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Fink! Still at large: the anxiety of terrorism. (Opinion).

Some older patients remember the skittish days of "duck and cover." But the anxieties created by Sept. 11 and the war with Iraq are leading some of our younger patients to panic. Is there a difference in your treatment strategy based on the age of your patients?

Start With Daily Routine

Since Sept. 11,2001, America has been under sustained stress--the anthrax scare, the sniper episode, the Columbia shuttle accident, and the Iraq war. I'm not sure if there has been a similar period in the United States when so many converging events continued to put people under stress.

As a result of this, there are several categories of populations. One group rarely, if ever, suffers from clinical anxiety. The other group is at risk of exacerbating clinical anxiety they had prior to these events. These people either had clinical anxiety in remission that was rekindled by these events or they currently had clinical anxiety that was made worse by these events. For this particular group, it is ideal for psychiatrists and primary care physicians to work together to differentiate bona fide physical events from psychiatric events.

There is no single strategy to treat these patients. I think of it as a synergy of various interventions that start from a basic daily routine. Maintaining a daily routine is extremely important. A secondary intervention, such as a combination of psychotherapy and psychopharmacology, may be required to complement daily routines. For children, it is important that they have opportunities not just to be told about these events but to express their concerns, fears, and anxieties. They should be able to engage in Purposeful, constructive activities that reassure their safety and allow them to express things they would like to do or things we can do for them that can make them feel safer. This should apply across the entire life cycle.

Finally, TV viewing should be limited in these times of stress, particularly the repetition of tragic, dramatic, and violent acts. It's better to read about these events than to watch them on television.

Eliot Sorel, M.D.


Manage Preparation Behaviors

Terrorism has been present throughout the world for centuries and is, in fact, endemic in some communities in the United States. When drug dealers threaten a neighborhood to prevent reporting, terrorism is present. What is new is that terrorism is now threatening our nation as a whole, and it is from foreign rather than domestic groups. Terrorism can cause distress symptoms in those who are healthy, and it can also cause changes in behavior that affect health and mental health.

For patients already in treatment and not directly exposed, it is important to listen for their particular experience of terrorism. For some, it will be increased fear. It may be a reminder of a past event or overprotectiveness of their children. For many, it will be a feeling of a pause or distraction from what they want to be doing. For others, it may be avoidance.

An important clinical issue is how to respond to questions about real needs to prepare. Not questions about duct tape, but those about communication plans or meeting spots for family members. Do you treat these as a symptom? I think not. They are realistic and warrant realistic responses. If undue concern persists, it can be addressed as, "You seem particularly concerned today even though you have done all that can be done at this point. Any ideas why?" Similarly, what of the patient who has not mentioned the topic? One might say, "I notice that you have never mentioned all the present concerns about terrorism and preparation. I have wondered about that."

This area of treatment management of preparation behaviors is an important and overlooked aspect of ongoing treatments. This is an area in which psychiatrists can be leaders, since those in community organizations may face similar avoidance, overconcern, or preoccupation.

Robert J. Ursano, M.D.

Bethesda, Md.

Age Has Some Bearing

In terms of any traumatic disorder, treatment is related to how the traumatic event threatens a patient's life. I think age is a crude marker for different patient reactions to these events in that it will have some bearing on why an event is traumatic and stressful. Children who lose their parents are devastated because they don't know who will support them and love them, while an older person may feel isolated when contacts are severed by such events. The capacity to process information also varies with age, so children at different stages have different levels of appreciation of a traumatic event.

We have good treatments for dear-cut posttraumatic stress disorder (PTSD) in adults, but we don't know much about medications for children with the disorder. We know even less about how to deal with acute trauma in adults or children.

When dealing with the public, we can emphasize what is an adaptive reaction to traumatic events or terrorist threats so that normal responses are not pathologized.

Julia Frank, M.D.


Dr. Fink replies: I do not believe that the age of the patient is an important variable when it comes to developing anxiety about the war in Iraq or the threat of worldwide terrorism. Several factors might cause an increase in anxiety in people who are terrified by the possibility of terrorism that might put them or their loved ones in danger.

Whenever we become worried about what might happen, we must realize that the concomitant fantasy is created by the person having the thought. For example, if a person says, "I'm so terrified that my mother's apartment building will be blown up," we might conjecture that he has a strong unconscious desire for his mother to be dead.

