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Health and Wellness

Not feeling strong after Marathon bombings?

Those who are struggling to cope after the attack should not view themselves as weak, experts say

“A lot of my patients have told me they feel like they're supposed to be over it when they see the Boston Strong sign, when they really need time to process the traumatic events,” said Monica O'Neal, a clinical psychologist.

Pat Greenhouse/Globe Staff

“A lot of my patients have told me they feel like they're supposed to be over it when they see the Boston Strong sign, when they really need time to process the traumatic events,” said Monica O'Neal, a clinical psychologist.

Four weeks after the bombings at the Boston Marathon, life for many in the city has regained a sense of normalcy. But for some — particularly victims, their caregivers, first responders, and others who witnessed the blasts — life may still be a struggle.

Those who are still facing overwhelming fear and take pains to avoid the site of the April 15 bombings could be suffering from post-traumatic stress disorder, mental health experts say.

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They may see images of smoke, bloody victims, and frantic crowds flashing in front of them unbidden while riding the T or walking to work. Or they could be drinking coffee with a friend when a loud truck honk triggers a surge of panic.

While such symptoms commonly occur in the first few days or weeks after witnessing a traumatic event, they usually resolve on their own; if they don’t, mental health specialists often diagnose PTSD.

Four weeks is usually the defining line between acute symptoms that diminish with time and long-term problems, said Dr. David Gitlin, chief of medical psychiatry at Brigham and Women’s Hospital. Those who have begun to resume their normal sleeping, eating, exercise, and social routines may be recovering, even if they have some lingering trauma symptoms.

The condition can also kick in several weeks after an event, in a kind of traumatic amnesia. “People’s psyches are somewhat self-protective,” said Dr. Michael Leslie, a psychiatrist who treats trauma patients at McLean Hospital in Belmont. “The brain may keep things from your conscious awareness that may be too overwhelming to deal with at first.”

For those who are just noticing symptoms, are not getting better, or are feeling worse, Gitlin said, "that’s the time to seek out professional help." He estimates that as many as half of people who directly witness a trauma will experience acute stress disorder, and about 5 to 10 percent will develop PTSD.

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The condition can be treated, often with a combination of antidepressants and behavioral therapy, but Boston public health officials can’t estimate how many of those affected by the bombings will require treatment.

No one knows how PTSD develops. Brain imaging studies suggest traumatic events can alter certain structures in the brain, while other researchers have found that the body’s stress response system becomes disrupted, setting off false alarms.

“It’s hard to predict who will go on to develop PTSD, but it’s very much dependent on the specific nature of their trauma, what they witnessed, and how they felt about it,” Leslie said.

Mental health specialists urge those who may be reluctant to admit any feelings of anxiety, lest they seem “weak,” to seek help. Some are concerned that the “Boston Strong” slogan adopted by the city in the days after the bombings may dissuade some people from admitting that they still feel traumatized. But they caution that the phrase is not meant to be taken personally.

“A lot of my patients have told me they feel like they're supposed to be over it when they see the Boston Strong sign, when they really need time to process the traumatic events,” said Monica O'Neal, a clinical psychologist who practices in Boston and teaches at Harvard Medical School.

Some who were standing near the finish line when the bombs went off have also found themselves grappling with unpredictable waves of sadness, wondering whether they could have done more to help the victims.

As the city honors heroes who tore their T-shirts into tourniquets or braved the risk of more explosions to help the injured, Gitlin said he’s counseled people who ran away from the explosions and have been asked why they didn’t stop to help. “Self preservation isn’t an unheroic instinct,” he said. “A lot of the people who ran — if they had had an opportunity to think it through — might have stopped to help.”

Those who have suffered from PTSD in the past could experience a recurrence of their trauma symptoms, even if they were nowhere near the Marathon attacks.

Leslie said he saw an increase in patients coming to McLean starting two weeks after the bombings, almost all of whom had symptoms from an old trauma triggered by the attack. One of Gitlin’s patients has been having nightmares and flashbacks of a mugging at knife-point she experienced two decades ago.

“I try to help patients understand that it’s not about their character,” he said, “that there’s nothing deficient or defective in them for having their emotional experiences. Those who beat themselves up can add to their trauma as a result.”

Health care providers and other caregivers may develop a stress condition similar to PTSD — called compassion fatigue; they feel sadness, despair, and burnout from trying to alleviate victims’ pain and emotional suffering. “I know of almost no staff caring for the wounded who was unaffected by the stress of the attack,” Gitlin said.

Treatment for PTSD may involve the use of antidepressants — typically selective serotonin reuptake inhibitors such as fluoxetine, paroxetine, or sertraline — and some form of behavioral therapy to help patients examine and challenge distressing thoughts and to better understand how the trauma changed the way they perceive the world.

While it’s important for PTSD sufferers to seek professional help, Dr. Paul Summergrad, chair of psychiatry at Tufts Medical Center, said family members and friends can also provide important emotional support. “Be there and present for them in an ongoing way, since this isn’t just for a week or two, but may last for several months.”

Those dealing with significant injuries may feel that their sense of self has been upended, and getting back to normalcy may not be possible right away. “Some days they may not be able to push as hard, so you need to remind them that they can push tomorrow,” Summergrad said. “Sometimes they need to exhale.”

Deborah Kotz can be reached at dkotz@globe.com. Follow her on Twitter @debkotz2.

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