psychiatric dimensions post-disaster: a public health ... · psychiatric dimensions post-disaster:...
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Psychiatric Dimensions PostPsychiatric Dimensions Post--Disaster: A Disaster: A
Public Health PerspectivePublic Health Perspective
Anthony T. Ng, MDAnthony T. Ng, MDUniformed Services School of MedicineUniformed Services School of Medicine
George Washington University School of George Washington University School of MedicineMedicine
DirectorDirectorMannaninMannanin
Healthcare, LLCHealthcare, LLC(917) 579(917) 579--57975797
[email protected]@mannainhealthcare.org
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PublicPublic’’s Mental Healths Mental Health
Protect nationProtect nation’’s capabilities, s capabilities, values, infrastructure and values, infrastructure and social capitalsocial capitalMitigate propagation of fear, Mitigate propagation of fear, distress, unhealthy changes in distress, unhealthy changes in behavior, psychiatric diseasebehavior, psychiatric diseaseMust be community, Must be community, population focuspopulation focusPromote community Promote community cohesivenesscohesiveness
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What is a Disaster?What is a Disaster?
Traumatic events that Traumatic events that overwhelm a communityoverwhelm a communityA 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 communitycommunityDisaster Disaster vsvs Mass Mass Casualties IncidentsCasualties Incidents
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Disaster PyramidDisaster Pyramid
Disaster VictimsDisaster Victims
Families/Friends/Rescue WorkersFamilies/Friends/Rescue WorkersMedical Professionals Medical Professionals
Public At LargePublic At Large
Presentation by Presentation by ReissmanReissman, 2005, 2005
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Potential Long Term Disaster Issues Potential Long Term Disaster Issues
Disaster itselfDisaster itselfDeath and injuriesDeath and injuriesDisplacement/relocationDisplacement/relocationRelationship dynamics (loss Relationship dynamics (loss and gain)and gain)Uniqueness and isolationUniqueness and isolationJob lossJob lossFinancial lossFinancial lossPost disaster experiencesPost disaster experiencesAnniversariesAnniversaries
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Ripple Effects of DisastersRipple Effects of Disasters
Population shiftPopulation shiftCultural displacementCultural displacementLong term unemploymentLong term unemploymentHealth problems related to Health problems related to ongoing stress and ongoing stress and psychological distresspsychological distressPoor life adjustmentPoor life adjustmentLoss of functional capacityLoss of functional capacityMedia coverageMedia coverageDiscrimination/Discrimination/scapegoatingscapegoating
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Factors Associated With Mental Factors Associated With Mental Health Outcomes and ResilienceHealth Outcomes and Resilience
The EventThe EventCommunity/Societal StructuresCommunity/Societal StructuresIdiosyncratic characteristics of the individuals Idiosyncratic characteristics of the individuals involved, including their interpersonal/familial involved, including their interpersonal/familial relationshipsrelationships
WarheitWarheit, 1986, 1986
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Groups at Increased RiskGroups at Increased Risk
Greater traumatic exposure, Greater traumatic exposure, injury, threatinjury, threatWomenWomenMiddleMiddle--aged adultsaged adultsEthnic minoritiesEthnic minoritiesChildren of distressed Children of distressed parentsparentsMothers with young childrenMothers with young children
