Terrorism
and Disaster

WHAT
CLINICIANS
NEED TO
KNOW

PsychiatricSequelae in a
Survivor of 9/11

Sponsored for CME Credit by
Rush University Medical Center
Release Date: April 1, 2005
Expiration Date: March 31, 2007

errorism
Tand isaster
D
SERIESEDITORS
Rush University
Medical Center
Chicago, Illinois
Stephanie R. Black, MD*
Assistant Professor of Medicine
Section of Infectious Diseases
Department of Internal Medicine
Daniel Levin, MD*
Assistant Professor
General Psychiatry Residency Director
Department of Psychiatry
Gillian S. Gibbs, MPH*
Project Coordinator
Center of Excellence for Bioterrorism
Preparedness
Linnea S. Hauge, PhD*
Educational Specialist
Department of General Surgery

AUTHORS
Rush University
Medical Center
Chicago, Illinois

WHAT
CLINICIANS
NEED TO
KNOW

Uniformed Services University
Health Sciences
Bethesda, Maryland
David M. Benedek, MD, LTC, MC, USA
Associate Professor of Psychiatry
Steven J. Durning, MD, Maj, USAF, MC*
Associate Professor of Medicine
Thomas A. Grieger, MD, CAPT, MC, USN*
Associate Professor of Psychiatry
Associate Professor of Military &Emergency Medicine
Assistant Chair of Psychiatry for Graduate& Continuing Education
Molly J. Hall, MD, Col, USAF, MC, FS*
Assistant Chair & Associate Professor
Department of Psychiatry
Derrick Hamaoka, MD, Capt, USAF, MC, FS*
Director, Third Year Clerkship
Instructor of Psychiatry
Paul A. Hemmer, MD, MPH, Lt Col, USAF, MC*
Associate Professor of Medicine
Benjamin W. Jordan, MD, CDR, MC, USNR, FS*
Assistant Professor of Psychiatry

Stephanie R. Black, MD*
Assistant Professor of Medicine
Section of Infectious Diseases
Department of Internal Medicine

James M. Madsen, MD, MPH, COL, MC-FS, USA*
Associate Professor of Preventive Medicine
and Biometrics
Scientific Advisor, Chemical Casualty Care
Division, US Army Medical Research Instituteof Clinical Defense (USAMRICD), APG-EA

Daniel Levin, MD*
Assistant Professor
General Psychiatry Residency Director
Department of Psychiatry

Deborah Omori, MD, MPH, FACP, COL, MC, USA*
Associate Professor of Medicine
Michael J. Roy, MD, MPH, FACP, LTC, MC*
Associate Professor of Medicine
Director, Division of Internal Medicine
Jamie Waselenko, MD, FACP**
Assistant Professor of Medicine
Assistant Chief, Hematology/Oncology
Walter Reed Army Medical Center
Washington, DC

Guest Faculty
Ronald E. Goans, PhD, MD, MPH*
Clinical Associate Professor
Tulane University School of Public Health &Tropical Medicine
New Orleans, LA
Sunita Hanjura, MD*
Rockville Internal Medicine GroupRockville, MD
Niranjan Kanesa-Thasan, MD, MTMH*
Director, Medical Affairs & Pharmacovigilance
AcambisCambridge, MA
Jennifer C. Thompson, MD, MPH, FACP*
Chief, Department of Clinical Investigation
William Beaumont Army Medical Center
El Paso, TX

Faculty Disclosure Policy
It is the policy of the Rush University Medical
Center Office of Continuing Medical
Education to ensure that its CME activities
are independent, free of commercial bias
and beyond the control of persons or organizations with an economic interest in influencing the content of CME. Everyone who
is in a position to control the content of an
educational activity must disclose all relevant
financial relationships with any commercial
interest (including but not limited to pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject
matter of the presentation topic) within thepreceding 12 months If there are relationships that create a conflict of interest, thesemust be resolved by the CME Course
Director in consultation with the Office ofContinuing Medical Education prior to theparticipation of the faculty member in thedevelopment or presentation of course
content.
* Faculty member has nothing to disclose.
**Faculty disclosure: CBCE Speaker’s Corefor SuperGen.

