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Psychiatric nurse Dorothy Hill cleaned out her closet and threw away old clothes soon after Sept. 11. "It made me feel much better," she said about the task, which was part of her stress management scheme in the wake of the terrorist attacks.

Hill is president of the American Psychiatric Nurses Association, and vice president of patient care and interim CEO at Acadia Hospital in Bangor, Maine. Nurses are dealing with considerable anxiety and stress since the attacks, she said, as is every other American. Many nurses, however, may be unaware of their level of emotional distress, and thus may not be handling it as well as they could be.

"Nurses historically have little time to process events at the time they occur-they are too busy taking care of others. We get focused on others' needs rather than our own. It's crucial to take good care of one's self in order to take care of others.

"Mind and body cannot be separated. If your emotional health is suffering, you will experience physical symptoms."

Medical experts and researchers predict that an avalanche of emotional and stress-induced problems will afflict millions of Americans in the next few months. They expect to see individuals suffering from a gamut of stress-related problems from migraines, sleeplessness and nightmares, to clinical cases of post-traumatic stress disorder.

"We're seeing more people with anxiety issues than before," said Sharon Vander Zyl, MSN, RN, is a psychotherapist at the Center for Christian Counseling in Madison, Wis. "I just saw a statistic noting that prescriptions for anti-anxiety medications have jumped dramatically in the last month. The number [of prescriptions] jumped about tenfold just in the Washington, D.C., and New York areas."

Nurses could be more susceptible to stress- and anxiety-induced problems because of compassion fatigue, Vander Zyl said. "Most of us nurses have an innate talent for empathy; that's both a blessing and a curse. It opens us up to compassion fatigue or burnout."

She said that nurses listen as patients, family members, friends and colleagues share their anxiety reactions to terrorism, while still having their own emotional responses to manage.

No one would expect those who were directly affected by the attacks and the subsequent rescue and recovery efforts to be untouched by the tragedy they witnessed. However, the nation has been indirectly affected by the events, and the emotional fallout is both immense and lasting.

"We've all been vicariously traumatized," said Pamela Valentine, Ph.D., MSW, researches psychological trauma at the University of Alabama at Birmingham. "Vicarious traumatization implies that we are not direct recipients of the trauma, but we heard about it, watched it or saw it. In doing that, we had our own notions of safety and justice shattered.

"We enter into empathy with the direct victims, put ourselves in their situation and say, 'Oh, no, what if that were me?' Interestingly enough, it does become you. What starts as empathy ends up in limiting our own ability to deal with the trauma," Valentine said.

Health care professionals, she said, need to stave off compassion fatigue by saying, " 'This didn't happen to me. I'm sorry it happened to them, but it wasn't me.' If you don't do that, you limit your ability to relate to others. You believe you're being empathetic, but you're caught up in the trauma yourself. Vicarious traumatization is almost like caring too much."

Two common responses to disaster, Valentine said, are to obsess about it, or to avoid all thoughts of it. People typically refuse to talk about it, or can't stop talking about it. She said she has observed recent patterns of people dealing with their emotions, noticing that they move through a fog, still functioning, but not working at their best.

Everyone experiencing the emotional aftereffects of terrorism has felt some degree of anxiety and stress. Common anxiety reactions include recurring thoughts about the event, increased fears-of flying, skyscrapers, people of other nationalities-a sense of a loss of control over one's life, a sense of numbness or a desire to cry unexpectedly.

These normal reactions to a terrifying event generally resolve over the course of weeks or months as individuals process the emotions and regain a sense of well-being or safety. When that well-being is not re-established, the anxiety persists and even deepens, and post-traumatic stress disorder becomes more likely. "The length of time one has symptoms determines whether it's PTSD, whether it interferes with sleep, concentration at work, ability to go about the daily routine," Vander Zyl said.

Diagnosis of the disorder, which contrary to common belief is not limited to war veterans, includes exposure to a traumatic stressor, re-experiencing of symptoms, avoidance of the emotions which leads to a sense of numbness, increased arousal (feeling jittery, shaky, easily startled, irritability and impatience) and significant impairment of functioning lasting more than one month.

The National Center for Post Traumatic Stress Disorder, which studies the effects of the disorder and educates professionals and the public about its prevention and treatment, offers fact sheets about the subject. The center's research has shown that women are more likely than men to develop the disorder, and that acts of deliberate violence, such as terrorism and war, are more likely to result in the disorder than natural disasters or accidents.

To manage the emotions and effects of the recent attacks and the possibility of future violence or war, Valentine urges health care professionals to "talk about [your feelings] where you can be heard, to express emotions you're [suppressing].

"You have to do something to restructure your life once your assumptions of safety and justice have been shattered. Come up with the exact assumptions you feel have been shattered. Anger is often what we feel safe expressing but anger can be a cover-up, a safer way of projecting blame on someone else. Talk about what values of yours have been trampled and increase your self-awareness."

"Whatever coping skills work for you, do more of them," Hill said. Take a walk, spend time with family and friends, work less overtime, get a massage, read a good novel-say to yourself, 'I am going to do something for me.' "

Hill said she encourages nurses to seek help if anxiety has not become more manageable. At Acadia Hospital where Hill is interim CEO, "staff have made time to gather over lunch; our chaplain is available on the units daily to talk to patients and staff."

Vander Zyl advises nurses to look at how they take care of themselves. "We pour out ourselves for others, but in terms of stepping back and paying attention to body signals, we aren't really good at it. Take time away and do healthy stress management."

"We've had time to share feelings in a special meeting and we're beginning to give massages this week as a stress reliever.

"As we talk of practice environments, safe staffing and keeping nurses in nursing, it would be good to review what makes a good work environment and what we can do to encourage those things in every hospital and every work environment where nurses practice," Hill said.