Number of negative life Number of negative life eventseventsGreater loss of resourcesGreater loss of resourcesPoor social supportPoor social supportPrior psychological sx, Prior psychological sx, substance abusesubstance abuseWorry and anxious traitsWorry and anxious traits
(Norris FH et al, 2002)
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Underlying AssumptionsUnderlying Assumptions
The majority of survivors and family members will The majority of survivors and family members will successfully successfully ““recoverrecover”” without MH assistancewithout MH assistance““RecoveryRecovery”” involves reclaiming and reconstructing involves reclaiming and reconstructing oneone’’s life s life -- finding a finding a ““new normal,new normal,”” which occurs which occurs gradually over yearsgradually over yearsA 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 interventionMH interventionMost people experiencing disaster trauma do not develop long term psychiatric pathology
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Common Diagnoses in Common Diagnoses in DisastersDisasters
Acute stress disorderPanic disorderAdjustment disorder with depressed, anxious or mixed featuresExacerbation of Personality disordersPsychotic illness, including Brief Psychotic DisorderSubstance use (exacerbations)Psychiatric Disorder due to medical conditionsExacerbation of pre-existing PTSD
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0
5
10
15
20
25
% o
f pop
ulat
ion
Adapted from Kessler et al. 1994, 1995
MOOD DISORDERS
ANXIETY DISORDERS
Majordepression
Alcoholuse
disorder
Druguse
disorder
SUBSTANCE USE DISORDERS
Bipolardisorder
GAD Panicdisorder
PTSD
LIFETIME PREVALENCE OF PSYCHIATRIC DISORDERS: NATIONAL COMORBIDITY STUDY
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Risk of PTSD Following Specific Risk of PTSD Following Specific Traumas in The U.S. PopulationTraumas in The U.S. Population
Per
cent
age
0
10
60
4%
Natural disaster
49%
Rape
32%
Beating
Breslau et al, Breslau et al, Arch Gen Psychiatry, Arch Gen Psychiatry, 55:62655:626––32, 199832, 1998
15%
Shooting orstabbing
54%
Kidnapping,torture,captivity
20
30
40
50
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Incidence of PTSDIncidence 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 dxdx24% had PTSD one year later and 12% with 24% had PTSD one year later and 12% with another psych another psych dxdx
½½ of PTSD cases over 3 years were in remissionof PTSD cases over 3 years were in remission
North CS et al. 1997
North CS et al. 2002
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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 monthF. Clinically significant distress / impaired functioningNote: 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
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0 10 20 30 40 50 60 70 80 90 100% of subjects meeting criteria
PTSDPTSD
SSYMPTOM YMPTOM GGROUPSROUPSOklahoma City Bombing (N=182)Oklahoma City Bombing (N=182)
Groups B, C, Groups B, C, andand DDPTSDPTSD
34%
Group CGroup CAvoidance/numbingAvoidance/numbing 36%
Group DGroup DHyperarousalHyperarousal
Group BGroup BIntrusive reIntrusive re--experienceexperience
82%
79%
94%94%
North et al 1999North et al 1999
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NEED TO MEET ALL 6 NEED TO MEET ALL 6 CRITERIA:CRITERIA:
A, B, C, D, E, A, B, C, D, E, ANDAND
F F
Not with a questionnaire, but the old fashioned Not with a questionnaire, but the old fashioned wayway……by taking a history to determine if by taking a history to determine if DSMDSM--
IVIV--TRTR
diagnostic criteria are metdiagnostic criteria are met
How Do You Diagnose PTSD?
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Disasters and PsychopathologyDisasters and Psychopathology
ButBut…………....