Psychiatric Sequelae
in a Survivor of 9/11
CASE AUTHORS: Molly J. Hall, MD, Col, USAF, MC, FS
Derrick Hamaoka, MD, Capt, USAF, MC, FS

ACCREDITATION & DESIGNATION STATEMENT
Rush University Medical Center is accredited by the Accreditation Council for Continuing
Medical Education (ACCME) to provide continuing medical education for physicians.
Rush University Medical Center designates this educational activity for a maximum of 1 credit of category 1 credit toward the AMA Physician’s Recognition Award. Each physician shouldclaim only those credits that he/she actually spent in the activity.
This CME activity was planned and produced in accordance with the ACCME Essentials.
CME credits are available free of charge through March 2007.

DISCLAIMER
This project was funded by the Metropolitan Chicago Healthcare Council (MCHC) througha grant from the Health Resources and Services Administration (HRSA).
The opinions or assertions contained herein are the private views of the authors and are not
to be construed as official or as representing the opinion of Rush University Medical Center,
the Department of the Army, Department of the Navy, Department of the Air Force,
Department of Defense, MCHC or HRSA.
FDA Approved Drug and Devices Assurance Statement
In accordance with requirements of the FDA, the audience is advised that information presented in this continuing medical education activity may contain references to unlabeled orunapproved uses of drugs or devices. Please refer to the FDA approved package insert for eachdrug/device for full prescribing/utilization information.

INSTRUCTIONS
The questions that appear throughout this case are intended as a self-assessment tool. For
each question, select or provide the answer that you think is most appropriate and compare
your answers to the key at the back of this booklet. The correct answer and a discussion of
the answer choices are included in the answer key.
Note: These self-assessment questions are not intended for CME credit. To apply for CME
credit, you must complete the CME Test at the back of this booklet and submit it according to
the directions provided.
In addition, a sign is provided in the back of this booklet for posting in your office or clinic.
Complete the sign by adding your local health department’s phone number.

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Copyright Act of 1976 as a “U.S. Government Work” and is therefore considered Public Domain Information,
however Rush University Medical Center reserves the right to copyright the design and layout of that information.

1

Psychiatric Sequelae
in a Survivor of 9/11
CASE AUTHORS: Molly J. Hall, MD, Col, USAF, MC, FS
Derrick Hamaoka, MD, Capt, USAF, MC, FS

INTENDED AUDIENCE
Mental health professionals including psychiatrists, psychologists, social workers,
hospital chaplains, and other physicians who will provide evaluation and care in theaftermath of a terrorist attack or other public health disasterE D U C AT I O N A L O B J E C T I V E S
Upon completion of this case, participants will be able to:• Discuss the common psychiatric sequelae to victims directly and indirectly
exposed to a mass disaster.
• Explain the recommendations for parents regarding their children’s viewing of
television replays in the immediate aftermath of disaster events.
• List the possible long-term psychiatric sequelae that victims may develop after aterrorist event.
• Describe a generally recommended cognitive behavioral therapy protocol for thetreatment of posttraumatic stress disorder.
• List the medications that have proven efficacy for the treatment of posttraumaticstress disorder.
• Discuss resilience and posttraumatic growth for victims exposed to a terrorist
attack.

CASE HISTORY
You are a psychiatrist in the larger Manhattan area. One of your internal medicine colleagues refers a patient, Mr. Daniels, for an intake appointment. It has been
almost a year since the World Trade Center disaster. Your colleague conveys that Mr.
Daniels originally presented with vague constitutional complaints, which included
insomnia, fatigue, anxiety, irritability, and a “detached” attitude. The medical workup
was negative, and Mr. Daniels continues to experience these symptoms as well as
occupational and relationship problems.
Mr. Daniels arrives for the intake appointment on time. He reports continuing
symptoms of low energy, insomnia, anxiety, irritability, and “indifference,” attributing
them to the increasing demands of his job, noting that it is “no big deal.” He states2that the workload has increased because of his company’s plan to move back to theoriginal office building near the World Trade Center. He almost dismissively comments on another reason for the increased workload — many of his colleagues died in
the World Trade Center collapse. He states that he is “picking up the pieces” andthat it is his “duty to work extra hard” because he is lucky; he missed his usual subway
train into the city on September 11th. The company has also made plans to unveil amemorial to his deceased coworkers. Mr. Daniels feels that this will be “too constant areminder” of his missing coworkers.
Mr. Daniels describes a “bout of depression” and “overall, being really anxious”
while in college; however, he did not seek treatment at that time. He also reluctantly
admits to drinking 3 to 4 beers every evening. He wishes he did not have to use alcohol, but feels that it “takes the edge off” and helps him sleep at night. Furthermore,
he describes feeling better when he is alone, barely tolerates distractions, such as hischildren, and no longer goes out with friends or attends social functions. His wife has
told him that he has changed since the event, saying that he is “tough to be aroundnow.” Partners at the firm have also commented on his job performance, and majorclients are asking to be reassigned. Clients cited a change from a once “top-notch”
and amiable lawyer to one that now “lacked sufficient attention to detail” and wasoccasionally argumentative. He admits it was difficult to come to this appointment
and he did not know what to expect. His expectation was to be “medicated withpsychiatric drugs.”
COMMENT: Following a major disaster or terrorist event it is common for patients struggling withpsychological symptoms to present to primary care facilities. The most common disorders that develop
in the wake of such events are:• depression• anxiety• somatization• substance abuse problems• increased family or domestic conflict
Posttraumatic stress disorder (PTSD), the disorder we typically associate with traumatic events may also
develop. As in the above narrative, it is common for these patients to be seen first in a primary care setting. Providers should be aware that increased substance use and familial discord may also be present.
Posttraumatic stress disorder is an anxiety syndrome that affects survivors and witnesses of traumatic
events. Posttraumatic stress disorder involves 3 symptom clusters, which together cause impairment in
the interpersonal, social, and occupational functioning of affected individuals.
The first cluster involves re-experiencing of the traumatic events. The re-experiencing of the event canoccur in a number of ways, including:• intrusive recollections• recurrent dreams• feeling as if the event was actually recurring.
Other ways the trauma can be re-experienced include responses to cues that remind the individual of
the trauma such as:• psychological responses, eg, panic, fear
• physiological responses, ie, palpitations, sweating3

