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The building collapse in Surfside, Florida last week killed at least 16 people, and nearly 150 remain unaccounted for, but what will become of those who survived? How will they get their lives back, and will they ever be able to go into -- much less sleep in -- a high-rise again? MedPage Today Washington Editor Joyce Frieden talked with John Markowitz, MD, professor of clinical psychiatry at Columbia University, about the therapies used to treat those who need help overcoming such traumas. Their conversation was edited for length and clarity.

Tell us a little about yourself and your work.

John Markowitz, MD: I'm a professor at Columbia University and a research psychiatrist at New York State Psychiatric Institute. I'm basically established as a psychotherapy researcher -- work I've done for years.

How do people survive something like the building collapse in Florida?

Markowitz: It depends what kind of survivor you are. It's very scary to think that one moment, the floor is solid, and the next moment it isn't. There was a quote in the newspaper from a man who said, "I looked out and there was nothing there." He opened the door to an abyss and got out just in time, apparently. It's very scary when what you consider solid suddenly isn't, and you could die.

Then there are families, next-door neighbors, the survivors of the people who actually died. And how horrible to be living in the twin building [close by] and not know whether your building is safe, although the inspectors say it is. Then there are the first responders who are sorting through the debris, looking for bodies -- all these people are affected. A major event like this stirs up major feelings.

What diagnoses do these people end up with?

Markowitz: Trauma tends to lead to one or more of several diagnoses, depending on what you came in with. So, most people when they face something horrific like this are in shock, initially, and hopefully they talk to some other people and get support; we know this is really important. And if you can process the trauma -- "I have to tell you I've just been through the most upsetting thing. Can I tell you about it?" -- you're likely to do better than if you try to keep it in and pretend nothing happened. It's hard to shrug off a catastrophe.

So different people have different responses. The most common diagnosis and response to trauma is actually depression. A lot of other people are going to develop post-traumatic stress disorder [PTSD]. You need a major trauma in order to get that diagnosis, and this is certainly bad enough. Other people will develop substance problems -- if that's your vulnerability, that's your go-to, then it's a good excuse to shoot up. So, different people have different responses and you can have more than one: you can be depressed and have PTSD, or you can have PTSD and use alcohol or drugs.

How do you care for these patients; what can you do so that they are able to go into -- or even sleep in -- a high-rise building again?

Markowitz: Different conditions require different treatments. Medication can be helpful, but when you have been through something this upsetting, you have to talk about it. And most people will do that and hopefully find a support group or talk to their family or talk to their friends, and process the trauma, and they will be resilient. They'll be really upset but they won't develop a psychiatric disorder.

A subset will develop depression or PTSD or substance and alcohol problems, and you have to treat those accordingly; usually that's principally talk therapy that's indicated, and sometimes you need medication with that. But medication alone does not usually help you deal with having been through a catastrophe. And you wouldn't want to be able to enter a high-rise building only because you were popping Valiums.

If you're a resilient person, what do you tell yourself when you enter a high-rise building after having been through this type of tragedy?

Markowitz: It is a possibility that at any moment, something fatal could happen to you if you stop to think about it, right? If you're walking down the street, a brick could fall off a facade and hit you in the head. You could catch a stray bullet. Or you could trip and fall, bang your head, and have a bleed and die. Life is fragile, if you stop to worry about it -- lots of things can go wrong. Most of the time we ignore those risks unless they're imminent. We screen out worries that don't really make sense.

What happens with PTSD is that the people who develop it tend to try to bury their feelings, to not think about what happened, because it's too upsetting. And if you try to do that -- you're saying, "I'm not going to think about this, I'm not going to think about this" -- everything starts to remind you of what you're trying not to think about. So if you see a tall building, if you see a certain light in the sky which is the time of day when you last looked at the building, if you hear a certain sound, like a siren -- lots of things are going to start to remind you of what you're trying not to think about, so it really doesn't work.

There are different ways to treat that. One is to face the reminders that you're trying to avoid; that's called "exposure therapy." If you can do that -- you say, "I'm not going near any tall buildings," but if you just go near the building, and stand there until you calm down a little bit; you think, "Well it's a tall building. I'm not going in it yet, but it's actually not falling down." And there's a difference between what happened before, and being near a tall building -- tall buildings aren't inherently dangerous, just that one was.

And so, by gradually exposing somebody to their fears, they can habituate because in general, tall buildings are not dangerous. That one was, and we still don't really know why; there may have been a sinkhole, there may have been corrosion, there are all kinds of theories right now. And we just don't know. But presumably not all tall buildings are dangerous, and so you wouldn't want to give them all up.

