Jewish World Review June 12, 2002 / 2 Tamuz 5762

Knowing what to expect

By Dr. Abraham Twerski, M.D. | After undergoing oral surgery, the doctor told me that within a few days I would feel some of the material he placed around the sutures break loose and that the stitches would fall out. Had he not alerted me to this, I might have feared that my jaw was becoming unhinged. He also told me how I could reach him promptly if I had any concern about what and how I felt. This reassurance prevented much anxiety.

Anxiety trends to feed on itself, and may progress to panic. Unfamiliar and unanticipated feelings can provoke anxiety. Knowing what is normal and what to expect can greatly diminish the sense of foreboding and anxiety.

Any severe trauma may have long-term effects. This may result in a condition known as Post Traumatic Stress Disorder (PTSD). What constitutes severe trauma is highly variable. Numerous factors are operative in the reaction to trauma. What is a minor trauma for one person may be a severe trauma for another.

Similarly, what is a "normal" reaction to trauma, or a threat, can vary greatly. Previous experiences can color our reactions. For example, a cough due to a common cold generally does not elicit anxiety. However, if a person had surgery for lung cancer ten years earlier, the cough of a common cold may precipitate the fear that the cancer has recurred. There is no single "normal" reaction to trauma. What is abnormal for one person may be normal for another.

Let us not think that that national trauma was born on September 11. Unfortunately, we have experienced many traumatic events, collectively and individually, publicly and privately. We have much information about psychological disorders pursuant to combat in wars. We have tragically learned a great deal from Holocaust survivors. There are studies of victims and survivors of natural disasters: floods, tornadoes, earthquakes, volcanic eruptions. We have data from victims and witnesses of violence.

From these we can extrapolate principles and techniques that can help, us cope with our current challenges.

While the media and the government are preoccupied with the current crisis, it is also important to discuss the effects of personal trauma. These, too, may have long-term effects, requiring both coping skills and ways to attain relief.

Freezing in your tracks. The immediate reaction to trauma may be numbness due to shock. This has been referred to as "freezing" or "immobility" response. This is NOT character weakness. Rather, it is a normal, involuntary response in both humans and animals. You may have noticed, while driving along the interstate late at night that a deer caught in the bright headlights of an oncoming car may "freeze". If the freezing results in the animal or person becoming incapacitated, frozen "in his tracks" and unable to escape, then it is destructive. However, in some situations it ism protective, as it may save the victim from pain.

As the numbness wears off, there may be denial, described in Article 2, or anxiety of varying intensity. Even after one has achieved a state of calm, there may be a recurrence of anxiety at any time. Any form of stimuli may remind the person or trigger the return of anxiety. A sudden loud noise, an ambulance siren or even the ringing of the telephone when one is asleep may cause anxiety.

Stimuli which are in themselves innocent and harmless may nevertheless provoke anxiety. For example, someone who was at a particular point on the road when she heard the news of the World Trade Center attack may experience anxiety when she again reaches that point while traveling weeks or even months later. A friend of mine was in Jerusalem during the Gulf War of 1991. Whenever he heard the air raid siren he would move his wife and three young children into their sealed room and put on their gas masks. He had a wave of fear come over him every time he heard the siren. He told me that for six months after the end of the scud missile attacks, whenever he heard the beginnings of the wail of the Friday afternoon Jerusalem siren announcing the beginning of the Sabbath the wave of fear would overcome him and he would feel the anxiety in his chest. Even today, 11 years later, he still turns his head and looks up when he hears the sound of an ambulance siren, with a flash of memory --- could it be again?

Anything that was temporally or spatially associated with the traumatic event can trigger a return of the anxiety. Conscious awareness of this phenomenon may decrease the intensity of the anxiety.

Mood Swings. Another common reaction in the aftermath of trauma can be alterations in mood or even rapid mood swings. This does not mean that one is "bi-polar" or manic-depressive. Sleep may be erratic. There may be insomnia or nightmares.

Appetite may fall off.

Irritability. One may have moods of irritability and even explosive reactions. One man told me that two weeks after the World Trade Center disaster, he was testifying in court. When he felt his credibility was being questioned, he let loose with a barrage of invective at the lawyer, which was totally uncharacteristic of him. People who are usually courteous drivers may exhibit road rage.

Short Fuse. A person might become cantankerous or short-fused with family members, co-workers or employers. One may become argumentative, and interpersonal relationships may become strained. Or, one may withdraw from both family and friends. Work performance or school performance may suffer. One may lose interest in usual activities.

Can't Stop Talking About It. Some people will repeatedly talk about the traumatic episode, to the point that they may not talk about anything else. The wife or husband may say: "Enough already. It's getting on my nerves!", but the person may be unable to stop. There may be a preoccupation with one's health. A person may talk about death and dying.

It is important that we become aware that these changes may occur in ourselves or in those around us, as a reaction to a personal trauma. If we recognize these symptoms as "normal" reactions following severe trauma, we will not fear that we are "losing our minds". These changes will then not produce even more anxiety and will prevent a self-reinforcing vicious cycle.

A valuable coping device would be to consciously reflect on oneself and become more self aware. You might say to yourself and to those around you: "I am not quite feeling like my usual self. Please understand I am going through a difficult time right now." If those around us recognize these changes occurring in family members or in friends and know them to be reactions to trauma, they will likely be more empathic and will provide support rather than respond in anger.

If someone is experiencing anxiety long after the trauma it may give rise to physiologic symptoms such as headache, digestive problems and chest pain. A doctor should be consulted if these symptoms appear. One should not simply write them off as symptoms of anxiety. However, it is important for the public to be aware of these symptoms to anxiety in order to avoid panic.

People who were more personally adversely affected by terrorism may react more intensely than the symptoms of personal trauma described above. People who lost a relative or a friend in the World Trade Center attack, those who lost their jobs or those whose jobs are in jeopardy may have more severe symptoms. They should be aware of their vulnerability, and others should relate to them with greater empathy.


Psychological fallout in the shadow of terrorism
Self-esteem in the face of world terrorism

Abraham J. Twerski, M.D. is a psychiatrist and ordained rabbi. He is the founder of the Gateway Rehabilitation Center in Pittsburgh, a leading center for addiction treatment. An Associate Professor of Psychiatry at the University of Pittsburgh School of Medicine, he is a prolific author, with some 30 books to his credit. He has recently launched a new 12 step program for self esteem development Send your comments by clicking here.

© 2002, Abraham J. Twerski, M.D.