Psychiatric Dimensions Post- -Disaster: A Disaster: A Psychiatric - - PowerPoint PPT Presentation

Psychiatric Dimensions Post Psychiatric Dimensions Post-

• Disaster: A

Disaster: A Public Health Perspective Public Health Perspective

Anthony T. Ng, MD Anthony T. Ng, MD

Uniformed Services School of Medicine Uniformed Services School of Medicine George Washington University School of George Washington University School of Medicine Medicine Director Director Mannanin Mannanin Healthcare, LLC Healthcare, LLC (917) 579 (917) 579-

• 5797

5797 Anthony.ng@mannainhealthcare.org Anthony.ng@mannainhealthcare.org

Public Public’ ’s Mental Health s Mental Health

• Protect nation

Protect nation’ ’s capabilities, s capabilities, values, infrastructure and values, infrastructure and social capital social capital

• Mitigate propagation of fear,

Mitigate propagation of fear, distress, unhealthy changes in distress, unhealthy changes in behavior, psychiatric disease behavior, psychiatric disease

• Must be community,

Must be community, population focus population focus

• Promote community

Promote community cohesiveness cohesiveness

What is a Disaster? What is a Disaster?

• Traumatic events that

Traumatic events that

• verwhelm a community
• verwhelm a community
• A severe psychosocial

A severe psychosocial disruption which can disruption which can greatly exceeds the greatly exceeds the coping capacities of the coping capacities of the community community

• Disaster

Disaster vs vs Mass Mass Casualties Incidents Casualties Incidents

Disaster Pyramid Disaster Pyramid

Disaster Victims Disaster Victims

Families/Friends/Rescue Workers Families/Friends/Rescue Workers Medical Professionals Medical Professionals

Public At Large Public At Large

Presentation by Presentation by Reissman Reissman, 2005 , 2005

Potential Long Term Disaster Issues Potential Long Term Disaster Issues

• Disaster itself

Disaster itself

• Death and injuries

Death and injuries

• Displacement/relocation

Displacement/relocation

• Relationship dynamics (loss

Relationship dynamics (loss and gain) and gain)

• Uniqueness and isolation

Uniqueness and isolation

• Job loss

Job loss

• Financial loss

Financial loss

• Post disaster experiences

Post disaster experiences

• Anniversaries

Anniversaries

Ripple Effects of Disasters Ripple Effects of Disasters

• Population shift

Population shift

• Cultural displacement

Cultural displacement

• Long term unemployment

Long term unemployment

• Health problems related to

Health problems related to

• ngoing stress and
• ngoing stress and

psychological distress psychological distress

• Poor life adjustment

Poor life adjustment

• Loss of functional capacity

Loss of functional capacity

• Media coverage

Media coverage

• Discrimination/

Discrimination/scapegoating scapegoating

Factors Associated With Mental Factors Associated With Mental Health Outcomes and Resilience Health Outcomes and Resilience

• The Event

The Event

• Community/Societal Structures

Community/Societal Structures

• Idiosyncratic characteristics of the individuals

Idiosyncratic characteristics of the individuals involved, including their interpersonal/familial involved, including their interpersonal/familial relationships relationships

Warheit Warheit, 1986 , 1986

Groups at Increased Risk Groups at Increased Risk

• Greater traumatic exposure,

Greater traumatic exposure, injury, threat injury, threat

• Women

Women

• Middle

Middle-

• aged adults

aged adults

• Ethnic minorities

Ethnic minorities

• Children of distressed

Children of distressed parents parents

• Mothers with young children

Mothers with young children

• Number of negative life

Number of negative life events events

• Greater loss of resources

Greater loss of resources

• Poor social support

Poor social support

• Prior psychological sx,

Prior psychological sx, substance abuse substance abuse

• Worry and anxious traits

Worry and anxious traits

(Norris FH et al, 2002)

Underlying Assumptions Underlying Assumptions

• The majority of survivors and family members will

The majority of survivors and family members will successfully successfully “ “recover recover” ” without MH assistance without MH assistance

• “

“Recovery Recovery” ” involves reclaiming and reconstructing involves reclaiming and reconstructing

• ne
• ne’

’s life s life -

• finding a

finding a “ “new normal, new normal,” ” which occurs which occurs gradually over years gradually over years

• A significant minority will experience PTSD,

A significant minority will experience PTSD, depression, anxiety and distress and may benefit from depression, anxiety and distress and may benefit from MH intervention MH intervention

