasizes the importance of considering “the best interests of the child.”² These interests include:

Protection against discrimination
Safety
Wellbeing
Health
Ensuring to the maximum extent possible the child’s survival and development
Preservation of the child’s identity
Family integrity
Protection against the separation from parents against the child’s will
Free expression of ideas
Freedom
Education

The separation of children from their families and their detention under inhumane and deplorable conditions are in direct opposition to all these interests.

The emotional impact of the separation

The negative effects, both physical and emotional, on the children separated from their parents may not be apparent for many years and some may be irreversible.

The short-term emotional effects include:

Post-traumatic stress disorder
Anxiety
Depression
Low self-esteem
Feelings of helplessness and hopelessness
Behavioral problems
Irritability
Sleeping problems
Changes in appetite
Loss of interest in pleasurable activities
Poor self-care
Feelings of guilt
Suicidal thoughts or behaviors

The long-term emotional sequelae can be reflected in:

Developmental delay
Poor psychological adjustment
Poor school performance
Regressive behavior
Aggression
Increased vulnerability to physical illness
Alcohol and drug use

Studies show that no matter how brief the detention, it may cause severe and long-term psychological trauma and increase the risk of mental disorders.³

Parents may also be affected due to the uncertainty of what may be happening to their child, which may manifest itself in:

Increase in physical and emotional problems
Anxiety
Depression
Post-traumatic stress disorder
Difficulty in their relationships
Suicidal thoughts or behaviors

What is Attachment?

Attachment is the bond between the child and his parents, which plays a fundamental role in the social and emotional development of the child. Adequate attachment fosters feelings of security in the child. Poor attachment can make the child grow insecure, with separation anxiety, self-esteem problems, trust issues, behavioral problems, and even extreme dependence on others.

The relationship between parents and children can continue to be affected even after being reunited, which may be manifested in:

Attachment problems
Reduction in parental authority
Poor parent-child relationship
Difficulties in child rearing

How can we prevent these negative effects?

Putting a stop to the separation of families and to the inhumane conditions in the detention centers. The separation of a parent from a child should never occur, unless there are concerns for the safety of the child at the hands of his/her parent.
Early detection of symptoms through mental health assessments and periodic reevaluations (especially when symptoms may arise later as the separation or detention persists).
Coordination of services:
Psychotherapy and counseling can help the children and their parents to deal with their feelings or negative thoughts, identify stressors, and strengthen coping skills. Therapy can assist in processing emotions and offer support and hope.
Psychiatric medications may also control symptoms of depression, anxiety, post-traumatic stress disorder, or any other mental health condition.
Finally, there should be no shame in seeking help, which can improve the lives of the child and his/her family.

Remember…

Be Smart. Be Safe. Be Healthy. Be Strong.

Until next time!

Dr. Felix

References:

¹American Psychiatric Association. (2018, June 20). Mental health organizations urge administration to halt policy separating children and parents at U.S. border. Retrieved from https://www.psychiatry.org/newsroom/news-releases/mental-health-organizations-urge-administration-to-halt-policy-separating-children-and-parents-at-u-s-border/

²United Nations. Convention on the Rights of the Child. Retrieved from https://www.ohchr.org/en/professionalinterest/pages/crc.aspx/

³Linton, J.M., Griffin, M., Shapiro, A.J. (2017, March). Detention of immigrant children. American Academy of Pediatrics. Retrieved from http://pediatrics.aappublications.org/content/pediatrics/early/2017/03/09/peds.2017-0483.full.pdf

PTSD and Response to Traumatic Events in the Aftermath of the Boston Marathon Bombings, Sandy Hook and Other Recent Tragedies

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Following recent traumatic events, such as the Boston Marathon bombings, the Sandy Hook massacre in Newtown, Connecticut, and other tragedies in the United States and around the world, it is imperative to address the importance of early recognition and treatment of acute and posttraumatic stress disorders.

Acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) may arise after direct exposure to a traumatic event, actual or threatened death of a family member or close friend, or repeated exposure to details about a traumatic event (1). Symptoms of ASD and PTSD are fairly similar and the distinction is largely based on the time frame to the beginning and duration of symptoms. Symptoms related to ASD last up to four weeks and must arise within one month of exposure to the traumatic event. In PTSD, the duration of symptoms is beyond 30 days. While your repeated exposure to details of a traumatic event from media coverage is not considered a cause of ASD and PTSD, the impact of graphic and violent images may affect people in different ways and may lead to temporary mood changes or worsen any pre-existing depressive or anxiety disorders.

The lifetime prevalence of PTSD in the United States adult population is estimated to be 6.8% (2). Women may be up to three times more likely to develop PTSD than men. Risk factors to develop PTSD, in addition to exposure to a traumatic event, include: being a female, having other mental illnesses (like depression and anxiety), having a family history of psychiatric illness, being a victim of abuse, or having a poor support system.

The following are key symptoms of PTSD but this condition may affect you in many different ways. Symptoms may also become severe enough to the point that they affect your day-to-day life and functioning.

Flashbacks or intrusive thoughts about the trauma

Nightmares or recurring dreams (about the trauma or with related themes)

Avoidance of memories or outside cues that remind you of the trauma (for example: blocking memories, avoiding conversations about the trauma, or driving the long way home to avoid the intersection where your car accident occurred)

Anxiety

Being easily frightened or startled

Sleep problems

Difficulty concentrating

Irritability or anger

Survivor’s guilt

Social isolation

Depression

Loss of interest in pleasurable activities

Feelings of detachment or numbness

Inability to fully express your emotions

Mistrust of others

Thoughts of suicide or suicide attempts

Early intervention following a traumatic event is important. For some people, talking about it with a family member or friend (“getting it off your chest”) may be enough. Others may need longer treatment with therapy and even medication.

Talk about your feelings: How safe do I feel? How has the trauma affected me? Am I afraid to leave the house? Am I self-medicating with drugs or alcohol? Why is my family so worried? What can I do?

The National Suicide Prevention Lifeline (1-800-273-TALK or 1-800-273-8255) is an excellent source of support. It is for people in crisis, not just if you are thinking of ending your life. When you dial Lifeline, your call is routed to the crisis center closest to your location. The call is free and confidential. Someone will be there to listen to you and to provide you with information on mental health services in your community.

Remember, there is no shame in seeking help. We all need a little push every now and then.

Be Smart. Be Safe. Be Healthy. Be Strong.

Until next time!

Dr. Felix