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the face of horror 1

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October 26, 2009


October 26, 2009


rom typhoons to floods to landslides to earthquakes to massive fires, sea disasters, terrorist attacks and decadesold insurgency and war for secession, the Philippines is stomping ground for trauma and stress that ordinary human beings may find hard to deal with. 33 OO

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the face of horror

the face of horror

The recent deaths and havoc wreaked by typhoons Ondoy and Pepeng are but two of the more recent calamities to befall a nation already battered by poverty and an economic crisis that bear a heavy toll—physical, emotional, and mental—on its citizens. The impact goes beyond the faces of shock, horror and grief we see on the faces of survivors and those who lost not only property but loved ones as well, or the images flashed on our television screens and printed on the front pages of newspapers. It strikes deeper into their heart and psyche and can have lasting impact that if not addressed can lead to what psychiatrists call posttraumatic-stress disorder (PTSD). Its effects can last long after the floods have subsided, homes have been rebuilt, loved ones have been buried, or the last shot has been fired. Unfortunately, in disasters such as the one Ondoy and Pepeng wreaked, it is also the last, and the least, to be addressed—if it is not totally ignored. Says psychiatrist Norieta Balderama, president of the Philippine Psychiatric Association (PPA): “The psychological is always the last aspect addressed in disasters, kasi syempre, under our law, the physical needs for food and nutrition should be the priority.”

Low awareness Balderama believes that awareness about PTSD in the country is very low in proportion to the many trauma-inducing calamities visited by nature and man on these islands. “The public should be aware that there is an illness like PTSD because if left untreated, it can affect other areas of one’s life like studies and life decisions,” says Balderama. As a consultant at the child-protection unit of the University of the Philippines–Philippine General Hospital, Balderama sees PTSD playing out in more situations than are routinely captured in the evening news. Even small-scale tragedies like filial abuse or separation among families of overseas Filipino workers are grist for the PTSD mill. PTSD is second only to major depression as the most common psychological disorder diagnosed at the unit, seen in 33 out of the 300 mostly abuse-related cases referred in 2006. However, these figures also say that more than half of the cases referred to the center won’t involve any psychological problems at all. “What may be traumatic for you might not be traumatic for me,” says Balderama. “Trauma also depends on the eye of the beholder.” Any tragic event becomes a traumatic experience when the person’s capacity for coping is overwhelmed: he no longer has a sense of control or direction. The initial shock or numbness—and sometimes denial—becomes a psychological armor, a temporary defense mechanism that shields the individual from the sudden onslaught of intense emotions. Those likely to develop PTSD, Balderama points out, already have existing trouble with their coping mechanism as an individual, have many other problems besides the trauma or have experienced the traumatic episode repeatedly.

Recent research supports this notion that PTSD susceptibility might vary from person to person. Earlier this year, a Yale University study on US military personnel (including special forces involved in unconventional warfare) found that there are individuals with hormone profile that undermine the effects of extreme stress from their environment. “Their stress hormones are actually lower and the peptides that downregulate that stress are quite higher,” the Agence FrancePresse quotes the study’s author Dr. Deane Aikin. A person’s childhood experiences may also point up red flags for ptsd ahead of a any traumatic episode. Prof. Karestan Koenen


October 26, 2009


Twin Towers tragedy in 2001 and the Asian tsunami in 2004. But our colloquial understanding of shell shock or war shock is not by itself PTSD. It takes time, at least a month after the traumatic event, for a person to be definitively diagnosed with the condition, says Balderama. Until then, a placeholder condition— acute-stress disorder—is assigned to a person manifesting with symptoms that might be those of PTSD, in the hope that these might simultaneously resolve themselves after a month after the traumatic experience. The most outstanding symptoms associated with the condition are hypervigilance and flashbacks or reexperiencing the

of Harvard University’s school of public health found in a longitudinal study that factors like low IQ by age five, difficult temperament by age three, an impoverished background and unstable family life can put some people at greater risk. Certain genetic factors can also raise vulnerability to a trauma’s after-effects.

