eMedicine Specialties > Psychiatry > Emergency

Acute Treatment of Disaster Survivors

Author: Roy H Lubit, MD, PhD, Assistant Clinical Professor, Mount Sinai School of Medicine; Clinical Faculty, Department of Child Psychiatry, New York University School of Medicine; Private Practice
Contributor Information and Disclosures

Updated: Aug 28, 2008

Introduction

Disaster victims and those who love them are vulnerable to considerable emotional turmoil and a variety of symptoms following a traumatic event and the loss of loved ones. This article discusses common reactions to traumatic events and to the loss of loved ones. This article also explores when to seek professional help, ways that loved ones and friends can help victims and their families, and what professionals can do in these situations. In addition, specific assistance for children who have experienced emotional trauma or loss is discussed.

All people experience traumatic events in their lives. All people lose loved ones, 1 in 4 women experience rape or attempted rape during their lifetime, and 1 million children a year are abused or neglected. In 2000, one quarter of a million Americans were raped or sexually assaulted, three quarters of a million were robbed, and half a million were assaulted. Millions of children are bullied in school, 7% of men and 22% of women are assaulted by an intimate partner, and 3 million people a year are involved in car accidents. Most Americans were shocked by the loss of thousands of lives in the terrorist attack on the World Trade Center.

Psychiatric trauma

Freud defined trauma as the experience of having the ego rendered helpless by overstimulation. Winnicot said trauma was pathogenic for children because it catastrophically destroyed the child's illusion of omnipotence and the illusion that his parents would protect him. Trauma establishes a new possibility for the child of what can happen in the world and a preoccupation with danger and vulnerability.

In 1996, Van Der Kolk wrote that posttraumatic stress disorder (PTSD) involves the combination of a conditioned fear response to trauma-related stimuli, altered neurobiological processes leading to increased arousal, and altered cognitive schemata and social apprehension.

Horowitz said that trauma occurs when an individual is faced with an overwhelming and negative experience that is incongruent within existing schema. The individual repeatedly recollects the event in an attempt to integrate it and to accommodate existing cognitive schema with the new information. Meanwhile, numbness and withdrawal arise in an attempt to cope with the pain of memories. In 1993, Lifton discussed how trauma could transform the structure of the self.

Emotional response to disaster 

• Impact phase: During the first few days, individuals often feel stunned. In the first week, disbelief, numbness, fear, and possibly confusion to the point of disorganization occur.
• Crisis phase: After the initial impact has been absorbed, individuals can experience a number of feelings.
  • Individuals may alternate between denial and intrusive symptoms with hyperarousal.
  • Persons may experience somatic symptoms (eg, fatigue, dizziness, headaches, nausea) as well as anger, irritability, apathy, and social withdrawal. Individuals may be angry with caregivers who fail to solve problems or who are unable to respond in a fully organized way in the chaos of the crisis.
• Resolution phase: Grief, guilt, and depression are often prominent during the first year as individuals continue to cope with their losses.
• Reconstruction phase: During this phase, reappraisal, assignment of meaning, and the integration of the event into a new self-concept occur.

Potential outcomes of traumatic events

Traumatic events can lead to a wide variety of emotional reactions. The treating clinician must understand that underneath the individual's reaction is an attempt to cope with the traumatic event. The first 6 symptoms are particularly common. Most individuals have some symptoms following a significant traumatic event. A minority have sufficient symptoms to fulfill the diagnostic criteria for acute stress disorder (ASD) or PTSD.

