When I was young, we had a neighbor named Frank. A proud father of 5 and a trusted employee at the local mill, Frank lived an apparently peaceful and happy life together with his wife, Kay. Frank had a secret, however.
During World War II, Frank had participated in the invasion of Normandy, incurring shrapnel wounds and earning a Purple Heart in the process. After he returned to his hometown, life went on pretty much as before, with one significant exception. Every time a thunderstorm hit, Frank would go up into his attic, where he thought no one could hear him, and scream in terror at the top of his lungs. For as long as the storm lasted, he was back on the beaches of Normandy experiencing enemy fire. Then, when the storm subsided, he would descend the stairs and try to carry on as if nothing unusual had happened. However, the lingering impact was clear to those who knew and loved him. This went on for 50 years, and Frank never disclosed any of this to his primary care physicians. Frank was a proud man.
Kay did what she thought she could to help--largely to assist Frank in his cover-up of the toll that his experiences in the war had taken. He seemed fine between these episodes--nervous perhaps, but a good father and husband. While "combat fatigue" was known to exist, it was considered exotic, temporary, and self-limited. How could something that had happened so long ago continue to be so powerful? Certainly, guys like Frank did not consider this to be something that could be treated, as with "real" medical conditions like diabetes or high blood pressure. The stigma and mystery surrounding treatment of mental illness were profound then. Frank eventually passed away with both his pride and his secret intact. While that was his choice, it was not easy to watch from the sidelines.
Unfortunately, the problems Frank faced are not uncommon. Given the prevalence of terrorism, war, and natural disasters, identification and treatment of acute and chronic stress disorders will likely be an increasingly important goal for emergency health care providers. This issue of Psychiatric Issues in Emergency Care Settings reviews acute stress disorder (ASD) and posttraumatic stress disorder (PTSD). Dr Douglas Bremner and colleagues Negar Fani and Benjamin Hampstead provide a succinct review of these conditions and some of the medications that have been used to treat them. As the authors point out, there remains ample need for both basic and clinical research pertaining to the pathophysiology and treatment of ASD and PTSD.
The authors also point to the controversy surrounding psychological interventions in the acute aftermath of disaster. Emergency clinicians should be made aware that "debriefing" techniques have been linked with worse long-term outcomes and should educate themselves about the pros and cons if they will be administering psychological first aid after natural or man-made disasters.
The same authors provide clinical cases designed to elucidate the overlap between cognitive deficits seen in both PTSD and traumatic brain injury. Finally, in his Commentary, Dr Peter Buckley provides a helpful review of the epidemiology, assessment, and management of stress-related disorders. It is our hope that the information provided here will be directly useful to clinicians faced with diagnosing and treating stress disorders in the emergency setting.
Glenn Currier, MD, MPH
Director, Center for Biodefense and Disaster Preparedness
Department of Emergency Medicine
University of Rochester Medical Center
Rochester, NY