Not new PTSD is not new in medical annals, having been around in psychiatry books since the 1960s. It just received more attention in recent years because of the symptoms observed in American and British veterans of the two Gulf wars and the survivors of the 911


October 26, 2009

the face of horror

traumatic event. The person is prone to extreme moods like aggressiveness and submissiveness, risk-taking and difficulty in trying new things, but has a more limited range of emotions in between, like not being able to smile or take joy in anything. “It’s a natural tendency for anyone whose life has been threatened or whose safety has been shattered, to be now more vigilant,” says psychiatrist June Pagaduan-Lopez. Their heightened senses leave them tense all the time and easily startled. Something unremarkable and harmless may set off an internal alarm, causing them to palpitate and break out into a cold sweat. The trigger, a powerful stressor linked to the incident, can be an ordinary object similar to the one the attacker used, a distinct sound like the one heard immediately before the accident, or a strong scent identical to the one worn by the assailant. Tempers can flare easily, and sleep becomes difficult, if not impossible. “The symptoms might continue for several days or weeks, and they’re not necessarily considered abnormal or would require psychiatric treatment. They can go away naturally. But sometimes the vigilance becomes too much, it keeps the person from attending to his daily routine,” she notes. Victims can be fixated by their ordeal that they mentally replay it over and over again. The intrusive symptoms can also appear as uncontrolled flashbacks that erupt during waking hours, or as dreams that haunt them at night. Because of the tremendous stress during the trauma, the scenes are often relived not in vivid, chronological series, but in snatches and fragments like blown-up parts of a picture, such as a tattoo on the aggressor’s arm, or a swinging light bulb at the site of the attack. To prevent painful recollections, survivors stay away from a place, person, or object that’s associated with the trauma. Avoidance is a form of self-preservation; however, it can be ultimately destructive. Alcohol and drugs, for instance, help the person temporarily escape his turbulent emotions, but it’s a slippery slope that can lead to addiction. Withdrawal from family and friends, and avoiding usual activities are normal reactions when they last for a short time. “Or it could be so bad that they avoid life itself. They don’t want to go out of the house. They feel they’re not the same anymore, and when that happens, you now begin another set of symptoms—constriction symptoms,” Lopez says. At this point, the individuals may no longer be plagued by hyperarousal symptoms and recurring flashbacks and dreams. They may believe that they have shaken off the behavioral avoidance patterns. “But in many ways they are still avoiding,” Lopez avers, “and they can’t seem to go back to how they were. They can’t seem to return to work, to be the same person that they were, to be as happy, to be as interested with life in general. This becomes PTSD, because it affects the normal routine functioning of the person. That’s when they really need help.”

The enemies might be gone, but the danger may be far from over. When soldiers return from combat, they’re often shellshocked or battle-fatigued. It’s the body’s automatic response to the extreme peril and violence that comes with war. Maj. Maria Jesica Mateum-Vallangca, head psychiatrist of the AFP Medical Center, says, “The usual manifestations are anxiety, difficulty initiating sleep, and difficulty in concentrating at work. They sometimes isolate themselves; have a tendency to be irritable, to outbursts of anger, to exaggerated startle response.” The symptoms of stress can go away after a few months, as the soldiers readjust to normal life. “On average, they go back to combat in three to six months,” she notes. But for some, the demons would continue to haunt them and cripple their ability to function. The phenomenon is called posttraumatic-stress disorder (PTSD), an anxiety disorder that was first identified in US veterans of Vietnam War in the 1980s. In Jonathan Shay’s book, Achilles in Vietnam: Combat trauma and the undoing of character, one veteran recounts: “I haven’t really slept for 20 years. I lie down, but I don’t

Af the shot fire

Recovering from trauma Harrowing events, from death of a loved one to loss of home, are the turning points in life, the forks in the road that lead to either


