Mass shootings act as dramatic reminder of gun violence's traumatic 'ripple effect'

Charles R. Marmar, MD
Charles R. Marmar

Just 1 month after the tragedy in Las Vegas that left more than 50 dead and 500 injured, more than 25 people are dead in Sutherland, Tex., giving yet another stark reminder of the gun violence that seems increasingly endemic to the United States. According to CDC data, 93 deaths and more than 200 injuries related to guns occur every day in the U.S. Helping survivors cope with the possible PTSD associated with these incidents poses challenges for mental health professionals. Healio.com spoke with experts about helping survivors attempt to return to their lives after such a traumatic event, and how primary care physicians should consider approaching patients with symptoms of PTSD.

“Anyone that was exposed in Las Vegas really needs to be screened for traumatic stress symptoms, anxiety and other issues,” Steven J. Berkowitz, MD, director of the center for youth and family traumatic stress recovery at the University of Pennsylvania, told Healio.com. “The odds are pretty high that people are going to be symptomatic, and will benefit from some intervention or treatment. But, the problem is that if they’re not identified and they’re not treated, we know that it's one of those situations where the symptoms tend to get worse and people often become more dysfunctional. The other dilemma is that they may be able to cope for some time and then there’s a traumatic reminder – another shooting or horrific event. And then they become symptomatic, so it’s important to do ongoing monitoring of people who were exposed to the shooting in Las Vegas.”

PCPs’ approach to PTSD symptoms

An event as devastating and catastrophic as the Las Vegas shooting will create an ongoing conversation nationwide and the horrific imagery will continue to permeate the airwaves, according to Anthony Ng, MD, chief medical officer at Acadia Hospital and chief of the psychiatry service at Eastern Maine Medical Center.

“People are able to watch video of it, so a lot of people are seeing it and feeling it, and whether they were [in Vegas] or not, people are probably feeling some distress from it,” Ng told Healio.com. “Besides the people directly affected in Vegas, this has the potential to jar people with past trauma and make them relive their trauma from whatever. So, it’s important that physicians be on the look-out. Anytime there’s a big community stress event like this – hurricanes and especially things like this – they need to pay attention for their patients and see how they’re doing, especially if a physician suspects there’s some link to it.”

However, some experts noted that many primary care physicians are not necessarily equipped to handle patients who come in to the office with possible signs of PTSD.

“Typically not, unfortunately,” Berkowitz said. “I don’t think we can expect them to be equipped for everything, it’s just not fair. But they certainly can regularly identify those people and provide them with educational material about post-traumatic stress symptomatology. At the very least, they should have a network of providers who know how to manage this.”

Ng, who worked directly with family members of victims of the Sandy Hook Elementary School mass shooting in the days after the 2012 massacre, said he agrees that not all primary care physicians are well equipped to handle patients who present with signs of PTSD.

“There are a few who are, but I don’t think all of them are because to pick up some of the psychiatric distress, they may need to have the necessary tools, or people who have an awareness for the mental aspects of such an event,” he said. “Many of these primary care physicians have such a busy schedule they may not have a lot of room to really explore things. For instance, if a patient doesn’t bring it up, the physician may not notice the signs. It’s important that we educate families, bring it up with their family providers, but at the same time, I think PCPs need to be aware that such an issue may need to be confronted in their patients and that, even if they don’t know how to pick it up nor how to deal with it, they should identify resources that their practices can turn to.”

Diagnosing PTSD in primary care

Many of the victims who witnessed the Las Vegas shooting will be initially distressed and will likely recover within a few days to weeks, according to Charles R. Marmar, MD, chair of the department of psychiatry at NYU Langone Medical Center.

However, some of the families of those killed, those who experienced traumatic injuries, people that were present and could have easily been killed and the first responders are all at risk for developing a variety of post-traumatic psychopathology, he said. And, as Marmar noted, everyone affected should be carefully supported and monitored as time passes.

“Individuals who by 2 to 4 weeks, are having persistent symptoms of distress – which means sleep difficulties, daytime edginess, being on guard when there is no reason to be and being flooded by bad thoughts, images, memories and dreams – need a brief intervention of what we would initially recommend is a four- to six-session cognitive processing therapy, which helps individuals process the experience of the event, not become too phobic about it and restore their work and relationship functioning as soon as they are physically able to do so.”