Posttraumatic Stress Disorderinvolves 3 symptom clusters, which
together cause impairment in theinterpersonal, social, and occupational functioning of the affectedindividuals.
1. Re-experiencing the traumatic
events
2. Avoidance behaviors
3. Hyperarousal symptoms

The second cluster involves avoidance behaviors, including avoiding reminders of the people, places,
and activities associated with the trauma. In addition, within this same cluster, those people affected
may experience:• diminished interests• sense of detachment• sense of foreshortened future• an inability to recall important aspects of the trauma.
The third cluster involves hyperarousal symptoms, including:• insomnia• irritability• problems with concentration• increased startle response• hypervigilance

QUESTION 1
Given Mr. Daniels’ presentation, what would be the most appropriate
intervention?
a. Normalize feelings, assist with insomnia, and recommend abstaining fromalcoholb. Arrange for inpatient hospitalizationc. Excuse from work for the next 2 weeks
d. Start antidepressant medication immediately
Reminder: You can find the Answer Key & Discussion on page 9.
On the follow-up appointment, Mr. Daniels appears less anxious. He reports
improved sleep with the trazodone you prescribed at the end of his first appointment
and he has abstained from drinking alcohol in the interim period. Work continues tobe especially difficult; he specifically cites the upcoming memorial dedication as bothersome. There have been constant daily reminders of the disaster, such as posters,
fliers, and internal company email traffic, highlighting the upcoming dedication.
On questioning, Mr. Daniels recalls his original reaction to the attacks. He
describes feeling numb initially and that “things appeared to slow down.” This wasfollowed by disbelief — not being entirely certain that the attacks were real, although
he knows this doesn’t make sense. He then realized how fortunate he was to havemissed the train into the city that morning. He remembers being “worried sick” and“frantic” about the well-being of his wife and children, who had left earlier in themorning. He states in passing, “I must have called my wife’s cell phone and work
number a million times before I got through.” Feeling helpless, dismayed, and confused, Mr. Daniels relayed not knowing what to do immediately after the event. He
vacillated between thoughts of action and inaction. “Should I go into work and see
what I can do? Would it be better for me to stay at home? What other places aregoing to be hit next? Is New York even safe?”
COMMENT: The above account describes some of the acute reactions people may experience
after a disaster. Along with the initial shock and horror, there may be a sense of disbelief, a senseof derealization, dissociation, panic, a feeling that “time is slowing down,” and intense worry about
personal safety, and the safety of loved ones.

4Immediately following a disaster, there are some early interventions that can be effectively employed.
These “psychological first aid” interventions* include:• attention to basic needs• normalizing sleep-work cycles• providing sufficient rest
• facilitating reunions of families• providing information and education• limiting exposure to media reports and distressing images* For additional information regarding psychological first aid, see another case in this series,
Emergency Mental Health After a Suicide Bombing by David Benedek, MD, LTC, MC, USA.