October 26, 2009


despair or hope, to isolation or renewed faith in life, to living or merely existing. What makes one person rise above the tragedy, while another sink to defeat? Experts say it’s a confluence of factors, including social support. When family and friends show sympathy or empathy, it invites a level of security and trust that opens up communication, and discourages the person’s tendency to withdraw and shut others out. “Social support is how much understanding you were able to receive from those whom you expected to understand. There are certain forms of trauma that does not elicit sympathy. You’ll be surprised that rape, for example, does not easily elicit sympathy even from loved ones. I have patients whose greatest fear is how their loved ones will react, especially their husbands or boyfriends, if they were sexually assaulted. It’s the fear of being blamed. My old patients had decided to come out in public, only to be questioned about their character,” laments Lopez, who is also a board member of the Sexual Violence Research Initiatives of the World Health Organization. Lopez stresses that the biggest support anyone can offer a victim is to curb the blaming—avoiding accusations, and helping her from censuring her feelings and herself over what had transpired. Because the family serves as a “cushion,” in most trauma causes, Lopez counsels the members on those key points even before beginning the patient’s treatment proper. The nature of the trauma also influences the chances, speed, and degree of recovery. Losing one’s limb in an accident, for instance, would be harder for anyone to bounce back from than losing one’s home. “There are already studies which show that different kinds of trauma have their inherent, unique impact on the individual regardless of how normal you are,” the psychiatrist says. Trauma caused by nature is also less emotionally devastating than one caused by the violence of man. While natural disasters can be attributed to divine acts—”Filipinos say, hindi man natin maiintindihan, kagustahan iyan ng Diyos”—the latter impacts on a deeper, gut-wrenching level. Lopez describes it as a sense of betrayal, a shattering of one’s assumption that the world is safe; as people reeling from news of violence often say, “human beings simply do not do that to fellow human beings.” Armed conflict is also more destructive and potentially more traumatic. “In a natural disaster, everybody comes together. It’s all about saving what you can save and moving forward. Some can even rationalize it as ‘God’s will,” says Dr. Steven Muncy, executive director of Family Services International, a nongovernment organization helping Filipino and other Asian refugees of armed conflicts and natural disasters. “In situations of armed conflict, it can feel like it’s never going to end. It’s always dangerous. And for those displaced, they’re never sure if they’re going to be socially accepted in the place where they’re evacuating.”

sleep. I’m always watching the door, the window, then back to the door. I get up at least five times to walk my perimeter, sometimes it’s ten or fifteen times. There’s always something within my reach, maybe a baseball bat or a knife, at every door...” Along with the paranoia, a severe form of PTSD can cause hallucinations. Vallangca recalls one case where the soldier, who returned from combat during December, believed he was back at the battlefield when the fireworks exploded. His terror was so great, he hid under the bed for cover. The internal maelstrom may be compounded by guilt and self-blame for any soldier who has witnessed the death of his comrade. He may be driven by a hallucinatory voice—his comrade’s—that tells him to exact revenge by killing someone, the doctor says. Because trauma in the war zone can have profound and far-reaching effects, including death, our military leaders are trained to spot for severe signs of stress. Soldiers who might need medical attention can therefore be immediately referred to a station hospital in the area, and assessed for possible evacuation to the medical center.

fter e last t was ed...


October 26, 2009

the face of horror

Resilience Without a doubt, the most critical component to recovery is the individual’s ability to cope or what therapists call “resilience,” which is a result of upbringing, personal history, and genetics. Referring to trauma and recovery expert and author Judith Herman, Lopez’s guru, the doctor enumerates the three elements that increase a person’s resilience: task-oriented attitude, inner locus of control, and sense of humor. A person is task-oriented when he has the ability to concentrate on the goal at hand. “It’s the ability to not panic in a stressful situation and to tell yourself to focus on what you have to do now. I have a kidnap survivor who escaped after three days. She focused on how to convince her bantay (guard) to let her go, and in fact, they escaped together,” Lopez recounts. “Task-oriented trait is very true for traumas that are short term.” Having an inner locus of control, versus an external locus of control, places the individual in the driver seat of the situation, whether it’s in the face of trauma or in the aftermath. “It means having enough self-confidence to make judgments and decisions for yourself, and to be not so dependent on what other people think. Those who are independent minded and autonomous in their thinking are usually better survivors,” she elaborates. Lastly, no one can refute the healing power of sense of humor. It’s not a denial of what has occurred, but an ability to see the irony or the lighter side in situations, and to not taking oneself too seriously.