• Relatively common symptoms following traumatic events
  • Emotional reactions - Shock, daze, grief, anxiety, guilt, anger, numbness, helplessness, shame, emptiness, decreased ability to feel pleasure/interest/love; children may regress
  • Cognitive reactions - Nightmares, poor concentration, unwanted memories of the disaster, self-blame, confusion, disorientation, indecisiveness, worry
  • Physical reactions - Difficulty sleeping, exaggerated startle response, tension, fatigue, irritability, aches and pains, tachycardia, nausea, change in appetite, change in libido
  • Interpersonal reactions - Distrust, conflict, withdrawal, work problems, school problems, irritability, decreased intimacy, domineering demeanor, feeling rejected or abandoned; children may become clingy or oppositional
• More significant symptoms that call for professional consultation
  • Severe persistent problematic symptoms - Marked depression (eg, hopelessness, feeling worthless, overwhelmed with worry), marked hyperarousal (eg, panic attacks, rage, extreme irritability, intense agitation), extreme numbness, inability to control emotions even when important to do so, persistent problems in work or school, significant problems in self-care
  • Exacerbation or reoccurrence of preexisting psychiatric problems
  • Dissociative symptoms (eg, depersonalization, derealization, fugue, amnesia)
  • Intrusive reexperiencing - Terrifying memories, persistent nightmares, flashbacks
  • Acute stress disorder
  • PTSD (occurs in 10-30% of individuals who are highly exposed to the traumatic event)
  • Substance abuse
  • Aggression
  • In children, aggression, risk taking, sexual acting out

Acute stress disorder

ASD is a diagnosable Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) axis I disorder that includes a number of significant symptoms and often leads to PTSD. The main differences between ASD and PTSD are duration (ASD lasts only briefly) and the presence of several dissociative symptoms in ASD.

• In ASD, a person has been exposed to a traumatic event in which both of the following occurred:
  • Person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury or that involved a threat to the physical integrity of oneself or others.
  • The person's response involved intense fear, helplessness, or horror.
• Either while experiencing or after experiencing the distressing event, the individual exhibits 3 or more of the following dissociative symptoms:
  • Subjective sense of numbness, detachment, or absence of emotional responsiveness
  • Reduction in awareness of his or her surroundings (being in a daze)
  • Derealization
  • Depersonalization
  • Dissociative amnesia
• The traumatic event is persistently reexperienced in at least 1 of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience. Distress is observed on exposure to reminders of the traumatic event.
• The individual displays marked avoidance of stimuli that arouse recollections of the trauma.
• Marked symptoms of anxiety or increased arousal (eg, difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness) are observed.
• The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.
• The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.
• Signs and symptoms of ASD are as follows:
  • The individual experienced intense fear, helplessness, or horror in response to exposure to a serious traumatic event that caused or threatened serious harm of injury or violation of bodily integrity. Children may experience disorganized or agitated behavior.
  • The traumatic event is reexperienced in 1 or more of the following ways:
    • Distressing recurrent and intrusive recollections of the event (In young children, repetitive play of themes or aspects of the traumatic event may occur.)
    • Recurrent distressing dreams (In children, their dreams are frightening, but they may not have recognizable content.)
    • Acting or feeling as if the traumatic event was recurring
    • Intense psychological distress at exposure to cues that symbolize or resemble an aspect of the traumatic event
    • Physiological reactivity on exposure to cues that symbolize or resemble an aspect of the traumatic event
  • Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by 3 (or more) of the following:
    • Efforts to avoid thoughts, feelings, or conversations associated with the trauma
    • Efforts to avoid activities, places, or people that arouse recollections of the trauma
    • Inability to recall an important aspect of the trauma
    • Markedly diminished interest or participation in significant activities
    • Feeling of detachment or estrangement from others
    • Restricted range of affect (eg, unable to have loving feelings)
    • Sense of a foreshortened future (eg, does not expect to have a career, marriage, children, or a normal life span)
  • Persistent symptoms of increased arousal (not present before the trauma), as indicated by 2 (or more) of the following:
    • Difficulty falling or staying asleep
    • Irritability or outbursts of anger
    • Difficulty concentrating
    • Hypervigilance
    • Exaggerated startle response
  • Symptoms of reexperiencing the trauma, avoidance, and persistent arousal last more than 1 month.
  • The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Risk factors for ASD and PTSD

• Persons who lost a loved one
• Individuals who experienced an injury
• Persons who witnessed horrendous images
• Persons who had dissociation at the time of the event
• Those who experience serious depressive symptoms within a week and lasting for a month or more
• Individuals with numbness, depersonalization, sense of reliving the trauma, and motor restlessness after the event
• Those with preexisting psychiatric problems
• Persons with prior trauma
• Loss of home or community
• Extended exposure to danger
• Toxic exposure
• Individuals with a lack of social supports or whose social supports were also traumatized and are unable to be adequately emotionally available

Signs the patient needs help

• Task-oriented activities are not being performed.
• Task-oriented activity is not goal-directed, organized, or effective.
• The survivor is overwhelmed by emotion most of the time.
• Emotions cannot be modulated when necessary.
• The survivor inappropriately blames himself or herself, and the self-blame generalizes to the entire self.
• The survivor is isolated and avoids the company of others.
• Thoughts or plans of suicide or homicide.