Most people experiencing disaster trauma do not

develop long term psychiatric pathology

Common Diagnoses in Common Diagnoses in Disasters Disasters

Acute stress disorder Panic disorder Adjustment disorder with depressed, anxious or mixed

features

Exacerbation of Personality disorders Psychotic illness, including Brief Psychotic Disorder Substance use (exacerbations) Psychiatric Disorder due to medical conditions Exacerbation of pre-existing PTSD

5 10 15 20 25 % of population

Adapted from Kessler et al. 1994, 1995

MOOD DISORDERS ANXIETY DISORDERS

Major depression Alcohol use disorder Drug use disorder

SUBSTANCE USE DISORDERS

Bipolar disorder GAD Panic disorder PTSD

LIFETIME PREVALENCE OF PSYCHIATRIC DISORDERS: NATIONAL COMORBIDITY STUDY

Risk of PTSD Following Specific Risk of PTSD Following Specific Traumas in The U.S. Population Traumas in The U.S. Population

Percentage

10 60

4%

Natural disaster

49%

Rape

32%

Beating

Breslau et al, Breslau et al, Arch Gen Psychiatry, Arch Gen Psychiatry, 55:626 55:626– –32, 1998 32, 1998 15%

Shooting or stabbing

54%

Kidnapping, torture, captivity

20 30 40 50

Incidence of PTSD Incidence of PTSD

• 28% had PTSD one month after cafeteria

28% had PTSD one month after cafeteria shooting with 18% having another psych shooting with 18% having another psych dx dx

• 24% had PTSD one year later and 12% with

24% had PTSD one year later and 12% with another psych another psych dx dx

• ½

½ of PTSD cases over 3 years were in remission

• f PTSD cases over 3 years were in remission

North CS et al. 1997 North CS et al. 2002

• B. > 1 new Group B symptom (Re-experiencing):
• Intrusive memories
• Nightmares
• Flashbacks
• Upset by reminders
• Physiologic reactivity to reminders
• A. Exposure to traumatic event - threat to life or limb
• with victim response of fear, helplessness, or horror
• C. > 3 new Group C symptoms (Avoidance/Numbing):
• Avoids thoughts/feelings
• Avoids reminders
• Event amnesia
• Loss of interest
• Detachment/estrangement
• Restricted range of affect
• Sense of foreshortened future
• D. > 2 new Group D symptoms (Hyperarousal):
• Insomnia
• Irritability/anger
• Difficulty concentrating
• Hypervigilance
• Exaggerated startle
• E. Duration > one month
• F. Clinically significant distress / impaired functioning

Note: Delayed onset > 6 months; Chronic > 3 months

B, C, & D symptoms must be new after the event to qualify; existing symptoms such as sleep problems in the population are not counted & will yield inflated estimates of PTSD rates DSM-IV CRITERIA FOR PTSD DSM-IV CRITERIA FOR PTSD

10 20 30 40 50 60 70 80 90 100

% of subjects meeting criteria

PTSD PTSD

S SYMPTOM

YMPTOM G

GROUPS

ROUPS

Oklahoma City Bombing (N=182) Oklahoma City Bombing (N=182)

Groups B, C, Groups B, C, and and D D

PTSD PTSD

34% Group C Group C Avoidance/numbing Avoidance/numbing 36% Group D Group D Hyperarousal Hyperarousal Group B Group B Intrusive re Intrusive re-

• experience

experience 82% 79%

94% 94%

North et al 1999 North et al 1999

NEED TO MEET ALL 6 NEED TO MEET ALL 6 CRITERIA: CRITERIA: A, B, C, D, E, A, B, C, D, E, AND AND F F

Not with a questionnaire, but the old fashioned Not with a questionnaire, but the old fashioned way way… …by taking a history to determine if by taking a history to determine if DSM DSM-

• IV

IV-

• TR

TR diagnostic criteria are met diagnostic criteria are met

How Do You Diagnose PTSD?

Disasters and Psychopathology Disasters and Psychopathology

• But

But…… …….. ..