Mr. Daniels notes that “everything seemed to be on hold for weeks after theattacks.” New business stopped coming in, and he found himself having more time todwell on the attacks and what might have happened to him had he made it to workon time. He wondered if he could he have saved some of his coworkers or if he would
have been killed, too. During this time, he continued watching television, which
repeatedly replayed video of the jets striking the buildings and of the buildings collapsing. He remembered not being able to turn off the television, even though hebecame increasingly distressed with the unedited visual and audio replays. In fact, hischildren were watching the television replays with him. He did not want to “shieldthem” from what was going on because they knew something was wrong, but hewondered about how this might be affecting them.
COMMENT: Technology and immediate news coverage added another dimension to the
September 11th terrorist attacks. For days and weeks after September 11th terrorist attacks, footage
was replayed continually. Graphic images in the broadcasts included the planes crashing into the World
Trade Center, people jumping or falling from the building, and the towers collapsing. Those who
watched more television coverage were significantly more likely to report PTSD symptoms. Image andnews content did not predict probable PTSD. The only associated variable was the amount of television
coverage watched.1 Because television viewing is an example of indirect exposure to a traumatic event,
it is perhaps best thought of as a correlate of distress rather than as a measure of traumatic exposure.2
While additional research will add to our understanding of the media’s impact, there is a general consensus that there are groups of vulnerable people whose exposure to television news should be limited. These include children and those who were directly exposed to the traumatic event.3

After returning to work a couple of weeks after the World Trade Center attacks,
the firm held an informational briefing in which the facts, losses, and relocation of thecompany were presented. Mr. Daniels thought the briefing was “kind of detached andemotionless.” The law partners also encouraged employees to get additional help andinformed the group of available counseling. Mr. Daniels grinned because, at thattime, he never thought that he would need it. He knew coworkers who had been
killed and two closer friends with whom he regularly had lunch had died. Some of his
coworkers did not return to work right away, in order to get “things straight.” Herecalled feeling a bit “weird” about coming into work and carrying on without someof his coworkers and friends. Anger and sorrow followed and he felt that he could do
nothing to “correct this great wrong.” To add to this burden, the company also had amandatory follow-up debriefing session during which those who escaped the collapse
were encouraged to recount their harrowing stories. Mr. Daniels related that this only
made him feel more isolated and irrelevant.

5

COMMENT: One-time psychological debriefings do not prevent the development of psychologicaldisturbances, such as PTSD, as indicated from the findings of randomized, controlled trials.4-7 In fact,
these one-time debriefings do not demonstrate improvement over natural recovery, eg, the outcome
with or without the debriefing was the same. Although debriefing has been found to be of no provenbenefit, the intervention is often well-received by many of those who were debriefed. Psychologicaldebriefings, if utilized, should be conducted by well-trained personnel and participation should be voluntary. Voluntary participation is important because some people may be secondarily traumatized byhearing the disaster experiences of others.

Memorial services for the deceased were especially difficult. Mr. Daniels attended
the memorial of a close colleague and found the experience wrenching. At that time,
he decided not to go to any additional ceremonies. He felt extremely guilty but at thesame time relieved about this decision.
Mr. Daniels thought he was “all right,” except that he found himself frequently
consumed with thoughts of the disaster. He constantly worried about his safety, as
well as the safety of his wife and children. He did not suspect anything specificallywrong and identified the feeling as “being unsettled.” He thought these feelings
would pass, but they did not. As time progressed, he avoided talking about thedeceased, the collapse of the Towers, and he avoided any activity that might bringback these memories. Mr. Daniels found that there were many things that reminded
him of the event, just “little things here and there,” and described feeling a visceralknot and nausea when there was something which even remotely reminded him of
the event. In fact, he took over many client accounts that had belonged to deceased
coworkers, which made it “just that much more terrible.”
Mr. Daniels recalls that his father was diagnosed with PTSD years after hereturned from Vietnam. When the psychiatrist suggests that Mr. Daniels is sufferingfrom PTSD, Mr. Daniels thinks this is strange, because he does not think he is anything like his father. His father was irritable, distant, missed work, and had nightmares
about being back in Vietnam. As a child, he remembers visiting his father at the local
Veterans’ Administration psychiatric hospital when these problems were at theirworst. He recalled that his father was so disabled that he was not able to work andeventually became “100% disabled.” While growing up, Mr. Daniels’ family knewthat talk of the war was something to be avoided. He commented, “It was like thishuge minefield with my father — everyone had to be really careful not to upset him.
Sometimes he thought he was still over there.” He relayed the most stressful time
while growing up was the Fourth of July; firecrackers, fireworks, and loud noises would
put his father “over the edge.”
COMMENT: Symptoms of PTSD have variable intensity, duration, and impact on functioning. Mr.
Daniels experiences distress when confronting situations or cues that remind him of the disaster, seeks
to avoid such reminders (memorials) and has some persistent hyperarousal (insomnia and irritability).
Mr. Daniels’ father experienced some of the more severe symptoms including intrusive recollections(nightmares and possible flashbacks), marked avoidance behavior (unable to go to work), and hyperarousal symptoms (exaggerated startle response and explosive anger). These symptoms, if not managed, can lead to multiple impairments such as interpersonal problems (relationship difficulties, maritalconflict, divorce), substance use problems, and occupational problems (inability to advance, job loss).
Depression, hopelessness, suicidal ideation in combination with alcohol and substance abuse may
require inpatient hospitalization for stabilization.