Symptoms of Grief

Stages of bereavement and grief

Persons who have lost someone close or who have had a permanent injury experience grief and bereavement. Observers of the tragedy who did not lose someone are not affected. These stages may occur in any order.

• Shocked disbelief
  • This stage lasts up to 2 weeks
  • Episodes of deep sighing, lack of strength and appetite, choking, and breathlessness may occur.
  • The individual may deny the death.
  • The individual may feel numb and cut off from the world.
• Awareness develops
  • Loss of vitality, physical symptoms of stress, and development of symptoms similar to those of the deceased are possible.
  • Emotional symptoms include outbursts of weeping; hallucinations; searching; pining; guilt; idealization; loneliness; and anger at doctors, other family members, the deceased, or God.
• Bargaining: Individual attempts to strike a deal, or bargain, with God to undo what occurred.
• Depression
  • Depression may occur about 6 months after the trauma.
  • Loss of interest in the individual's own life and the lives of others occurs.
  • The individual's life may seem to be without purpose.
  • Existing personality problems may worsen.
  • Social isolation is possible.
• Resolution
  • The individual now believes he or she can cope.
  • Resolution may take 1-2 years.
  • The individual can begin to enjoy life without feeling disloyal to the deceased.

Mental status

• Appearance: Individuals may be disheveled and unclean and show the effects of dehydration and failure to care for themselves.
• Affect/mood: The patient may appear sad, anxious, irritable, emotionally labile, apathetic, angry, or calm. Depressive illness occurs in 17-27% of survivors during the first year after a death.
• Thought content: The individual may feel helpless, be in a state of disbelief, be confused, have markedly impaired concentration, have lowered self esteem, and likely be driven to search for the deceased.
• Perceptions: At this time, the individual may have hallucinations (visual or auditory) that the deceased person is present. Flashbacks, feelings of unreality, numbness, and denial may occur.
• Judgment/insight: Confusion in combination with preoccupation with those they have lost may impair individuals' judgment and insight.
• Suicide: Suicidal thoughts occur in as many as 54% of survivors and may continue up to 6 months after the death.
• Homicide: Thoughts or plans of homicide.

Physical complaints from grief

• Loss of appetite
• Changes in weight
• Trouble going to sleep or staying asleep
• Fatigue
• Chest pain
• Headache
• Palpitations
• Hair loss
• Gastrointestinal distress

Complicated/traumatic grief

• Traumatic grief is an example of a complicated grief reaction that occurs following the traumatic death of someone close.
• Traumatic grief may occur when the death results from war, disasters, accidents, suicide, or homicide.
• In traumatic bereavement, the individual is preoccupied with images of the traumatic event, rather than of the person who is deceased as in normal bereavement. Moreover, the individual has difficulty passing through the mourning process and moving on with his or her life.
• The individual needs treatment for both trauma and grief. The individual also needs help in remembering an intact representation of the person who is deceased and not be filled with images of the person being killed. If no body is present following the death, placing a picture of the individual in nondegradable plastic in the coffin can be helpful.

Differential Diagnosis

Posttraumatic Stress Disorder

Exacerbation of preexisting mental condition

Brief psychotic episode

Substance abuse

Adjustment reaction

Anxiety Disorders

Depression (See Medscape's Depression Resource Center.)