Disasters and Psychopathology Disasters and Psychopathology

• Although lifetime risk for exposure to PTE is extremely high

Although lifetime risk for exposure to PTE is extremely high (60% (60%-

• 90%), the prevalence of PTSD is relatively low

90%), the prevalence of PTSD is relatively low

Breslau et al., 1998; Kessler et al., 1995 Breslau et al., 1998; Kessler et al., 1995

• Approximately 9% of individuals exposed to any PTE report

Approximately 9% of individuals exposed to any PTE report PTSD at some point across the lifespan PTSD at some point across the lifespan

Breslau et al., 1998 Breslau et al., 1998

• Majority of individuals experience substantial reductions in

Majority of individuals experience substantial reductions in PTSD symptoms through the first three months and recover PTSD symptoms through the first three months and recover without professional help without professional help

Rothbaum Rothbaum et al, 1992; et al, 1992; Valentiner Valentiner et al, 1996 et al, 1996

Psychological Effects of Disaster Psychological Effects of Disaster

• Post traumatic stress of 17 % at 2 months after 9/11,

Post traumatic stress of 17 % at 2 months after 9/11, 5.8% at 6 months 5.8% at 6 months

• Greater risk with female gender, marital separation, and

Greater risk with female gender, marital separation, and previous physician diagnosed depression and anxiety previous physician diagnosed depression and anxiety disorder disorder

• Disengagement of coping skills associated with greater

Disengagement of coping skills associated with greater risk risk

• PTSD prevalence of 7.5% at 1 month after 9/11 to

PTSD prevalence of 7.5% at 1 month after 9/11 to 0.6% at 6 months 0.6% at 6 months

Galea S et al. 2003 Silver RC et al. 2002

Psychological Effects of Disaster Psychological Effects of Disaster

• Low rates of PTSD but high rates of post

Low rates of PTSD but high rates of post traumatic traumatic sx sx’ ’s s after school shooting after school shooting

• 5% met criteria for PTSD but 96% with PTSD

5% met criteria for PTSD but 96% with PTSD sx sx’ ’s s 3 years after a courthouse shooting 3 years after a courthouse shooting

Johnson SD et al. 2002 Schwarz ED & Kowalski JM, 1991

Most people experiencing Most people experiencing disaster trauma do not develop disaster trauma do not develop long term psychiatric pathology long term psychiatric pathology

Mental Health in Disaster

Mental Mental Health/ Health/ Illness Illness

• PTSD
• Depression

Human Human Behavior in Behavior in High Stress High Stress Environments Environments Distress Distress Responses Responses

• Change in Safety
• Change in Travel
• Smoking
• Alcohol
• Over dedication

Center for Traumatic Stress Studies 2005

Types of Distress Behaviors Types of Distress Behaviors

• Changes in lifestyles

Changes in lifestyles

• Changes in travel

Changes in travel

• Tobacco, alcohol use

Tobacco, alcohol use

• School dropout rates

School dropout rates

• Work absenteeism or

Work absenteeism or

• verwork
• verwork
• Divorce

Divorce

• Domestic or interpersonal

Domestic or interpersonal violence violence

• Health care seeking

Health care seeking

Hurricane Katrina (2005) Problems 5-8 months post (N=1043)

Kessler et al , 2006

Examples of Public Responses to Epidemic Examples of Public Responses to Epidemic and Bioterrorism Threat and Bioterrorism Threat

• Mass Exodus/Non

Mass Exodus/Non-

• cooperation with authorities

cooperation with authorities Three Mile Island, US, 1979 Three Mile Island, US, 19791

1

and Plague in Surat, India, 1994 and Plague in Surat, India, 19942

2

• Change in consumerist behavior

Change in consumerist behavior Mad Cow Disease, England, 1996 Mad Cow Disease, England, 19963

3 and SARS, Toronto, 2003

and SARS, Toronto, 20034

4

• Stigmatizing the group perceived to be affected

Stigmatizing the group perceived to be affected AIDS, US, 1980s AIDS, US, 1980s5

5

and SARS, Toronto, 2003 and SARS, Toronto, 20036

6

• Increase in demand for health services by non

Increase in demand for health services by non-

• affected people

affected people Anthrax, US, 2001 Anthrax, US, 20017

7

and Sarin gas attack, Tokyo, 1995 and Sarin gas attack, Tokyo, 19958

8

• Call for extreme government measures

Call for extreme government measures SARS, Toronto, 2003 SARS, Toronto, 20039

9

and AIDS, US, 1985 and AIDS, US, 198510

10

• 1. J Johnson 1983 2. J John 1995 3. S Jasanoff 1997 4. R Blendon 2003 5. D Nelkin 1986 6.R Blendon 2003 7. R Blendon 2002
• 8. C Digiovanni 1999 9. R Blendon 2003 10. ABC/NY Daily News.