Thus, one of the important detriments for an increase in anxiety is the patient's proneness to anxiety and his / her neurotic fears and usual prevailing level of anxiety before Sept. 11 and the current crisis. While mild anxiety is relatively normal, it is a source of concern when it becomes pervasive, exaggerated, excessive, and seems to overwhelm the patient. All of us are concerned about the international situation and the escalation of the war with concomitant terrorist acts on our own shores. We are talking about it more, and concerned about spouses and children who are called up to fight. These are normal reactions to any armed conflict.

When the anxiety takes over or when intermittent and repeated panic attacks take over, it is no longer within normal limits. In the same way we separate pathologic grief from the normal mourning process after the death of a loved one.

We anticipate that 6 months after a death, the person will begin to go back to life as usual, and, within a year, the day-to-day life of the individual should be the way it was before the death. As we all know, post-Sept. 11 some people have not flown and will not travel. Such people expect something bad to happen to them. The statistical reality of random occurrences seems to be incomprehensible to someone who sees life through negatively distorted glasses.

Another possible route to excessive anxiety in troubled times occurs in those with histories of early life trauma or previous traumatic events who develop PTSD symptoms because of a recurrence of the terror they once felt when the trauma occurred. In such patients, the onset of the PTSD symptoms appears to be natural. They say things like, "Isn't everyone upset, concerned, affected by the collapse of the twin towers?" Use of such affect-neutral terms denies the nightmares, flashbacks, and increased dysfunction that such patients experience. These people tend to withdraw, become paranoid and pessimistic, and expect disaster to occur around every corner.

One patient, who had been injured in an explosion at work 5 years before Sept. 11, became increasingly agitated and filled with dread over his expectation that he was "chosen" to be destroyed and the terrorists would be coming after him. Another class of people who may react with a higher level of anxiety is those who have lost someone in the twin towers or the Pentagon. In such cases, the unresolved grief or the persistent idea that "it should have been me, not him" makes it more difficult to return to a more calm state.

I believe the question should not be "What do we say to these patients," but rather "How do we explore the causes of the anxiety?" Suppose a patient comes to you with the complaint of anxiety and you discover that he or she has been wanting to see someone for his/her anxiety for 5 years but now is able to use the "cover" of Sept. 11 to justify entering therapy.

Exploring causality--you could call it taking an in-depth history--is the sine qua non of good therapy The therapist needs to get a grasp of what initiated the anxiety, what life events were going on, and how the person's upbringing may contribute to the onset of anxiety. When that is done, he or she can then set up a treatment plan, decide with the patient on the goals he or she wishes to achieve, and determine if combined psychotherapy and psychopharmacology should be instituted.

"How are Tom Ridge and the alerts and alarms affecting the overall communal angst?" is the other side of this question. All my friends are tolerant and philosophical about the increased inconvenience, delays, and precautions, most of which, in my opinion, are just an opportunity for low-paid employees to be sadistic. It is not just in airports; it is all government buildings, parking lots, etc., and I acknowledge that some of it is appropriate and justified, but I, for one, often find it more annoying and useless than helpful. Our home towns, after all, are not comparable to Tel Aviv or Kuwait City. The other day I observed a man delivering a lunch to a meeting standing in line and needing to "prove" that he had a legitimate reason to come into the building. Finally in frustration, he screamed, "I'm not going to blow up the building. I have a job to do!" To which the guards--all three of them--responded, "We're only following regulations."

Rightly or wrongly some get angry; others are calm and philosophical. Mixed into the reactions that people have to alerts and warnings and repeated TV images of airplanes flying into buildings is some anxiety that may grow under the external communal angst in which we are all immersed.


Join Dr. Paul J. Fink on a rambling tour of the contemporary scene.

Patient Suicide: One of the most painful experiences for a therapist is figuring out how to proceed when a patient commits suicide.

For Discussion: Have you ever experienced this? How did you cope with the tragedy? How did that incident change the way in which you approach your practice?

Deadline: May 16, 2003.

Share your thoughts with Dr. Fink by e-mailing him at or by writing to CLINICAL PSYCHIATRY NEWS, 12230 Wilkins Ave., Rockville, MD 20852.

DR. PAUL J. FINK is a psychiatrist and consultant in Bala Cynwyd, Pa., and professor of psychiatry at Temple University in Philadelphia.
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Author:Fink, Paul J.; Sorel, Eliot; Ursano, Robert J.; Frank, Julia
Publication:Clinical Psychiatry News
Date:May 1, 2003
Previous Article:Letters.
Next Article:Bioterrorism: are we ready?

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