Dissociative Disorders

Basic Principles of Intervention After Emotional Trauma

• Reduce stress by all possible means.
  • Ensure that survivors have a safe environment.
  • Promote contact with loved ones and other sources of support (eg, religious organizations).
  • Support self-esteem. Help the individual to understand that their reaction to the trauma is a normal reaction to an abnormal situation, not a sign of weakness or psychopathology.
  • Help the person to focus on immediate needs, such as rest, food, shelter, social supports, or sense of community (some feel cut off and detached).
  • Promote coping mechanisms.
  • Help individuals to reframe any destructive cognitions, such as he or she acted terribly and is a terrible person or is weak for being so distraught, life is hopeless or worthless, or the world is totally unsafe.
  • Administer medication (eg, propranolol, alpha-agonists, benzodiazepines, nonactivating selective serotonin reuptake inhibitors [SSRIs]), if needed, to decrease arousal.
• Avoid increasing stress.
  • Avoid prompting discussion of issues that cannot be resolved.
  • Avoid abreaction in groups and the resulting contagion effect.
  • Respect defenses, and do not force reality on persons who cannot handle it yet.
  • Debriefing may be harmful.
• Share the experience with persons who want to talk about it, and avoid pressuring those who do not want to talk about it.
• Identify persons at high risk: Screen for physical causes of psychiatric problems (eg, dehydration, head trauma, infection, metabolic abnormality, toxins).
• Have faith in the normal healing processes.
• Promote support networks.

Patient Education

Helping adults who are grieving

Be available, and do not allow a grieving person to become isolated.

• Take action (eg, call, send a card, give hugs, help with practical matters).
• Be available after others get back to their own lives.
• Be a good listener, but do not give advice.
• Do not be afraid to talk about the loss.
• Talk about the person who died by name.
• Do not minimize the loss; avoid clichés and easy answers.
• Be patient with the bereaved; there are no shortcuts.
• Encourage the bereaved to care for themselves.
• Remember significant days and memories.
• Do not try to distract the bereaved from grief through forced cheerfulness.

Helping children who are grieving or traumatized

• Reassure children of their safety and the safety of their loved ones (as much as possible); tell them that such things are very rare, that people are there to take care of them, and that they will always be loved.
• Be emotionally available to children despite personal loss (or fears).
  • Give children more time than usual.
  • Encourage them to share their feelings, to talk at weekly family meetings, and to use drawings and puppets to express their feelings.
  • Let them know it is all right to talk about unpleasant feelings (including sadness and anger) and listen to them. (Sharing personal feelings of sadness with them is all right as well.)
• Check to see if children feel that they somehow caused the death or disaster or if they have other misunderstandings, and reassure them or correct the misunderstanding. Do not assume children are fine just because they are not saying anything.
• Understand that children probably know more than you think.
  • Ask what the child knows and what questions the child has.
  • Monitor and limit TV watching after a disaster lest it flood them or desensitize them to violence.
  • When they watch TV, watch it with them and discuss the events.
  • Share only the details they can deal with. Do not overload them with facts. Be honest.
• Encourage action, such as sending letters to victims, to keep them from feeling helpless.
• Understand that regression, fear, sleep problems, and anger toward remaining family members are common after a loss or trauma.
• Do not force children to go to the funeral if they do not want to, but help them create a ritual.
• Maintain as normal a schedule as possible.
• Eat balanced meals on time, drink fluids, sleep, relax, exercise, and avoid alcohol and caffeine.
• Get help if serious signs appear and last more than a couple of weeks.
  • Extended depression and loss of interest in activities and events
  • Inability to sleep, loss of appetite, or prolonged fear of being alone
  • Extended period of marked regression
  • Excessive imitation of the deceased or repeated statements about wanting to join the deceased
  • Withdrawal from friends
  • Serious drop in school performance or refusal to go to school
  • Persistent fears
  • Persistent irritability and being easily startled
  • Behavior problems
  • Physical complaints

Online resources

The following are useful Web sites for patient and family education:

• Duke University Health Services, Bereavement, Coping After a Traumatic Death
• The University of Iowa, Coping with Death, Grief, and Loss
• Helpguide.org, Coping with Grief and Loss: Guide to Grieving and Bereavement
• Connect for Kids, Help with Healing, on the Web
• For other patient education resources, visit eMedicine's Mental Health and Behavior Center. Also, see eMedicine's patient education articles Grief and Bereavement and Post-traumatic Stress Disorder (PTSD).

Care of Rescue Workers

Rescue workers may develop the same symptoms, including those of PTSD, as victims. As many as 1 in 3 rescue workers develop PTSD.

