A ‘FRESH’ way to manage trauma
Ameliorating emotional trauma is key to avoiding long-term functional impairment. Consider a FRESH approach that involves families/friends, reassurance/retelling, education, addressing substance abuse, sleeplessness, and suicide risk, and taking a careful history.
Family and friends can be valuable to treatment but clinicians often overlook their importance. Overwhelmed or traumatized family members who are not counseled about the patient’s symptoms can undermine treatment by dismissing symptoms and withdrawing support. Involve them by emphasizing their supportive role. Alert them to normal and problematic trauma responses and stress disorder symptoms.
Reassurance/retelling. Explain that emotional pain is normal but usually fades with time. Consider effects of survivor guilt: Encourage the patient to retell the experience, but do not demand this. Help patients identify and correct thought distortions that foster avoidance. Though controversial, 1 critical incident debriefing and cognitive-behavioral therapy can help the patient recount the trauma and ultimately restore a sense of self, enjoyment of life, and expectations of safety, control, and trust. 2
Educate patients about normal variable stress responses. Warn traumatized patients against engaging in high-risk behaviors, through which they may try to deny their vulnerability, fear, and loss of control. Explain symptoms and risk factors for depression, posttraumatic stress disorder (PTSD), and other anxiety disorders.
Substance abuse, sleeplessness, and suicide are possible outcomes of trauma. Prescribe a non-narcotic sleep-promoting medication if insomnia is problematic. Alternately, consider a selective serotonin or serotonin-norepinephrine reuptake inhibitor 3,4 at normal or low starting dosages if presenting symptoms suggest an emerging anxiety or mood disorder or PTSD. Watch for signs of survivor guilt—such as an unrealistic sense of responsibility for the trauma—that can lead to depression with suicide risk after a significant loss.
History. Watch for factors that predict PTSD and comorbid disorders (trauma severity and chronicity, involvement of interpersonal violence, fear of death). Previous trauma, PTSD, depression, anxiety, personality disorder, childhood victimization, substance abuse, and poor social support increase the risk. Avoidance, numbing, dissociation, high guilt, and low acknowledged anger correlate with increased PTSD risk. Follow up with patients who exhibit these risk factors every 1 to 2 weeks with medication and/or psychotherapy.
1. Cloak NL, Edwards P. Psychological first aid: Emergency care for terrorism and disaster survivors. Current Psychiatry 2004;3(5):12-23.
2. Bisson JI. Early interventions following traumatic events. Psychiatr Ann 2003;1:37-44.
3. Davidson JR, Rothbaum BO, van der Kolk BA, et al. Multicenter, double-blind comparison of sertraline and placebo in the treatment of posttraumatic stress disorder. Arch Gen Psychiatry 2001;58:485-92.
4. Marshall RD, Beebe KL, Oldham M, et al. Efficacy and safety of paroxetine treatment for chronic PTSD: a fixed-dose, placebo-controlled study. Am J Psychiatry 2001;158:1982-8.
Dr. Sobel is a clinical instructor, University of California-San Diego School of Medicine, and consulting psychiatrist, University of San Diego Counseling Center.