our natural response to bereavement or the loss of a loved one, has traditionally and been defined in medical books in five stages: denial, anger, bargaining, depression, and acceptance. Although the emotional upheaval that follows bereavement can cause varied, healthy reactions, like depression and withdrawal, grief becomes unhealthy and “problematic” when the same conditions persist. Some experts peg the normal mourning period between three to six months; others argue that it can last to a year or more. Certain symptoms, however, are generally acknowledged to be signs of problematic grief: long-term loss of interest in work, social interactions, and other routine functions; an excessive preoccupation with activities, without feeling a sense of loss; and agitated behavior that may be accompanied by self-blame. For a prolonged period, the person rigorously avoids any reminder of the deceased, sometimes removing all photos from sight and steering clear of the people who were close to him. By contrast, someone who’s unable to accept reality might refuse to throw away any of the departed’s personal possessions.

Intervention Therapists rely on a variety of psychological and pharmaceutical treatments, from cognitive-behavior therapy to use of antidepressants, to help patients manage their grief or trauma. However, it is unusual for a practitioner of Western medicine to subscribe to an integrated or holistic approach. Lopez had never appreciated its value until she began her battle against Non-Hodgkin’s lymphoma just a few months ago. “If you’re undergoing anything of serious consequence, life-threatening to you, it would need no less than a broad range of interventions that would strengthen your resilience and help you cope,” she confides. It also involves physiotherapy, such as massage, breathing techniques, meditation, and exercises like qigong (chi gong), yoga, and tai chi. In formal programs abroad for survivors of sexual assault, martial arts is an integral module, aimed to restore empowerment and mastery over one’s body, she says. But treating the body and the mind is just two-thirds of the equation; Lopez believes the spiritual dimension should also be addressed: “Recovery of trauma is a physical and psycho-spiritual process for me. By spiritual, I do not mean that you become religious. It’s seeing that there’s a bigger power, a higher being who will protect us, understand us, who will usher in our deeper recovery. You have to acknowledge that there is something beyond you that will explain why you experienced it and help you regain your sense of empowerment and give you meaning. That’s

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spirituality. And it’s going to be very hard to find meaning in a trauma.” Muncy cautions against “over-medicalizing something that is in fact a normal response to an abnormal situation.” “Sometimes things are called medical conditions to justify the intervention of health workers when in fact, what is needed is a social worker or a priest because we’re dealing with personal grief,” he adds. An American who has worked with Filipinos for almost 30 years, Muncy thinks it’s precisely the disaster-prone character of the archipelago that confers many Filipinos good protection against trauma. “Filipinos are very resilient wherever they are, perhaps because of the many hardships from the high level of poverty and your political history,” he observes. Opportunities for social support, antidote to dwelling too much on one’s personal troubles, also abound in the Filipino culture. Even the simple act of eating, Muncy says, brings people together.

Front line against mental disaster Resilient or not, Filipinos who are potentially in harm’s away from the next mega-typhoon, ship sinking, or renewal of Islamicfundamentalist hostilities can benefit from more access to mental health services in the front lines of disaster. PPA has members all over who are trained in PTSD and other disaster-related disorders, and Balderama sees the need for more professional involvement in places like Mindanao. But she admits it is not easy to get psychiatrists to volunteer their services there because of the unstable peace and order situation. Another option is to train front-line workers in disaster areas. PPA has formed an ad hoc committee for training trainers from government agencies and NGOs on disaster-related psychological disorders. They can also seek out the National Center for Mental Health for training services. While he sees the training of more psychiatrists as an important long-term move, Muncy particularly advocates increasing the mental-health-services capacity of social workers, psychologists, and guidance counselors simply because there will always be more of them in theory than the psychiatrists. By the same logic, he recommends more emphasis on psychosocial and mental issues in the undergraduate medical curriculum so that doctors, whatever their specialty, who find themselves in the front lines of disasters would be able to minister better to the psychological, not just the physical, needs of their patients. Finally, mental-health services should be made readily available at the disaster front line. Balderama envisions trauma desks in police and fire stations rendering psychiatric first aid to crime and fire victims, guidance counselors offering the same services in schools, and national agencies involved in disasters incorporating a protocol for psychologically processing traumatic events as part of emergency relief activities. Medical Observer, with reports from Sunly Coo and Grace Roxas

