The patient appears frightened, may scream or cry. Clear cut panic (e.g. overt confusion, bewildered or aimless behaviour or running away), is rather infrequent even during disasters (<1 per cent). Although lowering of blood pressure is not part of the clinical features of panic, panic is often included in the concept of ‘shock’ used by lay people and media.

Physiological response to physical injury may be misunderstood as flight response. Patients with injury to the thorax hyperventilate and may appear anxious and scared. Cyanosis is not a sign of emotional distress in adults, and hyperventilation should always be considered as sign of respiratory problems needing urgent medical attention (e.g. pneumothorax). Patients with head injury may be confused and bewildered, but they seldom display the open anxiety seen in patients who panic.

Panic with severe behavioural disturbances may threaten the safety of the subject and provoke anxiety in bystanders and other victims who may themselves be afraid to lose control. Thus, whenever possible, patients with strong anxiety or panic should be offered immediate psychological support. Establishing physical (e.g. hand around the shoulder) and verbal contact is important to reduce panic and provide a sense of security and control. Verbal contact may also reveal the subject’s real or imagined fears and provide the subject with an alternative way to express their inner turmoil and despair and thus pave the way for more optimal coping and subsequent behavioural control. The subject should be removed from the accident scene, but not left alone. These subjects need to move around and should not be forcefully immobilized. A helper may walk with the patient until he calms down. The exception to this rule is rare instances where the subject’s behaviour is completely out of control representing an immediate threat to the physical safety of self or others.

Reuniting family members may reduce anxiety and worries.

Hyperventilation is treated as usual (breathing into a bag to increase the CO₂ -level) combined with physical and verbal contact as described above. It is crucial that somatic causes (e.g. pneumothorax, intoxication) have been ruled out.

Freeze responses include halted surprise or in more extreme cases emotional numbness (apathy). Apathy causing lack of appropriate lifesaving activities occur rather infrequently among random samples of accidentally injured adults (less than 10 per cent). In less than 1 per cent, significant parasympathetic (vagus) responses with lowering of blood pressure occurs (‘emotional shock’). These patients appear pale and silent. The look of their eyes gives an impression of detached distance, if they were looking onto their own personal world somewhere far away from the actual accident scene. Rarely, an atypical freeze response characterized by blank denial of having sustained an injury when one, in fact, exists may be seen. These subjects may continue to behave as if nothing had happened and not take appropriate precautions at the accident scene.

Several physical injuries may mimic freeze-response. Patients with internal bleedings (e.g. liver, spleen) may appear pale and silent as if in emotional shock (‘freeze response’). The pulse is weak and fast (tachycardia), however, in contrast to the vagus tonus induced bradycardia of the freeze response.

If there is a risk of further injury associated with remaining at the accident scene, patients with freeze responses must be removed to a safe place. They should not be left alone, but covered with a jacket or a blanket over their shoulders and attended to in a calm and gentle way, encouraging them to express some of their thoughts and emotions. If the freeze response is severe and prolonged, the patient should be brought to an emergency room for renewed and extended medical evaluation and basic psychological care. Cases of complete denial of having sustained an injury despite evidence for the opposite, should clinically be handled as a freeze response.

Dissociative symptoms occur in about 15 per cent during the 1st second to minutes after an accident and may be associated with
flight or freeze responses. Brief symptoms of derealization are most common, even in relatively minor accidents (e.g. ‘unreal’, like a ‘dream’ or ‘slow movie’). Symptoms of depersonalization (e.g. ‘I watched my body burn from a distance’) are less common and usually signal a more severe psychological response. Brief symptoms of dissociation do not predict later psychiatric problems,^(5,7,8) but marked and prolonged dissociative symptoms still present weeks after the accident.⁽⁷⁾

Fight responses include irritability, anger and more rarely, open aggression. This response is most often seen among bystanders or helpers who feel threatened by the exposure of dead and mutilated bodies. They may quarrel with the rescue team, and sometimes even interfere with the work of police or helpers. Open aggression is rare among victims themselves with the exception of intoxicated victims with severe personality disorders and a few who have sustained severe head injuries (e.g. subdural hematoma, frontal brain contusion).

Irritability and aggressive comments should not be taken personally by the helpers, but interpreted a symptom of helplessness. In most cases, this response is psychological, but impaired behavioural control due to drug or alcohol may be contributing factors. The patient should be treated as being extremely anxious and under high emotional distress. Reuniting with family or significant others if possible may be helpful. Physical activity may reduce aggression. If suitable, simple tasks which require physical movements may be therapeutic (‘Can you give me a hand with … . .’), but subjects under stress should never be involved in important rescue tasks due to their impaired judgement ability and tendency to act irrationally.

