Background

We know that a person who has gone through a traumatic experience is at higher risk for developing a mental health concern, like post-traumatic stress disorder. The risk of developing an anxiety or depressive disorder is higher than for developing PTSD. Studies have shown that 80-90% of individuals who have experienced a traumatic event will go back to their normal functioning over time. The amount of time can vary, based on their functioning before the event, whether the trauma was human-caused or a natural disaster and whether harm was intended. Some can go back to their normal functioning after 2-4 weeks and, for others, it can take much longer. Some people are even able to make meaning or create purpose from a trauma they experienced.

The basic premise of Psychological First Aid is to use a non-pathologizing stance with the assumption of adaption and not of disease development. The goal is for crisis support to help survivors move to the adaptive side. There are 8 basic core actions that focus first on providing safety and comfort followed by coping skills and resources. The foundation is making sure people who have gone through a trauma have access to social support.

Reg Flags

There are certain “red flags” to be aware of as concerns that something else might be going on and further assessment and intervention could be helpful. These include social isolation and withdrawal, extreme avoidance of thinking/talking about the event, feeling numb or not feeling at all, intrusive images/flashbacks, nightmares and poor sleep, anger or violence, and excessive use of alcohol and drugs.

Core Action Steps:

1. Contact and Engagement

In the immediate aftermath of a trauma, people first need their basic needs met. Introducing yourself can help a person feel better connected.

2. Safety and Comfort

After letting someone know you are there to help, it can be nice to offer basic comforts like water and food, a blanket, etc. If there are children in the group, toys and plushies can be additional comforts.

3. Stabilization

People are understandably dysregulated after a trauma. There are some simple things that you can encourage someone to do to help him feel calmer and more regulated – deep breathing exercises, stretching and body movement. It can also help to validate how they are feeling and provide a quiet space.

4. Information Gathering

It is important to keep in mind that you don’t need to know details of a traumatic experience in order to help reduce symptoms and provide comfort and coping skills. It is better to not prompt for details. This is especially true for children. Some children play out their feelings about a traumatic experience and others use play as distraction to not think about the trauma. Research has shown that talking repeatedly about a traumatic experience does not necessarily help with recovery and can actually cause unintended consequences.

5. Practical Assistance

The next step is to help with basic needs including shelter, meals, etc.

6. Connection with Social Supports

PFA focuses on establishing social supports based on a homogenous experience. With mass disasters, not everyone experiences the same thing.  It is important to limit exposure to details of a traumatic event for those who hadn’t experienced those details to begin with. So groups should be put together keeping these factors in mind. It can be helpful to train someone within a particular culture on the PFA principles so that they can overlap their understanding of cultural factors and the PFA response to trauma.

7. Information on Coping

Basic CBT principles like reframing thoughts, focusing on doing enjoyable activities that bring happiness, and mindfulness practices can be useful coping strategies. Again one does not need to know the details of the trauma in order to be able to provide coping strategies.

8. Linkage with Collaborative Services

It is important to be aware of local resources, like SmartCare BHCS here in San Diego,  for when someone could benefit from further assessment or intervention after a trauma.

Further Resources

If interested in learning more, the National Center of Trauma and Stress Network offers a 6 hour course on PFA:

https://www.nctsn.org/resources/psychological-first-aid-pfa-online

There are also wonderful resources about school based PFA on their website:

https://www.nctsn.org/resources/psychological-first-aid-schools

Here is another resource on PFA for healthcare workers:

https://www.ptsd.va.gov/professional/treat/type/SFA/docs/SFA_HCW_Manual_508.pdf

AUTHOR:

Charmi Patel Rao MD, DFAACAP

Co-Medical Director, Vista Hill Foundation

Health Science Clinical Professor, UCSD Department of Psychiatry

President, San Diego Academy of Child and Adolescent Psychiatry

Most people who experience a traumatic event, however, do not develop PTSD, so it is important to be aware of the risk factors for someone to develop PTSD after a traumatizing event. There is a genetic susceptibility to developing PTSD. PTSD shares genetic variance with other anxiety disorders like panic disorder and generalized anxiety disorder. PTSD also shares genetic variance with substance abuse disorders. People who experience an interpersonal assault are more likely to develop PTSD compared to people who experience a non-assault based trauma. PTSD is commonly seen in patients with military experience but can also be seen as a result of sexual assault, physical abuse, and domestic violence, in children and adults. PTSD is more commonly seen in situations where someone is exposed to a repeated trauma rather than a single trauma.

People with smaller hippocampi (the part of the limbic system that plays a role in both memory and inhibitory control) are more likely to develop PTSD after a traumatic event.  The hippocampus is an area of the brain with high numbers of gluco-corticoid receptors, glucocorticoids being part of the physiologic response to stress.  In PTSD, there is an over-activation of the Hypothalamic-Pituitary-Adrenal (HPA) axis which results in an increase in the fight or flight response. This contributes to the symptoms that are seen in PTSD, including hyper-vigilance, avoidance of triggers, nightmares, intrusive flashbacks, experiencing distress with reminders of the trauma, sleep disturbance, irritability, anger outbursts, and exaggerated startle response. Children experiencing PTSD will display it in their play and might also exhibit aggression, regression in their development and hyperactivity and impulsivity.

Patients with PTSD are at higher risk for suicidal ideation and suicide. They are at higher risk for other mental health concerns like other anxiety disorders and major depression. They are at higher risk for substance abuse problems, in large part in an effort to “self-medicate”.

The mainstay of treatment for PTSD is therapy (individual and group) and medication if needed. Trauma focused CBT is an evidence-based therapy practice used for PTSD. Additionally some patients find EMDR (eye movement desensitization and reprocessing) helpful for their symptoms. The SSRIs and other antidepressants can be useful for the depressive and anxiety symptoms of PTSD. Additionally medications like Prazosin can be used adjunctively for nightmares and sleep disturbance. Benzodiazepines are not particularly helpful for PTSD and therefore are not generally a recommended treatment.

It is our hope that this primer on PTSD is helpful for primary care providers to be able to screen for PTSD appropriately and refer for a more thorough assessment as needed.