chapter7 psychological

1® BDLS is a registered trademark of the American Medical Association® BDLS is a registered trademark of the American Medical AssociationV 2.9 04/07V 2.9 04/07

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““Preparing Our Communities”Preparing Our Communities”

Welcome!Welcome!

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Faculty DisclosureFaculty Disclosure

• For Continuing Medical Education (CME) purposes as For Continuing Medical Education (CME) purposes as required by the American Medical Association (AMA) required by the American Medical Association (AMA) and other continuing education credit authorizing and other continuing education credit authorizing organizations:organizations:– In order to assure the highest quality of CME programming, In order to assure the highest quality of CME programming,

the AMA requires that faculty disclose any information relating the AMA requires that faculty disclose any information relating to a conflict of interest or potential conflict of interest prior to to a conflict of interest or potential conflict of interest prior to the start of an educational activity. the start of an educational activity.

– The teaching faculty for the BDLS course offered today have The teaching faculty for the BDLS course offered today have no relationships / affiliations relating to a possible conflict of no relationships / affiliations relating to a possible conflict of interest to disclose. Nor will there be any discussion of off interest to disclose. Nor will there be any discussion of off label usage during this course. label usage during this course.


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Psycho-Social Aspects of Psycho-Social Aspects of Terrorism and DisasterTerrorism and Disaster

Chapter 7Chapter 7

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Mission of Terrorism….

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D-I-S-A-S-T-E-R D-I-S-A-S-T-E-R for Psychological Issuesfor Psychological Issues

• DDetect Prevalence of Effects etect Prevalence of Effects and…and… Anticipate Resources Required to MitigateAnticipate Resources Required to Mitigate• IIncident Commandncident Command• SSecurity and Safetyecurity and Safety• AAssessment of Psychological Hazardsssessment of Psychological Hazards• SSupport from State upport from State && Federal Assets Federal Assets• TTriage and Treatmentriage and Treatment• EEvacuation / Disposition vacuation / Disposition • RRecovery & Resilienceecovery & Resilience

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DDetectionetection

in Butler, Panzer, Goldfrank, 2003

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Magnitude of ProblemMagnitude of Problem vs. Availability of Resourcesvs. Availability of Resources

• Transient Distress Symptoms Transient Distress Symptoms > 50%> 50%• Behavior Changes Behavior Changes / / Substance AbuseSubstance Abuse 10-25%10-25%• Anxiety Disorders in “Exposed” PersonsAnxiety Disorders in “Exposed” Persons

Children: Children: Prevalence of War-Related PTSD inPrevalence of War-Related PTSD in 12- 60%12- 60%

Adults: Adults: Disaster-Related PTSD inDisaster-Related PTSD in 5 - 80%5 - 80%

Military: Military: ““Combat Stress Response” inCombat Stress Response” in 10 - 30%10 - 30%

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Risk FactorsRisk Factors

•Degree of Exposure Degree of Exposure •ExhaustionExhaustion

Factors Increasing Rate of Psychosocial Problems:Factors Increasing Rate of Psychosocial Problems:

•Physical HarmPhysical Harm •Loss of Someone Close Loss of Someone Close •History History ofof Mental Disorder Mental Disorder ……Associated with Depression / SuicideAssociated with Depression / Suicide

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Incident CommandIncident Command

• Need Formally-Designated Leader,Need Formally-Designated Leader, Accountable for Coordination and Accountable for Coordination and Communication among Potential ProvidersCommunication among Potential Providers

• Need Training and PracticeNeed Training and Practice• Need Integration of VolunteersNeed Integration of Volunteers• Therefore, Need a Prospective PlanTherefore, Need a Prospective Plan Integrated with State/Local PlansIntegrated with State/Local Plans

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VolunteersVolunteers

Need to Address…Need to Address… • CredentialingCredentialing• ““Just-in-Time” Training Just-in-Time” Training • Management:Management: logistics, supervision, logistics, supervision,

transportation, medical & other care needstransportation, medical & other care needs• Well-Meaning Volunteers Can… Well-Meaning Volunteers Can…

Overwhelm, Interfere, Confuse, Overwhelm, Interfere, Confuse, Burden Burden & & Even EndangerEven Endanger

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SSecurity and Safetyecurity and Safety of Respondersof Responders

• Responders Can Have SameResponders Can Have SamePsychological Responses as Others Psychological Responses as Others

• Exposure to the Trauma of Disasters Exposure to the Trauma of Disasters Often Worse than Past ExperiencesOften Worse than Past Experiences

• Even “Veteran” Responders Affected… Even “Veteran” Responders Affected… esp.esp. If Co-Workers Become Victims If Co-Workers Become Victims

• Acute Acute && Subsequent Post-Traumatic Subsequent Post-Traumatic Stress Disorders Both Common Stress Disorders Both Common


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Post-Disaster Counseling Services