Marked or severe flight, freeze or fight reponses are included in the ICD-10 (F43.0) definition of acute stress reaction (ASR). ASR is defined as immediate onset of marked psychological symptoms (within 1 hour) following exposure to an exceptional mental or physical stressor. The symptoms must begin to decrease after 8 hours if the stressor is transient (e.g. accident). If exposure to the stress continues (e.g. combat zone, hostage situation) the symptoms must begin to diminish after 48 hours. In contrast, the DSM-IV concept ‘acute stress disorder’ (ASD) describes development of symptoms not earlier than 2 days after the trauma but within one month after exposure.

Psychotropic drugs are seldom needed to treat acute psychological responses at the accident scene if proper medical care including emotional contact from skilled, empathic helpers is offered. Violence towards victims having lost behavioural control may increase the anxiety among other victims and bystanders, and in fact, increase the risk for more behavioural disturbance within the group, and should thus be avoided.

Some injured persons do not report pain complaints during the 1st second to minutes after even severe physical injury, and some may even continue to perform tasks as usual. This response occurs particularly in situations with continous threat to others or own life (e.g. wounded soldiers). This is part of a brief dissociative response which may be life saving and does not reflect psychopathology. However, a few accident victims respond differently. They may report the most painful physical sensations ever experienced. In the absence of severe physical injury, this response most often reflects catastrophic cognitions associated with severe anxiety⁽⁵⁾ and should be treated accordingly. Most injured patients report some degree of pain as minutes pass, however.

Severe pain should be treated at the accident scene and will contribute to psychological and physical recovery from the injury.⁽⁹⁾ Anxiety and fear may lead to increased pain complaints, so may imagined (!) severe injuries. For those reasons, it is important not only to examine the presence of actual injury, but also explicitly ask the victim if he or she believes or fears having sustained serious or life-threatening injuries not detected by the medical personnel. If yes, factual information combined with additional proper medical examination if needed, should be provided to reduce the subject’s fears and worries. Faced with true life-threatening injuries, the helper should admit facts if asked, but nevertheless provide some hope and cautioned optimism. It is often hard to evaluate true prognosis at the accident scene and advanced trauma surgery may save the life of many severely injured subjects who would have died a few decades ago.

Rear end collision may cause a whiplash like movement of the neck. Biomechanical studies suggest overstretch of cervical facet-joint capsules as a possible source of pain. Neck pain, stiffness or tenderness may occur minutes to hours after the accident. A medical examination including an X-ray of the cervical columna seldom reveals pathological findings (Quebec classification grade I). In more severe cases, distortion and minor bleeding in capsules, ligaments, tendons or muscles (grade II) may lead to additional musculoskeletal signs such as decreased range of motion and point tenderness. In severe injuries, neurological findings (impaired myostatic reflexes, pareses, loss of sensibility, grade III) or even fractures (grade IV) may be present. In patients with whiplash related injury grade I or II, acute psychological distress and associated neck pain is the most important predictor of long-term outcome.

In the emergency room, treatment should aim at providing the subject with adequate information about the good prognosis. Pain after whiplash-injury usually lasts for four-to-six weeks (!), but gradually disappears. In cases of pain without somatic findings, pain killers or antiflogistic medication have uncertain effect and should not be prescribed for more than a week. Sick leave should be avoided or be as short as possible. Mobilization and early return to work is recommended. Overtreatment by physicians or physiotherapists (e.g. application of stiff collar despite no findings of injury to the cervical columna) may lead to permanent illness behaviour and pain-fixation.⁽¹⁵⁾ The optimal physical treatment of whiplash injury is still unsettled,⁽¹⁶⁾ but premorbid pain and psychiatric disorders represent a risk for development of chronic disabling symptoms and should be treated.

Relatives or survivors may want to see dead significant others brought to hospital, and touch them. This process helps the relatives to work through the traumatic event and should be encouraged. If the dead body is grotesquely disfigured, the most horrifying parts should be covered prior to exposure. In any case, a physician or a skilled nurse should accompany the relatives during exposure. Small childrens’ emotional response to dead bodies mirror the adults’ response. Accordingly, reducing the anxiety and fear of the adults is the best way to help children cope with dead ones. Correspondingly, in cases of severe anxiety in accompanying small children, addressing the helplessness and anxiety of the parents is important. If dead bodies are stored in hospital chapels, care must be taken to cover the presence of religious symbols incongruent to the religious status of the dead one and his family (e.g. Christian crosses should be covered in case of a Jew or a Muslim). The reader is referred to chapter 4.16 for more information on culture specific responses to stress and trauma.

In disaster situations, the need for information varies among relatives, depending on whether their loved ones are missing, injured, or dead (survivor status). Those who have lost loved ones often want to talk to rescuers or get information with regard to any hint about the emotional status of the dead one at the time of death. Accordingly, in situations with several hundred relatives come to the hospital, information is provided in separate groups according to the significant other survivor status. The logistics of such procedures should be outlined in the hospital’s disaster plan.