Disaster Effects Disaster Effects

• Perceived Safety

Perceived Safety

• Change in Behavior

Change in Behavior

• Stigmatization

Stigmatization

• Confidence in Government

Confidence in Government

Risk Perceptions Risk Perceptions

“ “Whereas technologically sophisticated Whereas technologically sophisticated analysts employ risk assessment to analysts employ risk assessment to evaluate hazards, the majority of citizens evaluate hazards, the majority of citizens rely on intuitive risk judgments, typically rely on intuitive risk judgments, typically called called “ “risk perceptions. risk perceptions.” ”

Slovic Slovic, 1987 , 1987

Perceived Safety Perceived Safety

• Erode sense of

Erode sense of national security national security

• Disrupt the continuity

Disrupt the continuity

• f society
• f society
• Destroy social capital

Destroy social capital

• Morale

Morale

• Cohesion

Cohesion

• Shared Values

Shared Values

Longitudinal National Study of Longitudinal National Study of Reactions to Terrorist Attack Reactions to Terrorist Attack

2 weeks (N=2729), 2 months (N=933) 2 weeks (N=2729), 2 months (N=933) 6 months (N=787) 6 months (N=787)

Silver et. al. 2002

Outside of NYC Outside of NYC 2 mos. 2 mos. 6 mos. 6 mos. 9/11 Posttraumatic Stress 17.0% 5.8%

Longitudinal National Study of Longitudinal National Study of Reactions to Terrorist Attack Reactions to Terrorist Attack

2 weeks (N=2729), 2 months (N=933) 2 weeks (N=2729), 2 months (N=933) 6 months (N=787) 6 months (N=787)

Silver et. al. 2002 Outside of NYC Outside of NYC 2 mos. 2 mos. 6 mos. 6 mos.

Fears of Future Terrorism Fears of Future Terrorism 64.6% 37.5% 64.6% 37.5% Fear of Harm to Family Fear of Harm to Family 59.5% 40.6% 59.5% 40.6%

Change in Consumerist Behavior: Change in Consumerist Behavior: The Economic Impact of SARS The Economic Impact of SARS

9% 7% 35% 9% 16%

Americans Toronto Area Residents

Avoided public events Avoided international air travel*

• 1. HSPH/ICR survey, May 2003 2. HSPH/Health Canada/GPC survey, June 2003.

*Among those who reported international air travel in the past 12 months

SARS has made it unsafe to travel to Canada1

Precautions against SARS2

% saying they…

1 2

People Take More Precautions People Take More Precautions When Concerned When Concerned

10% 7% 19% 8% 11% 39% 21% 26% 28% 29% 32% 56%

Not concerned about SARS Concerned about SARS

Harvard School of Public Health/Health Canada/GPC Research poll, June 2003.

Example: In Toronto, those concerned about SARS took more precautions

Used a disinfectant at home or at work Avoided Asian restaurants

• r stores

Avoided public events Carried a disinfectant to clean objects Avoided people you think may have recently visited Asia Purchased a face mask

Disaster Disaster

• Opens the fault lines, the potential cracks in

Opens the fault lines, the potential cracks in

• ur society
• ur society
• Racial/ethnic

Racial/ethnic

• Economic

Economic

• Religious

Religious

Cycle of Disaster Mental Health Cycle of Disaster Mental Health

Acute Response Post- Disaster Pre- Disaster

• Planning and preparedness

Planning and preparedness

• Education

Education

• Mitigation

Mitigation

• Response

Response

• Recovery

Recovery

State and Local Systems State and Local Systems

• State disaster plan has mental health component

State disaster plan has mental health component

• Disaster mental health response coordinated through

Disaster mental health response coordinated through community mental health services community mental health services-

• must also sustain care

must also sustain care

• f regular patients
• f regular patients
• Gaps in services and outreach

Gaps in services and outreach-

• clinics serve pre

clinics serve pre-

• existing

existing client base and private practioners may not have client base and private practioners may not have relationship with gov relationship with gov’ ’t agencies to provide care t agencies to provide care

• Federal funding does not cover extensive ongoing care

Federal funding does not cover extensive ongoing care

• Transition from post

Transition from post-

• disaster psychological counseling to

disaster psychological counseling to

• ngoing care
• ngoing care
• Importance of school based mental health services

Importance of school based mental health services

Private Sector Systems Private Sector Systems

• Human services

Human services providers providers

• Workplace

Workplace-

• Employee Assistance

Employee Assistance Programs Programs

• Primary Care

Primary Care

• Faith

Faith-

• based

based

• Local providers

Local providers

Integration of Disaster Mental Health, Integration of Disaster Mental Health, Public Health & Human Services Public Health & Human Services