6

When he thought about it, he wondered if some of his coworkers were sufferingfrom PTSD. He noticed that some were conspicuously missing from work. Many ofthem were taking more sick days, and were isolative, irritable, becoming emotional
every time the subject of the disaster was raised.
At the close of this appointment, Mr. Daniels decided that talking with a psychiatrist about his reactions to the World Trade Center attacks was helpful. He inquires
about other treatments that might be useful. He understands there are medications
available. However, he does not want to start medication now, particularly as he isbeginning to feel some relief.

QUESTION 2
Which medication(s) would be indicated for the treatment of posttraumaticstress disorder?
a. Amitriptyline
b. Sertraline or Paroxetine
c. Bupropriond. Lorazepam

QUESTION 3
Which form of psychotherapy has most consistently demonstrated efficacy inclinical research studies of PTSD?
a. Hypnosis
b. Interpersonal Psychotherapyc. Cognitive Behavioral Therapy (CBT)d. Eye Movement Desensitization and Reprocessing (EMDR)

Mr. Daniels agreed to start cognitive behavioral therapy (CBT). The therapy
took place over 12 sessions, each lasting approximately 60 minutes. Through thecourse of therapy, Mr. Daniels was educated regarding his symptoms. He was also
taken through prolonged imaginal exposure (exposure therapy). This particular technique had Mr. Daniels provide personal, in-session narratives of all relevant details of
his experience, including detailed sensory cues and his affective responses. Throughthis experience, he was able to identify and examine his automatic negative thoughts
and assumed views surrounding his traumatic memories. He was able to challenge theassumptions regarding threats, safety, and his view of the world following the disaster.
Also, he was able to incorporate management tools for anxiety control in his daily lifethat he learned to use in the therapy sessions while he was recounting his experiences.
COMMENT: The paragraph above describes a course of CBT for PTSD. Within the context of thistime-limited therapy, the aim is to normalize feelings and reactions, provide anxiety management tools(such as deep muscle relaxation and deep breathing techniques), and promote imaginal exposure(recounting the trauma through verbal and written accounts). Cognitive behavioral therapy strategies
are utilized to develop new cognitive schema that dispute previous automatic thoughts and assumptions resulting from trauma.8

7

Mr. Daniels did well with the course of therapy. His symptoms decreased significantly, his relationships at work and at home improved, and he started to feel like“things were settling back in their place.” Although he didn’t know what he felt for
certain, he expressed feeling “different” as a result of the experience. When he tried
to describe it, he conveyed feeling more appreciative, more careful, more adaptive,
and increasingly attuned to things that he had never given much prior thought. For
example, in one of his final sessions, he expressed thinking that he “wanted to domore” and had considered practicing civil rights law, which was something he had notthought about since law school. At the conclusion of his treatment, he felt thankful
for the assistance and felt like he could now move on with his life.
COMMENT: Researchers have attempted to identify qualities that would predict that a person
would be more resistant to the negative psychological sequelae of traumatic experiences. Some ofthese factors include altruism, optimism, working effectively despite fear, and ability to bond with agroup toward a common goal.9
Researchers have also examined the dimension of growth and adaptation after experiencing a traumatic event, often referred to as posttraumatic growth. The individuals who experience posttraumatic
growth describe positive changes through dealing with the trauma and the aftermath. Posttraumatic
growth is believed to develop over many areas, ranging from improvement in an individual’s sense ofself, positive changes in one’s relationships, and positive changes in spirituality.10
The risk of developing PTSD is highest in those individuals who are directly exposed to high magnitude,
severely disturbing events (see table). These individuals may or may not have other risk factors, such as apreexisting psychiatric condition or recent negative life events. Studies of the impact of September 11th
have shown that distress and ongoing stress symptoms are not predicted simply by the degree of traumatic exposure, extent of physical injury, or other loss. Individuals not directly exposed may suffer as muchas those directly affected.