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Disasters and PsychopathologyDisasters 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 low90%), the prevalence of PTSD is relatively low
Breslau et al., 1998; Kessler et al., 1995Breslau 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 lifespanPTSD at some point across the lifespan
Breslau et al., 1998Breslau 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 helpwithout professional help
RothbaumRothbaum
et al, 1992; et al, 1992; ValentinerValentiner
et al, 1996et al, 1996
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Psychological Effects of DisasterPsychological 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 months5.8% at 6 monthsGreater 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 disorderdisorderDisengagement of coping skills associated with greater Disengagement of coping skills associated with greater riskrisk
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 months0.6% at 6 months
Galea
S et al. 2003
Silver RC et al. 2002
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Psychological Effects of DisasterPsychological Effects of Disaster
Low rates of PTSD but high rates of post Low rates of PTSD but high rates of post traumatic traumatic sxsx’’ss after school shootingafter school shooting
5% met criteria for PTSD but 96% with PTSD 5% met criteria for PTSD but 96% with PTSD sxsx’’ss 3 years after a courthouse shooting3 years after a courthouse shooting
Johnson SD et al. 2002
Schwarz ED & Kowalski JM, 1991
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Most people experiencing Most people experiencing disaster trauma do not develop disaster trauma do not develop long term psychiatric pathologylong term psychiatric pathology
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Mental Health in Disaster
Mental Mental Health/Health/IllnessIllness
• PTSD• Depression
Human Human Behavior inBehavior in
High Stress High Stress EnvironmentsEnvironments
Distress Distress ResponsesResponses
• Change in Safety• Change in Travel
• Smoking• Alcohol• Over dedication
Center for Traumatic Stress Studies 2005
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Types of Distress BehaviorsTypes of Distress Behaviors
Changes in lifestylesChanges in lifestylesChanges in travelChanges in travelTobacco, alcohol useTobacco, alcohol useSchool dropout ratesSchool dropout ratesWork absenteeism or Work absenteeism or overworkoverworkDivorceDivorceDomestic or interpersonal Domestic or interpersonal violenceviolenceHealth care seekingHealth care seeking
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Hurricane Katrina (2005) Problems 5-8 months post (N=1043)
Kessler et al , 2006
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Examples of Public Responses to Epidemic Examples of Public Responses to Epidemic and Bioterrorism Threatand Bioterrorism Threat
Mass Exodus/NonMass Exodus/Non--cooperation with authoritiescooperation with authoritiesThree Mile Island, US, 1979Three Mile Island, US, 197911
and Plague in Surat, India, 1994and Plague in Surat, India, 199422
Change in consumerist behaviorChange in consumerist behaviorMad Cow Disease, England, 1996Mad Cow Disease, England, 19963 3 and SARS, Toronto, 2003and SARS, Toronto, 200344
Stigmatizing the group perceived to be affected Stigmatizing the group perceived to be affected AIDS, US, 1980sAIDS, US, 1980s55
and SARS, Toronto, 2003and SARS, Toronto, 200366
Increase in demand for health services by nonIncrease in demand for health services by non--affected peopleaffected peopleAnthrax, US, 2001Anthrax, US, 200177
and Sarin gas attack, Tokyo, 1995and Sarin gas attack, Tokyo, 199588
Call for extreme government measuresCall for extreme government measuresSARS, Toronto, 2003SARS, Toronto, 200399
and AIDS, US, 1985and AIDS, US, 19851010
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.
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Disaster EffectsDisaster Effects
Perceived SafetyPerceived Safety
Change in BehaviorChange in Behavior
StigmatizationStigmatization
Confidence in GovernmentConfidence in Government
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Risk PerceptionsRisk 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.””
SlovicSlovic, 1987, 1987
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Perceived Safety Perceived Safety
Erode sense of Erode sense of national securitynational securityDisrupt the continuity Disrupt the continuity of societyof societyDestroy social capitalDestroy social capital
MoraleMoraleCohesionCohesionShared ValuesShared Values
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Longitudinal National Study of Longitudinal National Study of Reactions to Terrorist AttackReactions 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 NYCOutside of NYC
2 mos.2 mos.
6 mos.6 mos.