• Encourage staying in touch with family and friends.
• Be sure that rescue workers get rest, food, exercise, and relaxation.
• Encourage understanding of survival guilt.
• Explain how chaos and confusion inevitably leads to upset between individuals and groups that are participating in the rescue effort.
• Develop a buddy system, and encourage support of coworkers.
• Encourage workers to defuse after troubling incidents and following each shift.
• After the rescue operation, workers should take a few days to decompress and attend a debriefing.
• Do not overwhelm children with talk of experiences as a rescue worker; ask about their activities.

Therapeutic Interventions

Debriefing^1,2,3,4,5

Critical incident stress debriefing is one of the most common interventions thought of following a traumatic event. (Caution: Critical incident stress debriefing has not been shown to reduce the later development of depression, anxiety, or PTSD, and it may harm individuals by increasing their arousal and overwhelming their defenses.)

Classically, critical incident stress debriefing has 7 stages, including (1) introduction (purpose of the session), (2) describing the traumatic event, (3) appraisal of the event, (4) exploring the participants' emotional reactions during and after the event, (5) discussion of the normal nature of symptoms after traumatic events, (6) outlining ways of dealing with further consequences of the event, and (7) discussion of the session and practical conclusions.

Research does not support the effectiveness of critical stress debriefing in the prevention of PTSD, depression, or anxiety, and, if performed poorly, debriefing can even be harmful. It can increase arousal and overwhelm the survivor's defenses. Operational debriefing, which focuses on normalizing emotional response, informing of services available, and providing general support, is safer. In engaging in a 1- to 2-session intervention following a traumatic event, a number of guidelines help avoid harm and maximize the chance of benefit for some individuals.

• Provide trained individuals to perform the intervention.
• Avoid ventilating feelings at high levels; this can lead to contagion and flooding, rather than calming and helping cope with feelings.
• Do not pressure individuals to talk about things they do not want to; respect their defenses, including denial.
• Critical tasks to cover include the following:
  • Psychoeducation to help patients see that the feelings they are having are not a sign of weakness or mental illness but a normal reaction to a very disturbing situation.
  • Discuss ways of improving coping skills, including getting adequate rest, recreation, food, and fluids.
  • Avoid excessive exposure to media coverage of the traumatic incident.
  • Discuss common cognitive distortions, such as survivor guilt and fears that the world is totally unsafe.
  • Explain the signs and symptoms indicating that someone should get professional help.

Cognitive behavior therapy^{6,7,8,9,10,11}

While 70% of those receiving supportive therapy or no therapy develop PTSD, cognitive behavior therapy (CBT) used shortly after a trauma has been shown to reduce the rate of PTSD development to 10-20%. Moreover, patients who received CBT and CBT/hypnosis reported less re-experiencing and less avoidance symptoms than patients who received supportive counseling. Individuals are aided by the following:

• Seeing that people are concerned about them
• Learning about the range of normal responses to trauma and hearing that their emotional reactions are normal responses to an abnormal event (rather than a sign of weakness or pathology)
• Being reminded to take care of concrete needs (eg, food, fluids, rest)
• Cognitive restructuring (changing destructive schema, such as "having fun is a betrayal of the injured," "the world is totally unsafe," "I am responsible for the disaster," or "life is without meaning," to more constructive ones)
• Learning relaxation techniques
• Undergoing exposure to avoided situations either via guided imagery and imagination or in vivo

Resources permitting, current data suggest that a 4- to 5-session course of CBT should be offered to those at high risk for developing PTSD. CBT should be performed by someone trained in the technique. Severe, relatively common destructive cognitions may arise after a traumatic event and need to be addressed.

On the left side of the Table below are malignant schemata that an individual may have after a traumatic event. On the right side are more constructive schemata that a clinician can suggest for consideration by the individual.

Cognitive Interventions

Open table in new window

Brief school intervention

Intervention lasts 1-2 hours and uses 4 therapists per class. A teacher is present, and parents are informed.

• Introduce the therapists, and ask students to guess why they have come to the classroom.
• Explain that therapists have come to talk about the disaster, and encourage students to share what they know for 10-30 minutes; validate correct information, and be calm.
• Have children draw while therapists circulate, and ask students to tell them about their drawings.
• Reassure students that their symptoms are normal and will ease; that people have different symptoms; that disasters are rare; and that teachers, parents, and counselors are available to help them.
• Having students do a second drawing in which they depict a future and a positive state of the world is very important. The first picture is likely to focus on the trauma, their loss, and its effect on them. They now need to do a second picture that shows healing and restoration of normal life.
• Thank the students and the teachers, and redirect their attention to learning.