Grieving tends to be more problematic when the death was sudden or violent. When the mourner’s sense of purpose is defined by the departed—for instance a home-bound mother who devotes her time to raising her child—the loss creates a vacuum in the person’s sense of identity. The person gets stuck in the grieving process, unable to move forward, unable to let go. Sometimes the difference between recovery and limbo depends on the status of the relationship, especially if it had been ambivalent or fraught with conflict and unresolved issues. One of Lopez’ patients had difficulty coming to grips with her husband’s death, that months after he perished in a shipping disaster, she remained steadfast against the children’s proposal to discontinue the search for his body; the family couldn’t even begin to mourn. “I put her under hypnosis, which actually just gave her a chance to feel like she was still talking to her husband,” the doctor explains. “She saw him peering through the porthole of the ship, talking to her, saying goodbye, and forgiving her,” since the couple had parted under bitter terms. Once she resolved her feelings for him, the family could finally grieve and start their journey of healing.”

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Do some math Weigh yourself, measure your height, and calculate your body-mass index (BMI). BMI is one way of taking stock of your body’s ideal weight. It is calculated by dividing your weight (in kilograms) by your height (in meters). Say, if you weigh 50 kilos and stand 2.2 meters, your BMI would be 22.7, which means you are within the normal range of 18.5 to 25. A BMI below 18.5 is considered underweight and above 25 either overweight or obese.

Step on the treadmill If you have not been

exercising for some time now, today is a good day to restart the routine. Daily exercise not only helps you lose unwanted pounds. It keeps you fit and your heart in good shape. It improves your blood circulation, lowers your blood pressure, and relieves you of stress. So go ahead, step on that treadmill, ride the stationary bike, or do some abdominal exercises even at home.

Measure your pressure Even though you may not have hypertension, it is advisable to

have your blood pressure checked regularly. Hypertension does not present any symptoms and the only way you’ll know if you may have developed it is to have your blood pressure checked. The normal blood pressure is 110/70 to 120/80; 130/80 is slightly above normal while 140/90 is slightly hypertensive. You don’t have to go to a clinic to have your BP checked. You can get yourself one of those handy digital or analog sphygmomanometers. Choose the brachial type—the one that measures your BP from your upper arm, not the wrist or finger. It is more accurate.

Stub it out If you

smoke and have long wanted to quit, today is as good as any day to make the resolve to stub out the habit. Smoking is one of the leading causes of hypertension, heart disease, and lung diseases, including cancer. It causes the blood vessels to constrict, restricting your blood circulation. It is a leading cause of emphysema and chronic obstructive pulmonary disease. So join the millions now enjoying the benefits of kicking the habit. Stub out your last stick.


Shift to wine

If you’re going out tonight with friends, you might consider having wine instead of the usual hard drinks. Studies have shown that regular and moderate intake of red wine is good for the heart.

Get a massage It’s been tiring

and stressful week on the job. So go ahead, treat your body to a massage. Massage not only relieves you of stress, it improves blood circulation, relieves you of joint and muscle pains, relaxes your nerves and tones your muscles.

Get out of bed and off that couch Sunday is always a tempting day to stay long in bed or lounge on the couch all day, especially after a long week. But it is also the best day to get out, get some sunshine, and make your body sweat. Wash the car instead of taking it to the car wash, take a walk around the neighborhood, or clean the house.

Medical Observer OctOber 2009

Publisher Editor Art Director Online Editor Circulation Manager VP-Marketing Advertising Manager

the face of horror 


T. Anthony C. Cabangon Conrado I. Generoso Eduardo A. Davad Ruben M. Cruz Jr. Ronald Allan S. Callao Albert V. de los Santos Aldwin M. Tolosa

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October 26, 2009


October 26, 2009


October 26, 2009


The Face of Horror