Table. Factors for Increased Risk of Developing PTSD
• Directly exposed to the trauma/event• Previous exposure to trauma, particularly in childhood• Familial factors, such as parental PTSD
• Family history of depression and anxiety• Premorbid psychiatric illness• Acute losses• Negative life events after the trauma• Female gender

8

ANSWER KEY & DISCUSSIONQUESTION 1
Given the above presentation, what would be the most appropriate intervention?
a. Normalize feelings, assist with insomnia, and recommend abstaining fromalcoholb. Arrange for inpatient hospitalizationc. Excuse from work for the next 2 weeks
d. Start antidepressant medication immediately
ANSWER: The correct answer is a. It is important to normalize feelings by acknowledging that thepast year has been very stressful and provide empathic support. Addressing prominent issues, such asproblems with sleep (with a non- benzodiazepine agent, such as trazodone), would also help build rapport.
Identifying the overuse of alcohol as a problem that contributes to insomnia, fatigue, and depression isimportant.
Mr. Daniels is not currently suicidal, homicidal, or severely impaired with regard to functioning. If any oneof these were present, then arranging for inpatient hospitalization would be an option. These issues areimportant to explore in all mental health assessments.
Keeping him from work and other regular activities would be detrimental. This would reinforce avoidance
behavior and the lack of structure might exacerbate other symptoms such as guilty thoughts about thedeath of coworkers.
Starting antidepressant medication immediately might be an option; however, it would be helpful to know if
he can cut down on his alcohol use before prescribing an antidepressant. Characterizing the alcohol problem first is important. Exploring his assumptions/expectations of visiting a psychiatrist is also warranted.

QUESTION 2
Which medication(s) would be indicated for the treatment of posttraumatic stressdisorder?
a. Amitriptyline
b. Sertraline or Paroxetine
c. Bupropriond. Lorazepam
ANSWER: The correct answer is b. Both of these medications have been FDA-approved for the treatment of PTSD. These medications are selective serotonin reuptake inhibitors (SSRIs); other medications
within this class are citalopram and fluoxetine. All of the SSRIs are used and are likely to be similarly
effective. These medications also have an added advantage of treating other anxiety disorders anddepression. They are generally well-tolerated. Potential side effects include gastrointestinal upset andmild sedation that is usually transient, and sexual dysfunction that unfortunately persists.
Amitriptyline is a tricyclic antidepressant with multiple side effects including sedation, weight gain, andprolongation of cardiac conduction time. It is highly lethal in overdose and has cross reactivity withalcohol. Although PTSD symptoms may respond to tricyclics they are rarely used as a first-line treatment.
Buproprion is an antidepressant that would be most suitable for primary treatment of major depressive
disorder. It has the advantage of minimal to no sexual side effects but has no anxiolytic or anti-panic
activity. It would not be indicated for PTSD, although it may be helpful as an adjunct to manage
associated comorbid depression.
Lorazepam is a short-acting anxiolytic that might initially decrease some of the hyperarousal symptoms.
However, it may be abused by those with a history of chemical dependence and does not treat thesymptoms of PTSD.
9QUESTION 3
Which form of psychotherapy has most consistently demonstrated efficacy inclinical research studies of PTSD?
a. Hypnosis
b. Interpersonal Psychotherapyc. Cognitive Behavioral Therapy (CBT)d. Eye Movement Desensitization and Reprocessing (EMDR)ANSWER: The correct answer is c. This is the most studied psychotherapeutic modality for PTSD
and has been found to be an effective treatment. Protocols typically offer the traditional cognitive andbehavioral approach and techniques. Many also include exposure therapy, which utilizes repeated anddetailed imaging of the traumatic experience in a safe setting. The goal is to have the person face theexperience and gain control of the responses and reactions to the trauma.
Although hypnosis may serve as an adjunctive treatment, it is not well-studied in patients with PTSD
and has not proven to be efficacious as a primary treatment. Interpersonal psychotherapy as a timelimited therapy may have some usefulness in PTSD, but is not the most well-studied psychotherapy forthe treatment of this disorder. This modality focuses on conditions (such as depression) caused by grief(loss), role disputes, role transitions, and interpersonal deficits.
There are small studies demonstrating the efficacy of eye movement desensitization and reprocessing(EMDR) for the treatment of PTSD; however, this is not the most well-studied psychotherapeutic intervention for this disorder. This therapy combines elements of cognitive behavioral therapy, exposure
therapy, and eye movements in order to stimulate the brain’s information processing centers. Further
study is needed in order to clearly identify the effective subcomponents of this therapy (ie, to determine
whether eye movements are necessary for the efficacy of this therapy).