9/11 Posttraumatic Stress 17.0% 5.8%
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Longitudinal National Study of Longitudinal National Study of Reactions to Terrorist AttackReactions 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 NYCOutside 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%
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Change in Consumerist Behavior: Change in Consumerist Behavior: The Economic Impact of SARSThe 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
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People Take More Precautions People Take More Precautions
When ConcernedWhen Concerned
10%
7%
19%
8%
11%
39%
21%
26%
28%
29%
32%
56%
Not concerned about SARS Concerned about SARSHarvard 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 or stores
Avoided public events
Carried a disinfectant to clean objects
Avoided people you think may have recently visited Asia
Purchased a face mask
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DisasterDisaster
Opens the fault lines, the potential cracks in Opens the fault lines, the potential cracks in our society our society
-- Racial/ethnicRacial/ethnic
-- EconomicEconomic
-- ReligiousReligious
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Cycle of Disaster Mental Health Cycle of Disaster Mental Health
Acute Response
Post-Disaster
Pre-Disaster
Planning and preparednessPlanning and preparednessEducationEducationMitigationMitigationResponseResponseRecoveryRecovery
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State and Local SystemsState and Local Systems
State disaster plan has mental health componentState disaster plan has mental health componentDisaster mental health response coordinated through Disaster mental health response coordinated through community mental health servicescommunity mental health services--must also sustain care must also sustain care of regular patientsof regular patientsGaps in services and outreachGaps in services and outreach--clinics serve preclinics serve pre--existing existing client base and private practioners may not have client base and private practioners may not have relationship with govrelationship with gov’’t agencies to provide caret agencies to provide careFederal funding does not cover extensive ongoing careFederal funding does not cover extensive ongoing careTransition from postTransition from post--disaster psychological counseling to disaster psychological counseling to ongoing careongoing careImportance of school based mental health servicesImportance of school based mental health services
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Private Sector SystemsPrivate Sector Systems
Human services Human services providersprovidersWorkplaceWorkplace--Employee Assistance Employee Assistance ProgramsProgramsPrimary CarePrimary CareFaithFaith--basedbasedLocal providersLocal providers
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Integration of Disaster Mental Health, Integration of Disaster Mental Health, Public Health & Human ServicesPublic 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 individualsindividualsEnsure buy in by all Ensure buy in by all parties and stakeholdersparties and stakeholdersMore efficient resource More efficient resource allocationallocationFocus on basic human Focus on basic human services and medical services and medical needsneeds
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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. 2Disasters. 2ndnd
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. CenteSubstance Abuse and Mental Health Services Administration. Center for Mental r for Mental
Health Services: 2000. DHHS Publication No. ADM 90Health Services: 2000. DHHS Publication No. ADM 90--538538
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Immediate/Delayed Reactions to Immediate/Delayed Reactions to a Sudden and Violent Eventa Sudden and Violent Event
PhysicalPhysicalEmotionalEmotionalCognitiveCognitiveBehavioralBehavioralSpiritualSpiritual
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Hurricane Katrina (2005) Stress Reactions at 5-8 months (N=1043)
Kessler et al , 2006
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Health Issues and DisasterHealth 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 event12 months or more after the event
Victims with preVictims with pre--disaster psych issues were at greater disaster psych issues were at greater risk for postrisk for post--disaster psych problemsdisaster psych problemsRelocated 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 attentiionattentiionBoth groups of victims had increased GI morbidityBoth groups of victims had increased GI morbidity
Freedy
JR and Simpson WM. 2007
Yzermans
CJ et al. 2005
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Signs of ImpairmentSigns of Impairment
Inability to use life support systems such as Inability to use life support systems such as family, friends and social groupsfamily, friends and social groupsInability to care for self and familyInability to care for self and familyInability to deal with benefit issuesInability to deal with benefit issuesSuicidal and homicidal behaviorsSuicidal and homicidal behaviorsPsychosisPsychosisMarked anxiety and depressionMarked anxiety and depression
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Principles of Disaster Mental Health Principles of Disaster Mental Health ServiceService
Resilience and recoveryResilience and recoveryMost cope well, even strengthenedMost cope well, even strengthenedMay be transformativeMay be transformative-- ““postpost--traumatic growthtraumatic growth””Not a fixed attribute but variable: vulnerability, protective Not a fixed attribute but variable: vulnerability, protective mechanisms, affective and coping stylemechanisms, affective and coping style
PrePre--disaster level of functioningdisaster level of functioningAvoidance of mental health labelingAvoidance of mental health labeling
““Stress and supportStress and support”” servicesservices
Support local community care Support local community care
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Phases of Mental Health ResponsePhases of Mental Health Response
EmergencyEmergency-- Triage: Protect, Direct, ConnectTriage: Protect, Direct, Connect
PostPost--impactimpact——up to 8up to 8--12 weeks, psychoeducational 12 weeks, psychoeducational interventions, crisis counselinginterventions, crisis counseling
RestorationRestoration——long term recovery programslong term recovery programs
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Goals of Disaster Mental Health Goals of Disaster Mental Health ServicesServices
Crisis stabilizationCrisis stabilizationSurveillanceSurveillancePromotion of resilience, Promotion of resilience, copingcopingManage acute stress Manage acute stress reactionsreactionsReduce maladaptive Reduce maladaptive behaviorsbehaviors
Flexible, supportive, Flexible, supportive, problemproblem--solvingsolvingMaintain and improve Maintain and improve role functionrole functionPrevent, treat chronic Prevent, treat chronic distress, illnessdistress, illnessReferralReferral
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How Do We Know How to How Do We Know How to Respond Following Disasters?Respond Following Disasters?
