Aurora-style rampages can lead to anxiety, depression among the public

More than 1,500 miles east of Aurora, Colo., in New York City, some patients of psychiatrist T. Byram Karasu, MD, are afraid to go to the movies.

They fear they might be shot.

Their anxiety stems from the July 20 shooting at an Aurora movie theater that left 12 people dead and 58 injured during a midnight opening of “The Dark Knight Rises.”

Dr. Karasu

Anxiety, depression and panic attacks can arise in the public after a large-scale and widely publicized random act of violence, mental health professionals say. Such violence can lead to “a sense of loss of community, that everyone is out for themselves and that no one is safe,” said Dr. Karasu, psychiatrist-in-chief at Montefiore Medical Center in New York. “People feel helpless and can become totally irrational.”

For example, one of his patients now sits by the exit at a movie theater and bought a protective jacket, like those used by law enforcement, to wear while watching the film.

Although such responses typically are temporary, they can escalate if left untreated. Most at risk of developing problems are people with a history of mental illness and those who experienced a traumatic event in the past, including abuse, say mental health professionals.

Dr. Cookson

They encourage primary care physicians to be aware that incidents such as the Aurora shooting could negatively affect their patients, even if they have no connection to the tragedy. Some patients might feel depressed and have insomnia and unexplained physical complaints, including back pain, gastrointestinal problems and headaches.

When seeing a patient with those types of symptoms after a widely publicized violent event, physicians should inquire about whether the individual's feelings are linked to the incident, mental health experts say.

A doctor could ask the patient: Are these issues “related to something you might have experienced lately, including what happened in Colorado?” said Anthony Ng, MD, medical director of psychiatric emergency services at the Acadia Hospital in Bangor, Maine. Physicians should listen to their patients' concerns, respond with empathy and emphasize that these random events are rare, he said.

Curtis

“Doctors should reassure patients that this is not an everyday occurrence,” Dr. Ng said. “It's certainly a tragedy, but it's almost no different than an accident if you walk across the street.”

Responding to tragedy

In Aurora, several hours after the shooting, staff from the city's mental health center gathered near the movie theater to offer support to survivors and their families. Since then, the Aurora Mental Health Center has staffed a crisis phone line 24 hours a day and is allowing walk-in appointments during business hours. In the initial days after the shooting, the center was open for patient visits around the clock, said Marlene Husson, a clinical psychotherapist and grief counselor at the center.

Many of the center's patients are survivors of the shooting and family members of victims. They're grappling with a broad spectrum of mental health issues, including fear, a lack of control and trouble sleeping and eating, Husson said.

Posttraumatic stress disorder is among the most talked-about responses to a traumatic event, but it does not affect everyone involved in the incident, said Texas psychiatrist Carol North, MD. When caring for victims of a violent event, she encourages physicians not to assume that the individual has PTSD or will develop it. Twenty-five percent to 30% of victims of significant trauma develop PTSD, according to a Dec. 15, 2003, American Family Physician report.

“People can go through horrific experiences and not become psychiatrically ill as a result,” said Dr. North, director of the program in trauma and disaster at the VA North Texas Health Care System. She also is professor of psychiatry and surgery in the division of emergency medicine at the University of Texas Southwestern Medical Center in Dallas.

Several factors affect how people respond to trauma they experience or see. They include a person's emotional predisposition (anxiety or depressive), level of resilience and support system, psychiatrists say. Often exacerbating mental health issues among the public is footage of the event that is replayed on news programs for weeks, such as video of the Aurora shooting survivors dashing out of the theater, said Denver psychiatrist Elizabeth Cookson, MD.

“It's very hard for people emotionally to realize they're seeing the same thing over and over again. It seems like it wasn't an event that happened last week for 10 minutes, but an event that continues to happen and grow,” said Dr. Cookson, president of the Colorado Psychiatric Society.

She often recommends that patients stop watching programs that discuss the incident, especially if nothing new is being reported.

Large-scale acts of violence also can prompt the re-emergence of psychiatric problems caused by other traumatic incidents. For example, in Colorado, news of the Aurora shooting stirred up memories and fears of the 1999 Columbine High School shooting in the Denver area that killed 13 and injured 24, Dr. Cookson said.

Some of Dr. Karasu's patients in New York who were at the World Trade Center during the Sept. 11, 2001, attacks began experiencing anxiety and nightmares again after learning about what happened at the Aurora movie theater.

“The conditions [these patients have] decrease in intensity but always require” monitoring, Dr. Karasu said.

Talking to children about violence

Physicians can use the Aurora shooting to talk to patients about past abuse or trauma and identify people who might have trouble coping with large-scale random violence in the future, said American Medical Association President Jeremy A. Lazarus, MD, a Denver psychiatrist. He also encourages pediatricians and family physicians to discuss gun safety with the parents of their young patients.

Doctors should recommend that parents prohibit children younger than 8 from watching news related to any violent event, because the images and messages can be troubling for youths, said David F. Curtis, PhD, a psychologist at Texas Children's Hospital in Houston. Parents should closely monitor what older children watch and read about traumatic incidents, he said.

When discussing random violence with young patients, physicians should tell them that their concerns are normal, Curtis said. In fact, some doctors may have them, too.

Curtis attended a midnight showing of “The Dark Knight Rises” in Texas with two teenage nephews the same night as the Aurora tragedy.

“It certainly affected me,” he said. “It became part of our conversation for the rest of the week.”