• Better assessment of

Better assessment of needs of the community needs of the community and in turn the and in turn the individuals individuals

• Ensure buy in by all

Ensure buy in by all parties and stakeholders parties and stakeholders

• More efficient resource

More efficient resource allocation allocation

• Focus on basic human

Focus on basic human services and medical services and medical needs needs

Zunin LM, Myers D. Training Manual for Human Service Workers in Zunin LM, Myers D. Training Manual for Human Service Workers in Major Major

• Disasters. 2
• Disasters. 2nd

nd

• ed. Washington DC: Department of Health and Human Services.
• ed. Washington DC: Department of Health and Human Services.

Substance Abuse and Mental Health Services Administration. Cente Substance Abuse and Mental Health Services Administration. Center for Mental r for Mental Health Services: 2000. DHHS Publication No. ADM 90 Health Services: 2000. DHHS Publication No. ADM 90-

• 538

538

Immediate/Delayed Reactions to Immediate/Delayed Reactions to a Sudden and Violent Event a Sudden and Violent Event

• Physical

Physical

• Emotional

Emotional

• Cognitive

Cognitive

• Behavioral

Behavioral

• Spiritual

Spiritual

Hurricane Katrina (2005) Stress Reactions at 5-8 months (N=1043)

Kessler et al , 2006

Health Issues and Disaster Health Issues and Disaster

• Disaster exposure increased primary health care use for

Disaster exposure increased primary health care use for 12 months or more after the event 12 months or more after the event

• Victims with pre

Victims with pre-

• disaster psych issues were at greater

disaster psych issues were at greater risk for post risk for post-

• disaster psych problems

disaster psych problems

• Relocated victims showed excess of MUPS especially in

Relocated victims showed excess of MUPS especially in the period of increased media the period of increased media attentiion attentiion

• Both groups of victims had increased GI morbidity

Both groups of victims had increased GI morbidity

Freedy JR and Simpson WM. 2007 Yzermans CJ et al. 2005

Signs of Impairment Signs of Impairment

• Inability to use life support systems such as

Inability to use life support systems such as family, friends and social groups family, friends and social groups

• Inability to care for self and family

Inability to care for self and family

• Inability to deal with benefit issues

Inability to deal with benefit issues

• Suicidal and homicidal behaviors

Suicidal and homicidal behaviors

• Psychosis

Psychosis

• Marked anxiety and depression

Marked anxiety and depression

Principles of Disaster Mental Health Principles of Disaster Mental Health Service Service

• Resilience and recovery

Resilience and recovery

• Most cope well, even strengthened

Most cope well, even strengthened

• May be transformative

May be transformative-

• “

“post post-

• traumatic growth

traumatic growth” ”

• Not a fixed attribute but variable: vulnerability, protective

Not a fixed attribute but variable: vulnerability, protective mechanisms, affective and coping style mechanisms, affective and coping style

• Pre

Pre-

• disaster level of functioning

disaster level of functioning

• Avoidance of mental health labeling

Avoidance of mental health labeling

• “

“Stress and support Stress and support” ” services services

• Support local community care

Support local community care

Phases of Mental Health Response Phases of Mental Health Response

• Emergency

Emergency-

• Triage: Protect, Direct, Connect

Triage: Protect, Direct, Connect

• Post

Post-

• impact

impact— —up to 8 up to 8-

• 12 weeks, psychoeducational

12 weeks, psychoeducational interventions, crisis counseling interventions, crisis counseling

• Restoration

Restoration— —long term recovery programs long term recovery programs

Goals of Disaster Mental Health Goals of Disaster Mental Health Services Services

• Crisis stabilization

Crisis stabilization

• Surveillance

Surveillance

• Promotion of resilience,

Promotion of resilience, coping coping

• Manage acute stress

Manage acute stress reactions reactions

• Reduce maladaptive

Reduce maladaptive behaviors behaviors

• Flexible, supportive,

Flexible, supportive, problem problem-

• solving

solving

• Maintain and improve

Maintain and improve role function role function

• Prevent, treat chronic

Prevent, treat chronic distress, illness distress, illness

• Referral

Referral

How Do We Know How to How Do We Know How to Respond Following Disasters? Respond Following Disasters?