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InterventionsInterventionsfor Respondersfor Responders

• Refer Identified Affected Responders Refer Identified Affected Responders to Professionals Trained in Both to Professionals Trained in Both Cognitive-Behavioral & Cognitive-Behavioral & Pharmacological TherapiesPharmacological Therapies

• Therapies Are Not Be the Domain of Non-Therapies Are Not Be the Domain of Non-Professional VolunteersProfessional Volunteers

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Haddon MatrixHaddon Matrix

in in Butler, Panzer, GoldfrankButler, Panzer, Goldfrank, 2003, 2003

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TTriage/Treatmentriage/Treatment

• Efficient Triage of Persons with Normal vs. Efficient Triage of Persons with Normal vs. Abnormal ResponsesAbnormal Responsesand those with symptoms from co-morbid conditionsand those with symptoms from co-morbid conditions

• Treat Within Scope of Competency & Treat Within Scope of Competency & ResourcesResources

• Identify High-Risk Persons for Immediate Identify High-Risk Persons for Immediate Referral and TreatmentReferral and Treatment

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Normal ResponsesNormal Responses

A Threat Normally Induces….A Threat Normally Induces….

• A Sense of Apprehension, Worry, Edginess & A Sense of Apprehension, Worry, Edginess & Difficulty Concentrating Difficulty Concentrating

• Rational (and Irrational) Attempts to Rational (and Irrational) Attempts to Remove the Threat or Escape ItRemove the Threat or Escape It

• On a Social Scale…Altruistic Behaviors On a Social Scale…Altruistic Behaviors Intended to Ameliorate the SituationIntended to Ameliorate the Situation

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A Disaster Normally Induces….A Disaster Normally Induces….• Guilt Guilt • Manifested in Many WaysManifested in Many Ways• Results in Zealous Volunteerism Results in Zealous Volunteerism

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Prevalent SyndromesPrevalent Syndromes

Sub-Diagnostic Sub-Diagnostic DistressDistress (“worried well”)(“worried well”)

• Some Symptoms of DistressSome Symptoms of Distress• Multiple Concerns / AnxiousMultiple Concerns / Anxious• Somatization Somatization (physical complaints)(physical complaints) Do Not Meet Diagnostic “Thresholds” for Do Not Meet Diagnostic “Thresholds” for

Psychiatric DisordersPsychiatric Disorders

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Treatment of Sub-Diagnostic DistressTreatment of Sub-Diagnostic Distress

• Normalize Responses (reassurances) Normalize Responses (reassurances) While While Empathizing with DistressEmpathizing with Distress

• Supportive Counseling & Sx Reduction Supportive Counseling & Sx Reduction Through Relaxation TechniquesThrough Relaxation Techniques

• If Symptoms Such as Insomnia are If Symptoms Such as Insomnia are Debilitating, Treat SymptomaticallyDebilitating, Treat Symptomatically

• Generally, Role of Anxiolytics is SlightGenerally, Role of Anxiolytics is Slight• Monitor for Persistence / DissociationMonitor for Persistence / Dissociation

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Psychological First AidPsychological First Aid

• Protect Survivors from Further HarmProtect Survivors from Further Harm• Reduce Physiological ArousalReduce Physiological Arousal• Get Support for Most DistressedGet Support for Most Distressed• Keep Families Together Keep Families Together • Facilitate Reunions of Family / FriendsFacilitate Reunions of Family / Friends• Provide Reassurance & Education with Provide Reassurance & Education with

Effective Risk Communication MethodsEffective Risk Communication Methods

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Abnormal ResponsesAbnormal Responses

A Substantial Problem Exists if A Substantial Problem Exists if Symptoms are Greater in:Symptoms are Greater in:

Intensity and DurationIntensity and Duration Resulting Impairment or DisabilityResulting Impairment or Disability Avoidance of Certain Situations Avoidance of Certain Situations

or Objects, Impairing Daily Lifeor Objects, Impairing Daily Life An Unusual and Significant An Unusual and Significant

Pattern of SymptomsPattern of Symptoms

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Prevalent DisordersPrevalent Disorders• Anxiety DisordersAnxiety Disorders

• Acute Stress DisorderAcute Stress Disorder• Post-Traumatic Stress DisorderPost-Traumatic Stress Disorder

• Affective DisordersAffective Disorders• Major Depressive DisorderMajor Depressive Disorder• Dysthymic DisorderDysthymic Disorder

• Bereavement Evolves intoBereavement Evolves intoMajor Persistent DepressionMajor Persistent Depression

• Substance Dependence Substance Dependence andand//oror Related Mood Related Mood && Anxiety DisordersAnxiety Disorders

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Medical Community Re-Focuses…

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Anxiety DisordersAnxiety Disorders due to General Medical Conditionsdue to General Medical Conditions