Disaster ResearchDisaster ResearchExtrapolationExtrapolationConsensusConsensusClinical ExperienceClinical ExperienceCustomer feedbackCustomer feedbackProgram evaluation Program evaluation
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Evidence Base for Early Evidence Base for Early Intervention for AdultsIntervention 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
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Evidence Base for LaterEvidence Base for Later--Stage Stage Interventions for AdultsInterventions for Adults
High level of evidence:CBT
Medium level of evidence:EMDR, SSRIs
Low level of evidence:Psychodynamic therapy, “Alternative” therapies
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General Considerations
Consider social structure of communitySocio-economic status, gender, race ethnicityDiverse effects of disaster’s: loss of life, injury, property damage, economic impact
Respect victims’ internal and external coping capacities““First, do no harmFirst, do no harm”” (NIMH, 2002)(NIMH, 2002)
Tierney, 2000Norris et al, 2002Everly, 2003
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General PrinciplesGeneral Principles
Challenges in assessmentChallenges in assessment
Vulnerability to side effectsVulnerability to side effects
Clarification of goalsClarification of goals
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What do you see?What do you see?
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NOW what do you see?NOW what do you see?
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AssessmentAssessment
Conduct a standard interviewConduct a standard interviewEmphasize 5 key risk factors for psychopathology:Emphasize 5 key risk factors for psychopathology:
Past psychiatric history Past psychiatric history ““dose of traumadose of trauma”” (exposure) (exposure) Problems of living prior to disaster Problems of living prior to disaster Level of impairmentLevel of impairmentAvailability of psychosocial supportsAvailability of psychosocial supports
DonDon’’t forget ETOH/Drug uset forget ETOH/Drug use
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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.
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Psychological First AidPsychological First Aid
Flexible, supportive, problemFlexible, supportive, problem--solvingsolvingNeeds of survivorsNeeds of survivors--not aimed at emotional not aimed at emotional processingprocessing
Help navigate servicesHelp navigate servicesObtain food and shelterObtain food and shelterKeep families together, facilitate reunionKeep families together, facilitate reunionMay allow sharing thoughts and feelingsMay allow sharing thoughts and feelingsPermission to recontactPermission to recontact
Proximity, Immediacy, ExpectancyProximity, Immediacy, Expectancy
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Psychological First AidPsychological First Aid Field Operations Guide, 2Field Operations Guide, 2ndnd
Ed.Ed.