• Disaster Research

Disaster Research

• Extrapolation

Extrapolation

• Consensus

Consensus

• Clinical Experience

Clinical Experience

• Customer feedback

Customer feedback

• Program evaluation

Program evaluation

Evidence Base for Early Evidence Base for Early Intervention for Adults Intervention for Adults

High level of evidence:

none

Medium level of evidence:

Cognitive behavioral therapy

Low levels of evidence:

Debriefing, EMDR, Psychopharmacology,

Psychodynamic therapy, “Alternative” therapies

Evidence Base for Later Evidence Base for Later-

• Stage

Stage Interventions for Adults Interventions for Adults

High level of evidence:

CBT

Medium level of evidence:

EMDR, SSRIs

Low level of evidence:

Psychodynamic therapy, “Alternative” therapies

General Considerations

Consider social structure of community

Socio-economic status, gender, race ethnicity Diverse effects of disaster’s: loss of life, injury, property

damage, economic impact

Respect victims’ internal and external coping

capacities

• “

“First, do no harm First, do no harm” ” (NIMH, 2002) (NIMH, 2002)

Tierney, 2000 Norris et al, 2002 Everly, 2003

General Principles General Principles

• Challenges in assessment

Challenges in assessment

• Vulnerability to side effects

Vulnerability to side effects

• Clarification of goals

Clarification of goals

What do you see? What do you see?

NOW what do you see? NOW what do you see?

Assessment Assessment

• Conduct a standard interview

Conduct a standard interview

• Emphasize 5 key risk factors for psychopathology:

Emphasize 5 key risk factors for psychopathology:

• Past psychiatric history

Past psychiatric history

• “

“dose of trauma dose of trauma” ” (exposure) (exposure)

• Problems of living prior to disaster

Problems of living prior to disaster

• Level of impairment

Level of impairment

• Availability of psychosocial supports

Availability of psychosocial supports

• Don

Don’ ’t forget ETOH/Drug use t forget ETOH/Drug use

Psychological First Aid

Approach endorsed by an international expert panel* for universal application after mass violence or disaster.

• Sponsored by U.S. Department of Health and Human Services

& U.S. Department of Veterans Affairs. Bethesda, MD August, 2003.

Psychological First Aid Psychological First Aid

• Flexible, supportive, problem

Flexible, supportive, problem-

• solving

solving

• Needs of survivors

Needs of survivors-

• not aimed at emotional

not aimed at emotional processing processing

• Help navigate services

Help navigate services

• Obtain food and shelter

Obtain food and shelter

• Keep families together, facilitate reunion

Keep families together, facilitate reunion

• May allow sharing thoughts and feelings

May allow sharing thoughts and feelings

• Permission to recontact

Permission to recontact

• Proximity, Immediacy, Expectancy

Proximity, Immediacy, Expectancy

Psychological First Aid Psychological First Aid Field Operations Guide, 2 Field Operations Guide, 2nd

nd

Ed. Ed.

www.nctsn.org www.nctsn.org Or Or www.ncptsd/va/gov www.ncptsd/va/gov

Response to Disaster - Treat Disabling Symptoms

• Insomnia

Insomnia

• Teach sleep hygiene, relaxation techniques

Teach sleep hygiene, relaxation techniques

• Consider short

Consider short-

• term medication (non

term medication (non-

• benzodiazepines first)

benzodiazepines first)

• Anxiety

Anxiety

• Teach relaxation exercises

Teach relaxation exercises

• Physical exercise, rewarding activities

Physical exercise, rewarding activities

• Cautious, brief benzodiazepines for severe symptoms

Cautious, brief benzodiazepines for severe symptoms

• Acute stress disorder

Acute stress disorder

• Consider SSRI trial for symptoms of anxiety or depression

Consider SSRI trial for symptoms of anxiety or depression— — no data proving prevention of PTSD no data proving prevention of PTSD

Intermediate Intermediate-

• Intensity Individual

Intensity Individual Counseling Counseling

• 2

2-

• 3 weeks post trauma, 4

3 weeks post trauma, 4-

• 5 sessions

5 sessions

• Cognitive

Cognitive-

• behavioral approach

behavioral approach

• Education

Education

• Anxiety management training

Anxiety management training

• Imaginal exposure training, in

Imaginal exposure training, in-

• vivo exposure

vivo exposure

• Cognitive restructuring (CR)

Cognitive restructuring (CR)

• Tested in survivors of MVAs, industrial accidents, nonsexual

Tested in survivors of MVAs, industrial accidents, nonsexual assault assault

• Appears to prevent PTSD

Appears to prevent PTSD

Acute Stress Disorder: CBT Acute Stress Disorder: CBT

Study of 80 civilian trauma survivors with ASD: Study of 80 civilian trauma survivors with ASD:

• Randomized to CBT or supportive counseling in month

Randomized to CBT or supportive counseling in month after trauma after trauma

• 4 years later:

4 years later: PTSD in 8% CBT, 25% supportive counseling PTSD in 8% CBT, 25% supportive counseling CBT: CBT: ↓ ↓ PTSD symptoms, especially avoidance PTSD symptoms, especially avoidance

• CBT immediately after trauma may have lasting benefits

CBT immediately after trauma may have lasting benefits for those at risk for PTSD for those at risk for PTSD

Bryant et al, 2003.

Psychotherapy of PTSD

• Meta

Meta-

• analysis of controlled psychotherapies (cognitive, behavioral,

analysis of controlled psychotherapies (cognitive, behavioral, psychodynamic): significant symptom reduction over time for all psychodynamic): significant symptom reduction over time for all

• Cognitive therapy

Cognitive therapy

• Cognitive model: PTSD patient cannot process trauma

Cognitive model: PTSD patient cannot process trauma

• Treatment helps pt. process traumatic memories and automatic neg

Treatment helps pt. process traumatic memories and automatic negative ative expectations expectations

• Behavioral therapy

Behavioral therapy

• Behavioral model: classical conditioning produces PTSD

Behavioral model: classical conditioning produces PTSD

• Treatment de

Treatment de-

• conditions PTSD by pairing relaxation techniques with

conditions PTSD by pairing relaxation techniques with systematic desensitization systematic desensitization

• Dynamic psychotherapy for concomitant personality disorders or

Dynamic psychotherapy for concomitant personality disorders or maladaptive behaviors maladaptive behaviors

Sherman et al, 1998.

Components of Trauma Components of Trauma-

• Focused Cognitive

Focused Cognitive Behavioral Therapy TF Behavioral Therapy TF-

• CBT: Practice

CBT: Practice

• Psychoeducation

Psychoeducation, Parenting skills , Parenting skills

• Relaxation, personalized to child, adolescent and parents

Relaxation, personalized to child, adolescent and parents

• Affect modulation skills

Affect modulation skills

• Cognitive restructuring (thoughts, feelings, behaviors)

Cognitive restructuring (thoughts, feelings, behaviors)

• Trauma narrative and contextualizing interventions

Trauma narrative and contextualizing interventions

• In vivo mastery of trauma reminders

In vivo mastery of trauma reminders

• Conjoint child

Conjoint child-

• parent sessions

parent sessions

• Enhancing safety and social skills

Enhancing safety and social skills

Eye Movement Desensitization Eye Movement Desensitization Reprocessing (EMDR) Reprocessing (EMDR)

• Accidentally discovered 1987 when saccadic eye

Accidentally discovered 1987 when saccadic eye movements paired with active processing of traumatic movements paired with active processing of traumatic memories memories reduced distress reduced distress

• Successful desensitization described in 2

Successful desensitization described in 2-

• 3 sessions of

3 sessions of 90 minutes 90 minutes

• Some studies supportive of

Some studies supportive of EMDR EMDR’ ’s s benefits benefits

Other studies suggest eye movement may not be

necessary to effective treatment

Sheck et al, 1998; Wilson et al, 1996 Dunn et al, 1996; Pitman et al, 1996

Virtual Reality Exposure Therapy for Virtual Reality Exposure Therapy for PTSD Vietnam Veterans PTSD Vietnam Veterans

• Imaginal

Imaginal exposure immersed in stimuli exposure immersed in stimuli

• Sense of presence, immersive

Sense of presence, immersive

• Interactive computer simulation

Interactive computer simulation

• Hardware

Hardware

• Head

Head-

• mounted display, position and hand trackers

mounted display, position and hand trackers

• Headphones, microphone, monitor, thunder chair

Headphones, microphone, monitor, thunder chair

• Virtual Huey helicopter

Virtual Huey helicopter

• Simulates flying over jungles, walking in jungle clearing

Simulates flying over jungles, walking in jungle clearing

• Small study

Small study

• 10 PTSD veterans on meds, with moderate to severe PTSD

10 PTSD veterans on meds, with moderate to severe PTSD

• Significant improvement 3 months & 6 months later

Significant improvement 3 months & 6 months later

Rothbaum et al, 2001

Medication Treatment Medication Treatment

• SSRI

SSRI’ ’s s ( (Sertraline Sertraline, , Fluoxetine Fluoxetine, , Paroxetine Paroxetine, , Citalopram Citalopram) )