Medication

The use of medications to decrease arousal and insomnia may have a long-term impact.  

Propranolol (as well as clonidine) may limit hyperarousal initially and as a longer term problem.¹²  For extreme agitation, aggression, psychosis, or dissociation an atypical neuroleptic or mood stabilizer may be needed.  

Diphenhydramine and other medications may be helpful for sleep. Benzodiazepines may limit hyperarousal and foster sleep, which are helpful in the initial stages. Continuous administration, however, may interfere with grieving and readaptation because they interfere with learning.¹³ Longer-acting agents are particularly beneficial when medication is administered at the emergency site and follow-up treatment is in short supply.

SSRIs can be helpful in dealing with the core symptoms including anxiety, depression, and avoidance and have a central role in the longer term treatment. 

Comorbid conditions such as attention deficit hyperactivity disorder (ADHD) should be targeted. Reduction in even one disabling symptom, such as insomnia or hyperarousal, may have a powerful impact on the individual's ability to recompensate.

Beta-adrenergic blocking agents

These agents inhibit chronotropic, inotropic, and vasodilatory responses to beta-adrenergic stimulation.

Propranolol (Inderal)

May be useful for the treatment of hyperarousal.

Selective serotonin reuptake inhibitors (SSRIs)

First-line agent for managing anxiety, depression, avoidance behavior, and intrusive recollections. Antidepressant agents chemically unrelated to tricyclic, tetracyclic, or other available antidepressants. SSRIs inhibit CNS neuronal uptake of serotonin (5HT). SSRIs may also have a weak effect on norepinephrine and dopamine neuronal reuptake.

Citalopram (Celexa) or escitalopram (Lexapro)

Enhances serotonin activity due to selective reuptake inhibition at the neuronal membrane. Least-activating of the SSRIs; is particularly useful in ASD. Incidence of adverse effects (especially sexual) is less than with other SSRIs. Escitalopram is the S-enantiomer of citalopram. May have faster onset of depression relief (1-2 wk) compared with other antidepressants.

Benzodiazepines

These agents bind to a specific benzodiazepine receptor on the GABA receptor complex, thereby increasing GABA affinity for its receptor. They also increase the frequency of chlorine channel opening in response to GABA binding. GABA receptors are chlorine channels that mediate postsynaptic inhibition, resulting in postsynaptic neuron hyperpolarization. The final result is a sedative-hypnotic and anxiolytic effect.

Clonazepam (Klonopin)

Long-acting benzodiazepine that increases the presynaptic GABA inhibition and reduces the monosynaptic and polysynaptic reflexes.

Lorazepam (Ativan)

Sedative-hypnotic with short onset of effects and relatively long half-life. By increasing the action of GABA, which is a major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including limbic and reticular formation. Important to monitor patient's blood pressure after administering dose and to adjust dose as necessary.

Alpha-adrenergic agonists

Centrally acting alpha2-adrenergic agonists, clonidine and guanfacine have been used to treat children with ADHD. Inhibition of norepinephrine release in the brain may be its mechanism of action.

Clonidine (Catapres)

Frequently given to children but not approved by FDA for any psychiatric uses in children. Available in tabs or transdermal skin patches. Affects the alpha1-, alpha2-, and alpha3-adrenergic receptors.

Guanfacine (Tenex)

Action similar to clonidine but has a longer half-life and less sedation. More selective alpha-agonist. Not recommended for children <12 y. Effects alpha2-adrenergic receptors only.

Antihistamines, sedating

Older, sedating antihistamines (eg, diphenhydramine) are often prescribed as sedatives because of their CNS depressive properties.

Diphenhydramine (Benadryl)

Available as nonprescription preparations containing 25 mg of diphenhydramine in liquid, chewable, and capsule formulations.

Keywords

acute stress disorder, ASD, acute stress reaction, posttraumatic stress disorder, PTSD, symptoms of grief, stages of bereavement, psychiatric trauma, emotional response to disaster

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