However, Marmar noted that somewhere between one in five, and one in 10 individuals within that group will have persistent symptoms.

“The most important thing is that large at-risk group has to be followed and those that don’t recover by 2, 3 or 4 weeks, need a brief intervention,” he said. “And of those that get a brief intervention who don’t recover within another 3 to 4 weeks, they need more serious attention.”

Berkowitz and Marmar both recommended that physicians administer the 20-item self-report questionnaire PTSD Checklist for DSM-5 (PCL-5) if patients come in with concerns about possible PTSD symptoms.

“Patients can fill the questionnaire out while they’re in the waiting room, or while they're sitting in the exam room waiting for the physician to come in,” Berkowitz said. “It’s very straight forward and should give them [better information on the diagnosis].”

Additionally, Marmar said physicians should inquire about how well patients are sleeping after the incident, ask if the individual is able to concentrate and manage daily responsibilities, and if they are being flooded by bad images or memories.

“Officially you can’t make the diagnosis unless those symptoms persist for 4 weeks or longer, but if someone has symptoms at 2 to 3 weeks after the [traumatic event], and they are significant and interfere with their ability to work or function in family and relationship roles, you have to take care of them,” Marmar said.

Ripple effect of mass shootings

The long-reaching ramifications of an event like the mass shooting in Las Vegas are quite high for the communities directly involved, according to Berkowitz.

“There's a cascade effect when these things happen, and so it increases people’s stress level,” he said. “In a place like Vegas, there’s the potential to worry about the financial aspects in a possible drop in tourism. Individuals might not have post-traumatic stress symptoms, but they may have a lot of anxiety or stress-related problems.”

This shooting will ripple through the population, Marmar said.

“That does not mean that we are going to have mass psychiatric casualties and have large numbers of people with PTSD in the general population,” he said. “But what we will have rippling through America is increasing anxiety. Not nightmares, flashbacks and startled reactions, but more generalized worry [about safety].”

One of the tough things with an event like the shooting in Las Vegas is that people will constantly relive it, even if they were not physically at the concert, Ng noted.

“They’re so attracted to this event that they become a vicarious victim by listening to it and watching it,” he said.

Additionally, many individuals who were at the concert were not from Las Vegas and will be scattered throughout the country when they return home, Ng said.

“This is why we’re really encouraging folks to really pay attention anytime a mass event like this happens,” he said. “Given the nature of social media these days, rarely any of these events are localized. There’s going to be family assistance centers set up for people locally, and certainly Vegas is going to take the brunt of this and they’re still going to have many people from the Vegas area, but people still need to be mindful that folks may go back home after they [recover from injuries] or people may have just returned home after escaping injury. So, I think this is important that people keep an eye out for that. Because sometimes people are so focused on what happened in Vegas, someone may be affected when they go home and [people might not recognize why].”

Although initial reports appear to not include children among the victims, many children lost parents and will likely experience traumatic grief, Berkowitz said.

“Traumatic grief is a particularly complicated thing to treat as an individual is both dealing with grief and traumatic stress symptoms and interaction,” he said. “Not only will this effect children, but other family members are going to be dealing with this and being quite overwhelmed with the interplay of symptoms.”

Additionally, parents need to be aware of how any stress they exhibit can be translated to their children, Ng noted.

“Children are very intuitive,” he said. “If families are upset, over time children will pick up on that family member being upset. They may watch the events and get exposure to it, so it’s important that family members talk to their children. They may not put everything together, and that may be fine, but this is a large-scale event [and more information will continue to come out in the news].” – by Ryan McDonald

Disclosures: Berkowitz, Marmar and Ng report no relevant financial disclosures.

Charles R. Marmar, MD
Charles R. Marmar

Just 1 month after the tragedy in Las Vegas that left more than 50 dead and 500 injured, more than 25 people are dead in Sutherland, Tex., giving yet another stark reminder of the gun violence that seems increasingly endemic to the United States. According to CDC data, 93 deaths and more than 200 injuries related to guns occur every day in the U.S. Helping survivors cope with the possible PTSD associated with these incidents poses challenges for mental health professionals. Healio.com spoke with experts about helping survivors attempt to return to their lives after such a traumatic event, and how primary care physicians should consider approaching patients with symptoms of PTSD.