• TCA

TCA’ ’s s ( (Nortriptyline Nortriptyline, , Imipramine Imipramine) )

• Propranolol/Clonidine

Propranolol/Clonidine ( (Propanolol Propanolol, Methyldopa) , Methyldopa)

• Anxiolytic

Anxiolytic medications/Benzodiazepines (i.e., medications/Benzodiazepines (i.e., Lorazepam Lorazepam, , Clonzaepam Clonzaepam, , Alprazolam Alprazolam) )

• Hypnotic (

Hypnotic (Zolpidem Zolpidem, , Zaleplon Zaleplon, , Trazadone Trazadone) )

• Mood stabilizers (Lithium,

Mood stabilizers (Lithium, Valproic Valproic Acid) Acid)

• Antipsychotics (Haloperidol, Chlorpromazine,

Antipsychotics (Haloperidol, Chlorpromazine, Olanzapine Olanzapine) )

Implications of Medication Use Implications of Medication Use

• Legitimizing

Legitimizing distress/impairment distress/impairment

• Overshadow other

Overshadow other problems (i.e., problems (i.e., psychosocial, financial) psychosocial, financial)

• Reliance on medication

Reliance on medication

• Labeling pt

Labeling pt

• Potential long term side

Potential long term side effects effects

• Disability issues

Disability issues

Ways to Increase Compliance Ways to Increase Compliance

• Recognize patient

Recognize patient’ ’s concerns s concerns

• Support and reassurance

Support and reassurance

• Elicit social support/family

Elicit social support/family

• Target distressful symptoms

Target distressful symptoms

• Address side

Address side-

• effects promptly

effects promptly

• Reaffirm goals

Reaffirm goals

• Permit some patient flexibility

Permit some patient flexibility

Other Forms of Other Forms of “ “Intervention Intervention” ”

• Family

Family

• Friends

Friends

• Peers/colleagues

Peers/colleagues

• Church/spiritual

Church/spiritual

• Primary Care

Primary Care Physician Physician

• Exercises/sports

Exercises/sports

• Routines

Routines

• Alternative

Alternative medicine medicine

Think Outside of the Box Think Outside of the Box

Before Disasters: Before Disasters: During Disasters: During Disasters:

Wellness Skills Wellness Skills

• Have periodic reevaluation of why you want to

Have periodic reevaluation of why you want to work with disaster victims work with disaster victims

• Recognize and adhere to limits

Recognize and adhere to limits

• Have frequent consultation, formal and

Have frequent consultation, formal and informal, with colleagues informal, with colleagues

• Utilize team approach

Utilize team approach

• Take adequate breaks

Take adequate breaks

• Engage in pre

Engage in pre-

• established appropriate stress

established appropriate stress coping skills coping skills

The Good News The Good News – – Human Resilience is the Norm Human Resilience is the Norm

Resilience Resilience

• Confucius:

Confucius: “ “Our greatest Our greatest glory is not in never glory is not in never failing, but in rising every failing, but in rising every time we fall time we fall” ”

• Nietzsche:

Nietzsche: “ “That which That which does not kill us can only does not kill us can only make us stronger make us stronger” ”

Post-traumatic personal growth in the Katrina sample

% Became closer to loved ones 81.6 Developed faith in ability to rebuild life 95.6 Discovered inner strength 69.5 Found deeper meaning and purpose in life 75.2 Became more spiritual or religious 66.8

Kessler et al 2006

Post Post-

• Traumatic Growth Caveats

Traumatic Growth Caveats

• Those who report growth do not necessarily experience it in all

Those who report growth do not necessarily experience it in all areas areas

• The presence of growth does not mean the absence of pain and

The presence of growth does not mean the absence of pain and distress distress

• As the losses become more overwhelming, the ability to adapt

As the losses become more overwhelming, the ability to adapt and cope may simply be overwhelmed, and the possibility of and cope may simply be overwhelmed, and the possibility of growth may actually diminish or disappear. growth may actually diminish or disappear.

• Do not rush individuals towards growth

Do not rush individuals towards growth

Summary Summary

Post disaster psychiatric trauma has a complex etiology Post disaster psychiatric trauma is multifactorial Post disaster psychiatric trauma has variable course Ethnic, cultural, political, and economic factors may

influence long term recovery and create differing goals

Individual long term recovery must be community and

public health oriented

Move beyond lessons learned to lessons retained