United in Courage & Grief
It will be years before the full psychological and physiological impact on those who have witnessed these events--either in person or second-hand through television images--will be known. There has never been an event quite like this one, which has touched so many.
On this page you will find general information on the most common normal reactions--physiological and psychological following a tragedy and signs and symptoms indicating it is time to seek treatment. Also included is a section on Coping After Crisis. There is more information regarding the most common acute reactions, Acute Traumatic Response, Acute Grief Response, and Acute Stress Disorder. Finally there is a section that explores Complicated Mourning or Unresolved Grief paying attention to the most common long-term sequalae--Major Depression and Post Traumatic Stress Disorder--including ways of recognizing these disorders. An extensive bibliography of articles used to write this page as well as additional articles of interest found on the Internet is provided.
During the acute phase of a reaction to a traumatic event, the presenting signs and symptoms can mimic many medical emergencies. If there is any doubt as to whether the symptoms you might be feeling in the aftermath of the tragedy are physical or psychological seek professional treatment. The information in this section is provided for educational purposes and cannot substitute for a professional evaluation by a physician or mental health practitioner.
There is a realistic concern by those in the medical and mental health communities that it will be years before the full psychological and physiological impact on the millions who witnessed these events will be known.
Those who grieve
find comfort in weeping and in arousing their sorrow
until the body is too tired to bear the inner emotions
Prior to this event we have been a nation that denies and ignores grief. For the first time in a very long time, we have been faced with an event of such proportions that we, as a nation, are no longer able to ignore the pervasive grief response--too many people were killed or injured in the attacks, too many were watching as the events unfolded, too many people are impacted. We are a nation united in grief.
One way of helping in the aftermath of this tragedy is to normalize grief through education. If people understand that what they and others are feeling and experiencing is a normal response is to such an abnormal event--it will help improve the recovery process.
Common Normal Responses Following
There are a number of common reactions that occur following disasters. Most people who directly experience a major trauma have severe problems in the immediate aftermath. Thousands, if not millions, experienced this tragedy by watching it unfold on television. The feelings and reactions that one experiences in the aftermath of this event are likely to be the same ones as many other people are experiencing. These common responses include:
People may responds to differently to the same traumatic event. Everyone feels stress and responds to stress in different ways. Some may not appear to have been affected. Not everyone has a reaction to a disaster. Some people have delayed reactions that do not show up for days, to weeks or even months later. Others never have a reaction at all. Everyone has their own coping mechanisms. We should take care not to compare our reaction with the reactions of others, or judge their reactions or even lack of reactions. One helpful way of aiding in recovery is by education on what is a "normal response to an abnormal event" and by becoming more aware of the changes undertaken and the emotions experienced since the trauma.
In general, these feelings and reactions should disappear within four to six weeks or less as life continues and attention becomes focused on other things. Many people then feel much better within three months after the event, but others recover more slowly, and some do not recover enough without help. However, when a death is considered "traumatic" e.g. a death that is sudden or unanticipated, violent or destructive, random and/or preventable or when their are multiple deaths, this predisposes the grief process to be at a higher risk for complicated mourning. Complicated Mourning is a delayed or incomplete adaptation to loss or failure in the process of mourning. These types of losses are the ones that often require counseling and professional help from someone knowledgeable about traumatic losses to help the grieving cope with the loss. (More on Complicated Mourning later in this page)
Major Depression and Post Traumatic Stress Disorder
are potential sequalae of complicated mourning, that can also
result from being a secondary victim of the incident--from watching the events unfold on television. The diagnosis of depression or PTSD is only made after experiencing symptoms for several weeks to months after the initial event, we will just be starting to see people who will be diagnosed with these disorders in the aftermath of this tragedy.
Long ago we were taught to ignore grief rather than enter into it. Simply to hang on mindlessly until it is over. But this old perception cannot bear the weight of profound experience. Neat categories cannot accommodate the muddle of mature emotion. To get through grief, we let go rather than hand on, watching for the inner counselor who will guide us, ever mindful of the process that will slowly, patiently lead us where we need to go.