Exposure therapy is scary for people because you have to face the fears that you're most terrified of. But as you do that -- if you can do that -- you habituate, and you say, "Well actually it's not so scary any more. It's not a pleasant thought, but in fact, the building is still standing and I'm still standing. This building looks solid."

How long does exposure therapy take?

Markowitz: Usually that's a 10-session treatment -- 10 weekly sessions or sometimes even compressed into a couple of weeks. And that seems to help a lot. Once you get the principle, you start with the easier fears and build up to the scarier ones. After a while, people really get it, and say, "Okay, I've got my life back. I don't have to have that follow me."

It used to be thought that exposure therapy was the only way to treat post-traumatic stress disorder. We don't like dogmas like that, so we at Columbia, at the New York State Psychiatric Institute, funded by the National Institute of Mental Health, comparing three different kinds of psychotherapy. One is called "prolonged exposure," which is what I described earlier, where you create a kind of hierarchy of all the things that remind you, that scare you, from the trauma, and then you systematically expose yourself to them. You get used to them and the fears subside. That's the best-tested kind of treatment.

We compared that to interpersonal psychotherapy, which is a treatment we know helps with depression and eating disorders, anxiety disorders, other things -- that had never really been tested for PTSD. Instead of having to do the exposure, which a lot of people don't like because it's scary, we focus not on the idea that you have to face the trauma or re-live the story of the trauma, but rather: what has this done to your social functioning? What has this done to your interacting with other people?

People with PTSD tend to withdraw from other people, and not to trust anything, not just tall buildings; after a while, everything feels unsafe. And yet we know that social support -- being able to talk to the people around you -- is really protective. So we did this therapy where you didn't have to face your fears at all. You just had to deal with your feelings around other people and figure out who you trust and talk to, because not everybody is trustworthy. And that worked just as well as exposure therapy, without the exposure.

The third kind was a kind of "active control" treatment called relaxation therapy. You don't really do exposure and you don't focus on interpersonal functioning, but instead you do muscle relaxation, deep breathing, and physical relaxation, the idea being that when you get anxious, you then get physically agitated. And when you're physically agitated, your heart rate goes up, your muscles tense, and that bodily sensation feeds back to the brain and says, "tense," which makes you more anxious, which makes you more tense. Relaxing the body actually breaks that cycle, and people calm down. It's not quite as strong a treatment, but that also actually helps a fair number of people. There's more than one way to get people better. And then medication too.

Do you expect to see an increase in these types of trauma cases?

Markowitz: Yes. We live in a particularly violent country with lots of shooting deaths, and so far no effective way to institute appropriate gun control, so lots of people die violently from that. COVID has wiped out 600,000 Americans so far, and there's a lot of upset and stress from that -- and deaths under terrible circumstances where you can't go to the hospital to visit your loved one, and there are no normal funerals so you can't mourn in the normal way. So, lots of problems with these things. The more trauma there is, the more people are not going to be able to tolerate it, and a percentage of people will develop psychiatric problems, including PTSD.

How should communities respond when these tragic events occur?

Markowitz: What would be good is -- and I believe this is happening in Florida -- if there's a real community response. I think one of the things that helped limit the degree of post-traumatic stress in New York after September 11 was that people really pulled together. New Yorkers were friendlier than they've ever been before or since, supporting one another and being kind to one another. The bus would wait for you instead of leaving. So community support would be a really important thing, and I believe that it's happening there -- rescue teams have come in from all over the world to try to help out. So hopefully people feel supported, and able to talk about what they're going through.

And from a medical standpoint, how should primary care doctors respond when they see patients who appear to be suffering from the aftermath of a traumatic event?

Markowitz: Primary care doctors have it rough; they have on average less than 12 minutes with a patient, and they have to cover a lot of ground in that time, so it's hard to even think about psychiatric issues. But there's a significant overlap between medical conditions and psychiatric conditions, and people who are depressed are less likely to take care of themselves and take their other medications. So it's important to pay attention to your patient's state of mind.

If somebody looks really depressed, it's something to take very seriously and it's a very treatable condition, although people with depression often feel untreatable and hopeless. There are a variety of antidepressant medications available to treat depression.

And with PTSD, people often look very controlled, and emotion-less because they're burying their feelings, so it can be a little harder to pick up in some ways; depression is usually more obvious. But there are medications like serotonin reuptake inhibitors that can help with PTSD, and certainly psychotherapy.

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