10

REFERENCES
1. Schuster MA, Stein BD, Jaycox LH, et al. A national survey of stress reactions after the
September 11, 2001, terrorist attacks. N Engl J Med. 2001:345;1507-1512.
2. Pfefferbaum M, Nixon SJ, Tivis RD, et al. A television exposure in children after aterrorist incident. Psychiatry. 2001:64;202-211.
3. Ahern J, Galea S, Resnick H, et al. Television images and psychological symptoms after
the September 11 terrorist attacks. Psychiatry. 2002:65;289-300.
4. Bisson JI, Jenkins PL, Alexander J, et al. Randomised controlled trial of psychologicaldebriefing for victims of acute burn trauma. Br J Psychiatry. 1997:171;78-81.
5. Carlier IV, Voerman AE, Gersons BP. The influence of occupational debriefing on posttraumatic stress symptomatology in traumatized police officers. Br J Med Psychol.
2000:73;87-98.
6. Conlon L, Fahy TJ, Conroy R. PTSD in ambulant RTA victims: a randomized controlled
trial of debriefing. J Psychsom Res. 1999:46;37-44.
7. Mayou RA, Ehlers A, Hobbs M. Psychological debriefing for road traffic accident
victims: three year follow-up of a randomised controlled trial. Br J Psychiatry. 2000:176;
589-593.
8. Harvey AG, Bryant RA, Tarrier N. Cognitive behaviour therapy for posttraumatic stressdisorder. Clin Psychol Rev. 2003:23;501-522.
9. Charney DS. Psychobiological mechanisms of resilience and vulnerability: implications
for successful adaptation to extreme stress. Am J Psychiatry. 2004:161;195-216.
10.Calhoun LG, Tedeschi RG. Early posttraumatic interventions: facilitating possibilities for
growth. In: Violanti JM, Douglas P, Dunning C, eds. Posttraumatic Stress Intervention:
Challenges, Issues, and Perspectives. Springfield, Ill: Charles C. Thomas Publications Ltd;
2000:135-152.

SUGGESTED READING
1. Ursano RJ, Fullerton CS, Norwood AE, eds. Terrorism and Disaster: Individual andCommunity Responses to Extraordinary Events. London: Cambridge University Press; 2003.
2. Ursano RJ, Norwood AE, eds. Trauma and Disaster Responses and Management.
Washington, DC: American Psychiatric Publishing, Inc.; 2003.
3. National Center for PTSD web site. Available at: http://www.ncptsd.org. Accessed
December 17, 2004.

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NOTES

12

NOTES

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NOTES

14

EVALUATION FORMTERRORISM AND DISASTER: WHAT CLINICIANS NEED TO KNOW
Psychiatric Sequelae in a Survivor of 9/11
Participant Information
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Practice setting: ❏ Hospital/In-patient ❏ Outpatient/Clinic ❏ Other

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Rush University Medical Center
Office of Continuing Medical Education
600 South Paulina Street, Suite 433 AAF
Chicago, Illinois 60612
Fax: (312) 942-2000

Nancy L. Reid, LCSWRush University Medical Center
Utilization Management Department
1653 West Congress Parkway, Room 207 Kidston
Chicago, Illinois 60612
Social Workers, please include your Illinois License #_____________________________________________

Case Study Evaluation
Please rate this case study according to the following scale: 1=Very Poor 2=Poor 3=Fair 4=Good 5=Very Good 6=Excellent
1. Accredited CME activities must be “free of commercial bias for or against any product.” In this regard,
how would you rate this activity? If you perceived any bias, please provide specific comments below.

1 2 3 4 5 6oooooo__________________________________________________________________________

oooooo2. How well did the case study satisfy your purpose for reading it?

oooooo

3. To what extent were the stated objectives of the case study achieved?

oooooo4. In general, was the case study well organized and presented?
5. To what extent has this CME activity improved your preparedness to recognize and care for victims of aterrorism attack or other public health disaster?
6. What was your overall rating of this case study?

ooooooooooooo No

7. I would recommend this case study to a colleague.

o Yes

8. Based upon your review of this case, what specific action(s) could you take to enhance disaster
preparedness in your workplace?