www.nctsn.orgwww.nctsn.orgOrOr
www.ncptsd/va/govwww.ncptsd/va/gov
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Response to Disaster -
Treat Disabling Symptoms
InsomniaInsomnia••
Teach sleep hygiene, relaxation techniquesTeach sleep hygiene, relaxation techniques
••
Consider shortConsider short--term medication (nonterm medication (non--benzodiazepines first)benzodiazepines first)
AnxietyAnxiety••
Teach relaxation exercisesTeach relaxation exercises
••
Physical exercise, rewarding activitiesPhysical exercise, rewarding activities••
Cautious, brief benzodiazepines for severe symptomsCautious, brief benzodiazepines for severe symptoms
Acute stress disorderAcute stress disorder••
Consider SSRI trial for symptoms of anxiety or depressionConsider SSRI trial for symptoms of anxiety or depression——
no data proving prevention of PTSDno data proving prevention of PTSD
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IntermediateIntermediate--Intensity Individual Intensity Individual CounselingCounseling
22--3 weeks post trauma, 43 weeks post trauma, 4--5 sessions5 sessionsCognitiveCognitive--behavioral approachbehavioral approach
EducationEducationAnxiety management trainingAnxiety management trainingImaginal exposure training, inImaginal exposure training, in--vivo exposurevivo exposureCognitive restructuring (CR)Cognitive restructuring (CR)
Tested in survivors of MVAs, industrial accidents, nonsexual Tested in survivors of MVAs, industrial accidents, nonsexual assaultassault
Appears to prevent PTSDAppears to prevent PTSD
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Acute Stress Disorder: CBTAcute 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 traumaafter trauma
••
4 years later:4 years later:PTSD in 8% CBT, 25% supportive counselingPTSD in 8% CBT, 25% supportive counselingCBT: CBT: ↓↓
PTSD symptoms, especially avoidancePTSD symptoms, especially avoidance
••
CBT immediately after trauma may have lasting benefits CBT immediately after trauma may have lasting benefits for those at risk for PTSDfor those at risk for PTSD
Bryant et al, 2003.
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Psychotherapy of PTSD
••
MetaMeta--analysis of controlled psychotherapies (cognitive, behavioral, analysis of controlled psychotherapies (cognitive, behavioral, psychodynamic): significant symptom reduction over time for allpsychodynamic): significant symptom reduction over time for all
••
Cognitive therapyCognitive therapyCognitive model: PTSD patient cannot process traumaCognitive model: PTSD patient cannot process traumaTreatment helps pt. process traumatic memories and automatic negTreatment helps pt. process traumatic memories and automatic negative ative expectationsexpectations
••
Behavioral therapyBehavioral therapyBehavioral model: classical conditioning produces PTSDBehavioral model: classical conditioning produces PTSDTreatment deTreatment de--conditions PTSD by pairing relaxation techniques with conditions PTSD by pairing relaxation techniques with systematic desensitizationsystematic desensitization
••
Dynamic psychotherapy for concomitant personality disorders or Dynamic psychotherapy for concomitant personality disorders or maladaptive behaviorsmaladaptive behaviors
Sherman et al, 1998.
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Components of TraumaComponents of Trauma--Focused Cognitive Focused Cognitive Behavioral Therapy TFBehavioral Therapy TF--CBT: PracticeCBT: Practice
PsychoeducationPsychoeducation, Parenting skills , Parenting skills
Relaxation, personalized to child, adolescent and parentsRelaxation, personalized to child, adolescent and parents
Affect modulation skillsAffect modulation skills
Cognitive restructuring (thoughts, feelings, behaviors)Cognitive restructuring (thoughts, feelings, behaviors)
Trauma narrative and contextualizing interventionsTrauma narrative and contextualizing interventions
In vivo mastery of trauma remindersIn vivo mastery of trauma reminders
Conjoint childConjoint child--parent sessionsparent sessions
Enhancing safety and social skillsEnhancing safety and social skills
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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 memoriesmemories reduced distressreduced distressSuccessful desensitization described in 2Successful desensitization described in 2--3 sessions of 3 sessions of 90 minutes90 minutesSome studies supportive of Some studies supportive of EMDREMDR’’ss benefitsbenefits
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
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Virtual Reality Exposure Therapy for Virtual Reality Exposure Therapy for PTSD Vietnam VeteransPTSD Vietnam Veterans
ImaginalImaginal exposure immersed in stimuliexposure immersed in stimuliSense of presence, immersiveSense of presence, immersive
Interactive computer simulationInteractive computer simulationHardwareHardware
