Young Norwegian people who planned to spend late-summer days on decorating their bedsits, buying schoolbooks or going for that last swim are in deep mourning. They are challenged by psychological reactions to traumatic events of a nature that we can hardly comprehend.
In the days, weeks and months to come, many of the young people who returned from Utøya island and their families will seek advice and help. Many will nevertheless be reluctant to call their GP, crisis management teams, municipal services or psychiatric services. In addition, adolescents are especially vulnerable to interruptions in such contact, because they feel that the health services cannot fulfil their needs. Listening to how they feel, being generous with your time and not giving up could be your most important contribution as a doctor.
Protection and safety
The happy and safe community among the young people at Utøya island was shattered in an instant. When the fragmented stories and graphic images rolled over our TV screens, we knew that nobody had been spared from the fear that follows a brutal threat to life. They had all struggled in various ways to survive. They must now return to a life with major losses, with events they will never forget and with bodily and mental reactions they might find difficult to cope with and understand.
As doctors we are trained to treat people in crises, including children and adolescents, and this knowledge will be useful and necessary in the encounter with many of those who now need help. Still, this situation is a special and challenging one. First and foremost because terror is intended to harm us, and because it strikes so strongly at our experience of safety and security. The collective responses from society have called for more togetherness, fellowship and protection. In a similar manner, communicating a sense of protection and safety has served as a guideline for our assistance to the patients. There is broad agreement that our objective for the provision of assistance at an early stage is to promote safety and coping, to give help with practical matters, to stabilise emotional reactions in those who need it, and to ensure access to health services.
Post-traumatic stress
In our encounter with afflicted patients and their families, we need to take two general considerations into account. On the one hand, it is essential to respect natural processes of healing. Exaggerated attention to disorders and symptoms during the initial period may delay healing. On the other hand, the increased risk of long-term health problems after traumatic incidents will require enhanced alertness and follow-up of symptoms over time. Some will therefore need long-term support and interventions from the health services. Post-traumatic stress reactions are common, understandable and expected effects. They may nevertheless be experienced as extremely up-seting – especially reactions that reoccur frequently. Three different types of symptoms can be expected: reliving the event, avoidance and increased physiological response.
Reliving the event means that thoughts and images from the incident keep coming back, when awake as well as in dreams. Many also experience so-called «flashbacks», which are perceived as though the event or parts of the event are actually reoccurring. Furthermore, being reminded of the incident may evoke intense emotions or physiological reactions.
Avoidance and emotional numbness can be played out at an internal level by the adolescents avoiding the event in conversations or in their minds, or at an external level by them refraining from undertaking activities or visiting places that remind them of the events. Emotional numbness concerns the experience of emotional change, when adolescents for example lose interest in activities that were important to them before the event, or when they feel alienated from close family members or friends.
Increased physiological response is associated with autonomous reactions after the event that manifest themselves in difficulties in falling asleep, frequent awakenings, a lower threshold for outbursts of anger, and difficulties in concentrating. The senses are on higher alert than normal, and react to lower stimulations than they otherwise would: for example a slamming door may evoke a strong reaction. Children and adolescents may become restless and unfocused, or display changes in their pattern of behaviour.
Grief may take time
Even though grief is part of life, many adolescents will never have gone through grief and have therefore no experience in how to deal with the process. In addition, the sudden, unexpected and brutal death they witnessed during the terrorist attack may trigger grief reactions of a particularly difficult nature. Their thoughts often circle around the circumstances of the death, they brood over what could have been done to prevent it, how their friends perished and various aspects of the rescue work. This grief may last longer than other processes of grieving, because time will be needed before they can accept the reality of the incident and their losses. During the course of a process of grief and the processing of traumatic events, children and adolescents may develop typical symptoms of depression. Feelings of sadness and irritability, changes in sleep patterns and appetite, increased fatigue, feelings of hopelessness and suicidal thoughts may occur.
Somatic symptoms, such as headaches, abdominal pain, sleep problems and heart palpitations will often be the reason adolescents seek medical help. Anxiety attacks with strong heart palpitations, hyperventilation and other physiological reactions are also frightening and may be the reason for calling the doctor. In addition to appropriate medical treatment, your most important contribution will be to listen to how they feel and to help them find new strength and meaning in a changed life.
