Nightmares. Insomnia. Anxiety. Startle responses. Although it may seem that the country is moving on from last September's terrorist attacks, emotional stress symptoms such as these may not be evident for some time, and experts say health care providers may be faced with a second wave of patients showing emotional trauma reactions in coming months, or as the anniversary date of the attacks approaches.

But CME on emotional trauma can be a tough sell. “We did a videoconference on bioterror in October,” says Scott Waters, training and development consultant for videoconferencing at Kaiser Permanente in California, “and one on emotional trauma in November. The one on bioterror did much better. I'm not sure why — except it was very clinical, versus trauma, which is an emotional issue, and a little more nebulous.”

William M. Glazer, MD, executive producer and moderator of PsychLINK, an interactive forum for psychiatric CME distributed via satellite broadcast and other formats, and an associate clinical professor of psychiatry at Harvard Medical School, puts it this way: “There's still a terrible stigma in this country against mental illness, and clearly there is a subgroup of doctors who want nothing to do with patients with psychological symptoms. The only thing I can say is, ‘There are no such patients.’” (PsychLINK is produced by Interactive Medical Networks, which is owned by Primedia Inc., the company that also owns this magazine.)

Emotional Expertise

Trauma experts say even psychological professionals may need help coping with traumatized patients. “While a few psychiatrists may be knowledgeable about this, a lot aren't,” says Frederick J. Stoddard, MD, clinical professor of psychiatry at Harvard Medical School and past president of the Massachusetts Psychiatric Society. “And while the general level of understanding of psychological trauma is probably higher than it has been in the past, there are many who have little or no experience with it.”

Providers need more awareness of how traumatic stress may appear in their offices, and how to distinguish it from other conditions. “Primary care providers in particular will probably hear more about difficulty sleeping or other physical symptoms than about stress per se. And they need to ask about exposure to trauma, or they may never make the connection,” Glazer says. They also need to know when to refer to a psychiatric professional, for diagnostic help or for treatment.

Psychiatrists and psychologists who have dealt with community violence, childhood trauma, or who have worked with refugees may offer good insights. At the American Psychiatric Association conference and other meetings throughout the fall, those with experience from events like the Oklahoma City bombing, the parking garage bombing of the World Trade Center in 1993, and the recent attacks in New York and Washington were valuable session faculty.

Make It Real and Relevant

To persuade clinicians that emotional trauma may be relevant to their practice, Glazer suggests emphasizing the physiological basis for traumatic reactions. “Go heavy on the biological underpinnings,” he says. “Primary care providers can relate to that better. Show them that these symptoms have a biological basis — not every patient develops PTSD [post-traumatic stress syndrome] following a traumatic event. Showing them the physical basis can help them realize this is not something the patient is making up.”

He also recommends using videotapes of real patients, along with expert commentary: “Figure out how to present the human side of this condition — providing a videotape example of a person who's really been through it can be immensely helpful. Present it in a way that makes it something that could happen to them.”

Caring for Caregivers

In the wake of a large-scale event such as the terrorist attacks or natural disasters, there's also the issue of taking care of the caretakers, who are exposed in both their personal and professional lives.

“At our meeting in October, shortly after the September 11 attacks, we asked our members to help us put together special sessions to deal with the attacks,” says Kathleen Debenham, director of the department of CME for the American Psychiatric Association in Washington, D.C. “We found there was a very great need for interaction. And where most CME is about direct patient care, we found that a lot of these sessions were about providers taking care of providers, and providers needing help from each other.” The psychiatrists wanted sessions on community disaster response, and on how disaster affects those already chronically mentally ill.

Workshops, discussions, and roundtables, where many points of view can be expressed, seem particularly effective for these topics.

“We used a moderated roundtable discussion in our videoconference on trauma,” says Scott Waters. “We allow the physicians to phone in with their questions.”

Keep Hope Alive

Since many clinicians shy away from emotional issues precisely because they seem hopeless, it's also important to provide information on effective treatments — including some that are just common sense.

“We also need to understand normal response,” says Stoddard. “USA Today reported at one point that 70 percent of people in the U.S. were having insomnia in the first three weeks after the attacks,” says Stoddard. “Do we need to say that all those people are sick? I don't think so. But they may benefit, as I think we all do, from being able to talk.”

Emotional Trauma Resources

• The American Psychiatric Association Web site features a section, “Coping with Terrorism,” which includes resources, books, and other useful links. www.psych.org

• The National Institute of Mental Health site features “Helpful Information Following the Recent Terrorist Acts,” including information on post-traumatic stress disorder, depression, and anxiety disorders, and a special fact sheet on helping children and adolescents cope with violence and disasters. www.nimh.nih.gov

• The National Center for Post-Traumatic Stress Disorder offers information on “Managing the Traumatic Stress of Terrorism.” www.ncptsd.org