The response to a traumatic event should be viewed as a normal response to an abnormal event. The magnitude of the events that occurred on September 11, 2001, the traumatic nature of the death and the destruction, the suddenness and senselessness of the attack make it more likely that people who witnessed the events will have some response--physical (Physiological), emotional, cognitive or behavioral to this abnormal event. Depending on the perception and experiences of the event, people may experience one of the following responses or a combination of the following normal responses to this event:
Note: Not every response is evidenced by every person.
|** Difficulty breathing
** Shock symptoms
** Chest pains
* Rapid heart beat
* Elevated blood pressure
* Gastrointestinal upset
Muscle tension & pains
Cold, clammy skin
Grinding of teeth
** Require IMMEDIATE Medical Evaluation
* May need Medical Evaluation
Emotional Reactions: Acute Traumatic Response
Intense feelings of aloneness
Feelings of Guilt
Cognitive Reactions: Acute Traumatic Response
Difficulty in making a decision
A short attention span
Thoughts of losing control
Perseverative thoughts of the traumatic event
Questioning religious values
Feeling as though the world no longer "makes sense"
Difficulty remembering the event
Behavioral Reactions: Acute Traumatic Response
Changes in speech patterns
|Reluctance to abandon property
Inability to sit still
Exaggerated startle response
Increased alcohol consumption
Inability to attach importance to anything but this event
Refusing to talk
Feeling that one should not cry
Acute grief is a definite syndrome characterized by the following psychological and somatic symptoms:
1. Sensations of somatic distress that occur in waves lasting for 20 minutes to an hour characterized by:
Physical Symptoms: Acute Grief Response
Trouble initiating or maintaining sleep
Chest heaviness or pain
Shortness of breath
Tightness in the throat
Abdominal, stomach pain
Change in appetite – increased or decreased
Emotional Symptoms: Acute Grief Response
Social Symptoms: Acute Grief Response
Lack of initiative
|Lack of interest
Lowered self esteem
Behavioral Symptoms: Acute Grief Response
Sense of Unreality
|Feelings of unreality
Feelings of emptiness
Dreams of the deceased
Searching for the deceased
Sense the loved one's presence
Hallucinations of the deceased, sensing their presence (visual or auditory)
|Assuming mannerisms or traits of the loved one
Needing to retell the story of the loved one's death
Preoccupied with one's own death
Avoiding talking about loss so others won't feel uncomfortable
Common presenting signs and symptoms of Acute Stress Disorder include: generalized anxiety and hyperarousal, avoidance of situations or stimuli that elicit memories of the trauma, and persistent, intrusive recollections of the event via flashbacks, dreams, or recurrent thoughts or visual images. The symptom of dissociation, which is a perceived detachment of the mind from the emotional state or even the body, is a critical feature for the diagnosis. Dissociation also is characterized by a sense of the world as a dreamlike or unreal place, it may be accompanied by poor memory of the specific events, which in most severe form is known as dissociative amnesia.
Acute Stress Disorder is a diagnosis made by a mental health professional. There are specific diagnostic criteria which must be met before this diagnosis can be made.
A. The person has been exposed to a traumatic event in which both of the following were present:If the symptoms and behavioral disturbances of the Acute Stress Disorder persist for more than 1 month, and if these features are associated with functional impairment or significant distress to the sufferer, the diagnosis changes to Post Traumatic Stress Disorder.
1. the person experienced, witnessed, or was confronted with an event or events that involved actual or
threatened death or serious injury, or a threat to the physical integrity of self or others
2. the person's response involved intense fear, helplessness, or horror
B. Either while experiencing or after experiencing the distressing event, the individual has three (or more)
of the following dissociative symptoms:
1. a subjective sense of numbing, detachment, or absence of emotional responsiveness
2. a reduction in awareness of his or her surroundings (e.g., "being in a daze")
5. dissociative amnesia (i.e., inability to recall an important aspect of the trauma)
C. The traumatic event is persistently re-experienced in at least one of the following ways: recurrent images,
thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on
exposure to reminders of the traumatic event.
D. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, people,
conversations, activities, places).
E. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration,
hyper vigilance, exaggerated startle response, motor restlessness).
F. 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
G. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4
weeks of the traumatic event.
H. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
medication) or a general medical condition, is not better accounted for by Brief Psychotic Disorder, and
is not merely an exacerbation of a preexisting Axis I or Axis II disorder.
Nature provides the exact dosage for dealing with the constant strikes of pain we experience. Usually there is no real need for outside medication. Your body in its perfect wisdom gauges your requirements and numbs you accordingly. You will feel cold, but your bodymind will not allow more pain than you can tolerate. To disrupt the natural safeguards may only postpone the initial pain in your mourning process.
There is a realistic concern that due to the extreme traumatic nature of the events of September 11, 2001, that over time we will see a great potential for long-term psychological sequalae--for those directly involved in the events, as victims or as providers, and for those who were witnesses to the events; this is yet another byproduct of the terrorist acts.
Tragic events can be much more difficult to recover from quickly, or even at all. Much depends on the nature of the tragedy experienced or witnessed e.g. unnecessary or accidental death, rape, loss through natural disasters, death during war-time, unnecessary acts of violence. A death is considered to be "traumatic" it if is sudden or unanticipated, violent or destructive, random and/or preventable, when their are multiple deaths, or if there is no body available for viewing or burial; these factors predispose the grief process to be at a higher risk for complicated mourning. These types of losses are the ones that often require counseling and professional help from someone knowledgeable about traumatic losses to help the grieving cope with the loss and prevent Complicated Mourning or Unresolved Grief.
Complicated Mourning is a delayed or incomplete adaptation to loss or failure in the process of mourning. Unresolved Grief is a halting of the grief process, which becomes chronic unless treated.
11 Issues Inherent in Sudden,
Unanticipated Death that lead to Complicated Mourning
These issues explain the reasons why sudden, unanticipated deaths lead to complicated mourning.
1. The capacity to cope is diminished as the shock effects of the death overwhelm the ego at the same timeSymptoms and Behavior of Unresolved Grief/Complicated Mourning
new stressors are added e.g. heightened personal threat and vulnerability
2. The assumptive world is violently shattered without warning and the violated assumptions e.g. the world
as orderly, predictable, and meaningful, the self as invulnerable—cause intense reactions of fear, anxiety,
vulnerability and loss of control.
3. The loss does not make sense, and cannot be understood or absorbed.
4. There is no change to say good-bye and finished unfinished business with the deceased, which cause
problems due to the lack of closure.
5. Symptoms of acute grief and of physical and emotional shock persist for a prolonged period of time.
6. The mourner obsessively reconstructs events in an effort both to comprehend the death and to prepare
for it in retrospect.
7. The mourner experiences a profound loss of security and confidence in the world which affects all areas
of life and increases many kinds of anxiety.
8. The loss cuts across experiences in the relationship and tends to highlight what was happening at the
time of the death, often causing these last-minute situations to be out of proportion with the rest of the
relationship and predisposing to problems with realistic recollection and guilt.
9. The death tends to leave mourners with relatively more intense emotional reactions, such as greater
anger, ambivalence, guild, helplessness, death anxiety, vulnerability, confusion, disorganization, and
obsession with the deceased along with strong needs to make meaning out of the death and to determine
blame and affix responsibility for it.
10. The death tends to be followed by a number of major secondary losses because of the consequences of
lack of anticipation e.g. loss of home because of lack of financial planning.
11. The death can provoke post traumatic stress responses e.g. repeated intrusion of traumatic memories,
numbing of general responsiveness, increased physiological arousal.
Recognizing these symptoms in yourself or in others is the first step toward recovery and finding appropriate treatment. The symptoms to watch out for:
The symptoms of depression include feeling sad and blue, not enjoying activities once found pleasurable, having difficulty doing things that used to be easy to do, restlessness, fatigue, changes in sleep, appetite or weight, inability to make decisions, feelings of worthlessness, and thoughts of death or suicide.
Common Symptoms of Depression
Signs That May Be Associated
with Depression in Children and Adolescents
The diagnostic criteria and key defining features of major depression in children and adolescents are the same as they are for adults. However, recognition and diagnosis of the disorder may be more difficult in the youth for several reasons. The way symptoms are expressed varies with the developmental stage of the child. Children and adolescents may have difficulty in identifying and describing their internal emotions or moods; they may act out and be irritable with others, because they are unable to communicate how they are feeling; this behavior is often interpreted as misbehavior or disobedience.