Please estimate the probability
that you will act on this item
(0-100% where 100% = certainty)

A. ________________________________________________________________________

A. ___________

B. ________________________________________________________________________

B. ___________

C. ________________________________________________________________________

C. ___________o Please check this box if you prefer not to be contacted for follow-up about the impact of this activity on your clinical practice.
15

QUESTIONS FOR CONTINUINGEDUCATION CREDIT
1. Two high-risk groups who should limit exposure of media coverage oftraumatic events are:a. Elderly and teenagers
b. Directly exposed victims and childrenc. Homeless and directly exposed victims
d. Children and recently married couples
2. Which of the following is not recommended as an initial psychologicalintervention (“Psychological First Aid”)?
a. Providing educational pamphlets directing survivors to available mental
health resourcesb. Attending to basic needs, ensuring sufficient rest, normalizing
sleep-wake cycles
c. Employing mandatory one-time debriefings of those exposed to trauma in aneffort to reduce incidence of PTSD
d. Limiting exposure to media and facilitating reunions of families
3. Psychological debriefings in the aftermath of traumatic events:
a. Have demonstrated efficacy similar to that of cognitive behavioral therapy inthe prevention of PTSD.
b. Should be considered the first-line treatment to prevent PTSD.
c. Have been validated with randomized controlled studies to decrease theincidence of acute stress disorder.
d. May induce secondary traumatization in those who hear accounts of other’s
traumatic experiences.
4. In the psychopharmacologic treatment of PTSD, the medication classconsidered to be first line is:a. Tricyclic antidepressantsb. Benzodiazepines
c. Atypical antipsychotics
d. Monoamine oxidase inhibitors
e. Selective serotonin reuptake inhibitors
5. The following most accurately describe the symptom clusters required for the
diagnosis of PTSD:
a. Hyperarousal, avoidance, and re-experiencing
b. Depression, anxiety, and psychotic symptoms
b. Alcohol abuse, panic, and hypervigilancec. Re-experiencing, psychotic symptoms, and phobias
e. Somatization, depression, and avoidance

16

errorism
Tand isaster
D
Rush University Medical Center
faculty, in collaboration with facultyfrom the Uniformed Services
University of the Health Sciences(USUHS) authored a case series
to provide continuing medical
education (CME) for terrorism
preparedness and other publichealth emergencies.
A series of 14 case studies was developed to provide innovative learning
opportunities for health professionals
to problem-solve issues related toterrorism or other public healthemergencies. Due to the complicated and volatile nature of a terrorist
event, the case studies were designed
to expand outside the clinicianpatient interaction and involve:• deploying outside resources• notifying appropriate officials• coordinating a response team• dealing with media andconcerned public• initiating emergency/disaster plans
Each case provides the CME user
with decision-making challenges
within his or her discipline, alongwith scenarios that address broader
interdisciplinary issues. This interdisciplinary approach is particularly
important in disaster preparedness,when health professionals will likely
be called on to work outside their
day-to-day experiences.

WHAT
CLINICIANS
NEED TO
KNOW

Authored by experts in the field,
each self-paced case includes athorough case history, questions totest your knowledge, a resource listof additional readings and relevant
websites. One-hour CME andCEU credit is available for eachcase, following the successful completion of the CME questions
included with each case. The CME
and CEU credit is available free ofcharge through March 2007.

INTERDISCIPLINARY
The interdisciplinary cases address
basic medical management,general
disaster planning, communicatingwith the media and concerned
public, and psychosocial casemanagement.
• Inhalational Anthrax• Pulmonary Toxicants• SARS• Smallpox• Viral Encephalitis

The cases in the series include:
MEDICINE
The medicine cases address recognitionof the agent, diagnosis, treatment, andmedical case management.
• Pneumonic Plague• Radiation Attack• Sarin• Smallpox• Staphylococcal Enterotoxin B• Viral Hemorrhagic Fevers
PSYCHIATRY
The psychiatry cases address issuesof disaster psychiatry.
• Emergency Mental Health
After a Suicide Bombing• Psychiatric Sequelae in a
Survivor of 9/11
• Psychosocial Managementof a Radiation Attack

For more information or to order
your free copy of any of the casesin this series, please contact:
Office of Continuing
Medical Education
Rush University Medical Center
Suite 433 AAF
Chicago, Illinois 60612
Telephone: (312) 942-7119
Facsimile: (312) 942-2000
E-mail: cme_info@rush.edu