“Anyone that was exposed in Las Vegas really needs to be screened for traumatic stress symptoms, anxiety and other issues,” Steven J. Berkowitz, MD, director of the center for youth and family traumatic stress recovery at the University of Pennsylvania, told Healio.com. “The odds are pretty high that people are going to be symptomatic, and will benefit from some intervention or treatment. But, the problem is that if they’re not identified and they’re not treated, we know that it's one of those situations where the symptoms tend to get worse and people often become more dysfunctional. The other dilemma is that they may be able to cope for some time and then there’s a traumatic reminder – another shooting or horrific event. And then they become symptomatic, so it’s important to do ongoing monitoring of people who were exposed to the shooting in Las Vegas.”

PCPs’ approach to PTSD symptoms

An event as devastating and catastrophic as the Las Vegas shooting will create an ongoing conversation nationwide and the horrific imagery will continue to permeate the airwaves, according to Anthony Ng, MD, chief medical officer at Acadia Hospital and chief of the psychiatry service at Eastern Maine Medical Center.

“People are able to watch video of it, so a lot of people are seeing it and feeling it, and whether they were [in Vegas] or not, people are probably feeling some distress from it,” Ng told Healio.com. “Besides the people directly affected in Vegas, this has the potential to jar people with past trauma and make them relive their trauma from whatever. So, it’s important that physicians be on the look-out. Anytime there’s a big community stress event like this – hurricanes and especially things like this – they need to pay attention for their patients and see how they’re doing, especially if a physician suspects there’s some link to it.”

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However, some experts noted that many primary care physicians are not necessarily equipped to handle patients who come in to the office with possible signs of PTSD.

“Typically not, unfortunately,” Berkowitz said. “I don’t think we can expect them to be equipped for everything, it’s just not fair. But they certainly can regularly identify those people and provide them with educational material about post-traumatic stress symptomatology. At the very least, they should have a network of providers who know how to manage this.”

Ng, who worked directly with family members of victims of the Sandy Hook Elementary School mass shooting in the days after the 2012 massacre, said he agrees that not all primary care physicians are well equipped to handle patients who present with signs of PTSD.

“There are a few who are, but I don’t think all of them are because to pick up some of the psychiatric distress, they may need to have the necessary tools, or people who have an awareness for the mental aspects of such an event,” he said. “Many of these primary care physicians have such a busy schedule they may not have a lot of room to really explore things. For instance, if a patient doesn’t bring it up, the physician may not notice the signs. It’s important that we educate families, bring it up with their family providers, but at the same time, I think PCPs need to be aware that such an issue may need to be confronted in their patients and that, even if they don’t know how to pick it up nor how to deal with it, they should identify resources that their practices can turn to.”

Diagnosing PTSD in primary care

Many of the victims who witnessed the Las Vegas shooting will be initially distressed and will likely recover within a few days to weeks, according to Charles R. Marmar, MD, chair of the department of psychiatry at NYU Langone Medical Center.

However, some of the families of those killed, those who experienced traumatic injuries, people that were present and could have easily been killed and the first responders are all at risk for developing a variety of post-traumatic psychopathology, he said. And, as Marmar noted, everyone affected should be carefully supported and monitored as time passes.

“Individuals who by 2 to 4 weeks, are having persistent symptoms of distress – which means sleep difficulties, daytime edginess, being on guard when there is no reason to be and being flooded by bad thoughts, images, memories and dreams – need a brief intervention of what we would initially recommend is a four- to six-session cognitive processing therapy, which helps individuals process the experience of the event, not become too phobic about it and restore their work and relationship functioning as soon as they are physically able to do so.”

PAGE BREAK

However, Marmar noted that somewhere between one in five, and one in 10 individuals within that group will have persistent symptoms.

“The most important thing is that large at-risk group has to be followed and those that don’t recover by 2, 3 or 4 weeks, need a brief intervention,” he said. “And of those that get a brief intervention who don’t recover within another 3 to 4 weeks, they need more serious attention.”

Berkowitz and Marmar both recommended that physicians administer the 20-item self-report questionnaire PTSD Checklist for DSM-5 (PCL-5) if patients come in with concerns about possible PTSD symptoms.

“Patients can fill the questionnaire out while they’re in the waiting room, or while they're sitting in the exam room waiting for the physician to come in,” Berkowitz said. “It’s very straight forward and should give them [better information on the diagnosis].”