If the symptoms and behavioral disturbances of the Acute Stress Disorder (see above) persist for more than 1 month, and if these features are associated with functional impairment or significant distress to the sufferer, the diagnosis is changed to Post Traumatic Stress Disorder. Post Traumatic Stress Disorder is further defined in DSM-IV as having three distinct subforms: acute (< 3 months’ duration), chronic (> 3 months’ duration), and delayed onset (symptoms began at least 6 months after exposure to the trauma).
Post Traumatic Stress Disorder is characterized by the following:
Among those who may experience or have experienced PTSD are military troops who served in Vietnam and the Gulf Wars; rescue workers involved in the aftermath of disasters like the Oklahoma City bombing; survivors of accidents, rape, physical and sexual abuse, and other crimes; immigrants fleeing violence in their countries; survivors of the 1994 California earthquake, the 1997 South Dakota floods, and hurricanes Hugo and Andrew; and people who witness traumatic events, including watching the events on television. Family members of victims also can develop the disorder. PTSD can occur in people of any age, including children and adolescents. The highest rates of post traumatic stress disorder are found among women who are victims of crime, especially rape, as well as among torture and concentration camp survivors. Overall, among those exposed to extreme trauma, about 9 percent develop post traumatic stress disorder. An estimated 5.2 million American adults (ages 18 to 54) or approximately 3.6 percent of people in this age group in a given year, have PTSD.
Symptoms of this disorder usually occur within the first three months after the trauma, although there can be a delay of months or even years before symptoms appear. Length of symptoms vary from person to person. Approximately half of the people affected by PTSD tend to recover within 3 to 6 months. However many people report their symptoms lasting for longer than 12 months after the trauma. For many the disorder may persist for years, dominating a person's life.
For a more information on Post Traumatic Stress Disorder or to take a quick Screening Quiz for Post Traumatic Stress Disorder start with the information from the National Institute of Mental Health, Post Traumatic Stress Disorder (PTSD), A Real Illness at http://www.nimh.nih.gov/anxiety/ptsdri1.cfm
If there is any doubt as to whether the symptoms you might be feeling in the aftermath of the tragedy are physical or psychological seek professional treatment. The information in this section is provided for educational purposes and cannot substitute for a professional evaluation by a physician or mental health practitioner. It is not designed to be a substitute for informed medical advice or training. Do not use this information to diagnose or treat a mental health problem without consulting a qualified health or mental health care provider.
Department of Health and Human Services http://www.mentalhealth.org/cmhs/EmergencyServices/after.htm
Mental Health Aspects of Terrorism - http://www.mentalhealth.org/cmhs/EmergencyServices/terrorism.htm
National Depressive and Manic-Depressive Association. Coping with a Traumatic Event. http://www.ndmda.org/Posttraumatic_Stress.htm
National Institute for Mental Health. Response to Terrorist Acts Against America
National Institute of Mental Health. The Invisible Disease: Depression http://www.nimh.nih.gov/publicat/invisible.cfm
National Institute of Mental Health. The Effects of Depression in the Workplace http://www.nimh.nih.gov/publicat/workplace.cfm
National Institute of Mental Health. Reliving Trauma - PTSD http://www.nimh.nih.gov/publicat/reliving.cfm
National Center for Post Traumatic Stress Disorder. Disaster Mental Health: Dealing with the Aftereffects of Terrorism http://www.ncptsd.org/disaster.html
Mental Health Report of the Surgeon General, Chapter 4 - Anxiety Disorders. http://www.surgeongeneral.gov/library/mentalhealth/chapter4/sec2.html
Screening for Mental Health, Inc. When Depression and Other Illnesses Co-Exist http://www.mentalhealthscreening.org/brochure/index.htm
|United in Courage and Grief
- Introduction Page
Why does my heart feel so bad?
What is Different about this Event?
The Importance of Telling the Story
Wake-up Call for the World
Health Concerns for Witnesses
|Blessings, Lyrics, Poems & Quotes
Remembering Our Children
Helping Children to Cope with Tragedy
Ways of Coping then Helping
Creatively Expressing Grief