HeadHead--mounted display, position and hand trackersmounted display, position and hand trackersHeadphones, microphone, monitor, thunder chairHeadphones, microphone, monitor, thunder chair
Virtual Huey helicopterVirtual Huey helicopterSimulates flying over jungles, walking in jungle clearingSimulates flying over jungles, walking in jungle clearingSmall studySmall study10 PTSD veterans on meds, with moderate to severe PTSD10 PTSD veterans on meds, with moderate to severe PTSDSignificant improvement 3 months & 6 months laterSignificant improvement 3 months & 6 months later
Rothbaum
et al, 2001
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Medication TreatmentMedication Treatment
SSRISSRI’’ss ((SertralineSertraline, , FluoxetineFluoxetine, , ParoxetineParoxetine, , CitalopramCitalopram))TCATCA’’ss ((NortriptylineNortriptyline, , ImipramineImipramine))Propranolol/ClonidinePropranolol/Clonidine ((PropanololPropanolol, Methyldopa), Methyldopa)AnxiolyticAnxiolytic medications/Benzodiazepines (i.e., medications/Benzodiazepines (i.e., LorazepamLorazepam, , ClonzaepamClonzaepam, , AlprazolamAlprazolam))Hypnotic (Hypnotic (ZolpidemZolpidem, , ZaleplonZaleplon, , TrazadoneTrazadone))Mood stabilizers (Lithium, Mood stabilizers (Lithium, ValproicValproic Acid)Acid)Antipsychotics (Haloperidol, Chlorpromazine, Antipsychotics (Haloperidol, Chlorpromazine, OlanzapineOlanzapine))
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Implications of Medication UseImplications of Medication Use
Legitimizing Legitimizing distress/impairmentdistress/impairmentOvershadow other Overshadow other problems (i.e., problems (i.e., psychosocial, financial)psychosocial, financial)Reliance on medicationReliance on medicationLabeling ptLabeling ptPotential long term side Potential long term side effectseffectsDisability issuesDisability issues
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Ways to Increase ComplianceWays to Increase Compliance
Recognize patientRecognize patient’’s concernss concernsSupport and reassuranceSupport and reassuranceElicit social support/familyElicit social support/familyTarget distressful symptomsTarget distressful symptomsAddress sideAddress side--effects promptlyeffects promptlyReaffirm goalsReaffirm goalsPermit some patient flexibilityPermit some patient flexibility
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Other Forms of Other Forms of ““InterventionIntervention””
FamilyFamilyFriendsFriendsPeers/colleaguesPeers/colleaguesChurch/spiritualChurch/spiritual
Primary Care Primary Care Physician Physician Exercises/sportsExercises/sportsRoutinesRoutinesAlternative Alternative medicinemedicine
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Think Outside of the BoxThink Outside of the Box
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Before Disasters:Before Disasters:
During Disasters:During Disasters:
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Wellness SkillsWellness Skills
Have periodic reevaluation of why you want to Have periodic reevaluation of why you want to work with disaster victimswork with disaster victimsRecognize and adhere to limits Recognize and adhere to limits Have frequent consultation, formal and Have frequent consultation, formal and informal, with colleaguesinformal, with colleaguesUtilize team approachUtilize team approachTake adequate breaksTake adequate breaksEngage in preEngage in pre--established appropriate stress established appropriate stress coping skillscoping skills
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The Good News The Good News –– Human Resilience is the NormHuman Resilience is the Norm
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ResilienceResilience
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 falltime we fall””
Nietzsche: Nietzsche: ““That which That which does not kill us can only does not kill us can only make us strongermake us stronger””
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Post-traumatic personal growth in the Katrina sample
%Became closer to loved ones
81.6
Developed faith in ability to rebuild life 95.6Discovered inner strength
69.5
Found deeper meaning andpurpose in life
75.2
Became more spiritual or religious 66.8
Kessler et al 2006
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PostPost--Traumatic Growth CaveatsTraumatic 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 distressdistress
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 growthDo not rush individuals towards growth
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SummarySummary
Post disaster psychiatric trauma has a complex etiologyPost disaster psychiatric trauma is multifactorialPost disaster psychiatric trauma has variable courseEthnic, cultural, political, and economic factors may influence long term recovery and create differing goalsIndividual long term recovery must be community and public health orientedMove beyond lessons learned to lessons retained
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