Additionally, Marmar said physicians should inquire about how well patients are sleeping after the incident, ask if the individual is able to concentrate and manage daily responsibilities, and if they are being flooded by bad images or memories.

“Officially you can’t make the diagnosis unless those symptoms persist for 4 weeks or longer, but if someone has symptoms at 2 to 3 weeks after the [traumatic event], and they are significant and interfere with their ability to work or function in family and relationship roles, you have to take care of them,” Marmar said.

Ripple effect of mass shootings

The long-reaching ramifications of an event like the mass shooting in Las Vegas are quite high for the communities directly involved, according to Berkowitz.

“There's a cascade effect when these things happen, and so it increases people’s stress level,” he said. “In a place like Vegas, there’s the potential to worry about the financial aspects in a possible drop in tourism. Individuals might not have post-traumatic stress symptoms, but they may have a lot of anxiety or stress-related problems.”

This shooting will ripple through the population, Marmar said.

“That does not mean that we are going to have mass psychiatric casualties and have large numbers of people with PTSD in the general population,” he said. “But what we will have rippling through America is increasing anxiety. Not nightmares, flashbacks and startled reactions, but more generalized worry [about safety].”

One of the tough things with an event like the shooting in Las Vegas is that people will constantly relive it, even if they were not physically at the concert, Ng noted.

“They’re so attracted to this event that they become a vicarious victim by listening to it and watching it,” he said.

Additionally, many individuals who were at the concert were not from Las Vegas and will be scattered throughout the country when they return home, Ng said.

“This is why we’re really encouraging folks to really pay attention anytime a mass event like this happens,” he said. “Given the nature of social media these days, rarely any of these events are localized. There’s going to be family assistance centers set up for people locally, and certainly Vegas is going to take the brunt of this and they’re still going to have many people from the Vegas area, but people still need to be mindful that folks may go back home after they [recover from injuries] or people may have just returned home after escaping injury. So, I think this is important that people keep an eye out for that. Because sometimes people are so focused on what happened in Vegas, someone may be affected when they go home and [people might not recognize why].”

Although initial reports appear to not include children among the victims, many children lost parents and will likely experience traumatic grief, Berkowitz said.

“Traumatic grief is a particularly complicated thing to treat as an individual is both dealing with grief and traumatic stress symptoms and interaction,” he said. “Not only will this effect children, but other family members are going to be dealing with this and being quite overwhelmed with the interplay of symptoms.”

Additionally, parents need to be aware of how any stress they exhibit can be translated to their children, Ng noted.

“Children are very intuitive,” he said. “If families are upset, over time children will pick up on that family member being upset. They may watch the events and get exposure to it, so it’s important that family members talk to their children. They may not put everything together, and that may be fine, but this is a large-scale event [and more information will continue to come out in the news].” – by Ryan McDonald

Disclosures: Berkowitz, Marmar and Ng report no relevant financial disclosures.

    Perspective

    A. Alex Jahangir

    Gun violence and mass causality events seem to become more common recently, impacting all aspects of our communities. As physicians, we pride ourselves on our preparedness to treat our patients and the injuries they have sustained. As an orthopedic trauma surgeon and executive medical director of the Vanderbilt Center for Trauma, Burn and Emergency Surgery, this often means that my colleagues and I train to manage the urgent needs of victims of gun violence, and are always fine tuning our institutions response to any mass casualty events in order to save lives. However, focusing on the long-term mental health impact of gun violence and mass causality events can also save lives.

    Post-traumatic stress can present a serious problem for not only victims, but other members of the community including the medical professionals who take care of the victims. I would encourage not only PCPs, but all providers including surgeons who may have timelier follow-up of victims, to assess for PTSD. Additionally, physician leaders should ensure that mental health screening and services are available to the medical providers who helped treat these victims. Through these initiatives, we can do our part to ensure the long-term outcomes of traumatic events, such as gun violence, are minimized.

    • A. Alex Jahangir, MD, MMHC, FACS
    • Executive medical director
      Vanderbilt Center for Trauma, Burn and Emergency Surgery
      Associate professor of orthopaedic surgery and rehabilitation
      Division of orthopaedic trauma
      Vanderbilt University Medical Center
      Nashville, Tennessee

    Disclosures: Jahangir reports no relevant financial disclosures.