• Interruption of Care for Chronic ConditionsInterruption of Care for Chronic Conditions– Inability to Get MedicationsInability to Get Medications– Change in Priorities Change in Priorities (for Physicians and Patients)(for Physicians and Patients)– Lack of Monitoring and CommunicationsLack of Monitoring and Communications– Lack of Access to Emergent CareLack of Access to Emergent Care

• Affects on Undiagnosed Medical ConditionsAffects on Undiagnosed Medical Conditions– Hyperthyroid States and AnginaHyperthyroid States and Angina– Parental RelationshipsParental Relationships– Irritable Bowel SyndromeIrritable Bowel Syndrome

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Reactions of ChildrenReactions of Children

Ages Ages << 5 : 5 :• Separation FearsSeparation Fears• NightmaresNightmares• Regression of BehaviorRegression of Behavior

Ages 6 Ages 6 – – 11:11:• Atypical Disruptive BehaviorsAtypical Disruptive Behaviors• Withdraw from People, Daily ActivitiesWithdraw from People, Daily Activities• Irritability and Difficulty Concentrating Irritability and Difficulty Concentrating • Lower Grades at SchoolLower Grades at SchoolAdolescents Similar to AdultsAdolescents Similar to Adults

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CommonCommon StressStress DisordersDisorders

• Re-Experiencing Events Re-Experiencing Events (nightmares, flashbacks, intrusive thoughts)(nightmares, flashbacks, intrusive thoughts)

• Emotional Numbing Emotional Numbing (depersonalization, derealization, disoriented)(depersonalization, derealization, disoriented)

• Avoidance Avoidance (negative conditioning to event- related stimuli)(negative conditioning to event- related stimuli)

• Autonomic ArousalAutonomic Arousal• Disruptions of LifeDisruptions of Life

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Temporal Pattern of Stress Temporal Pattern of Stress DisordersDisorders

Acute Acute StressStress

Acute Acute PTSDPTSD

ChronicChronic PTSDPTSD

OnsetOnset Within Within 28 days28 days

Immediate Immediate (or Anytime (or Anytime Thereafter)Thereafter)


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Temporal Pattern of Stress Temporal Pattern of Stress DisordersDisorders

Acute Acute StressStress

Acute Acute PTSDPTSD

ChronicChronic PTSDPTSD

OnsetOnset Within Within 28 days28 days



DurationDuration 2-28 days2-28 days Up to Up to 3 Months3 Months

Greater Greater thanthan 3 Months3 Months

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Screening withScreening with SNAPSNAP

• SStartletartle• NNumbnessumbness• AArousal / Avoidancerousal / Avoidance• PPersistenceersistence

Derived fromDerived from Davidson et al,Davidson et al, J Nerv Mental DisJ Nerv Mental Dis 19891989

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ScreeningScreening for for DepressionDepression

Screening Question:Screening Question:

“ “In the past two weeks….In the past two weeks….•Have You Had a Depressed Have You Had a Depressed Mood Most of the DayMood Most of the Day??

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ScreeningScreening for for DepressionDepression

Screening Questions:Screening Questions:

““In the past two weeks….In the past two weeks….• Have You Had a Depressed Mood Have You Had a Depressed Mood Most of the Day?Most of the Day?

• Have You Had a Loss of Interest or Have You Had a Loss of Interest or Pleasure in Most Activities?”Pleasure in Most Activities?”

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Screening for SuicideScreening for Suicide

Screening Questions:Screening Questions:““Have You had Recent Thoughts that Life is Not Worth Have You had Recent Thoughts that Life is Not Worth

Living or That You’d Be Better Off Dead?”Living or That You’d Be Better Off Dead?”• ““This Past Week… Have You Had Thoughts about This Past Week… Have You Had Thoughts about

Hurting Yourself or Even Killing Yourself?” Hurting Yourself or Even Killing Yourself?” • If Answer is “Yes”….If Answer is “Yes”….

““What Have You Thought About?”What Have You Thought About?”““Have You Actually Done Anything to Hurt Yourself?Have You Actually Done Anything to Hurt Yourself?

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I Know It’s Still Morning…

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Screening for Alcohol and Screening for Alcohol and Substance AbuseSubstance Abuse

• Have You Ever Had a Problem with Have You Ever Had a Problem with Drugs?Drugs?

• Do You Drink Alcohol? Do You Drink Alcohol? If “yes”, thenIf “yes”, then CAGECAGE::

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• Have You Ever Had a Problem with Have You Ever Had a Problem with Drugs?Drugs?

• Do You Drink Alcohol? Do You Drink Alcohol? If “yes”, thenIf “yes”, then CAGECAGE::–Have You Felt You Should Have You Felt You Should CCut Down ut Down

on Your Drinking?on Your Drinking?

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• Have You Ever Had a Problem with Drugs?Have You Ever Had a Problem with Drugs?• Do You Drink Alcohol? Do You Drink Alcohol? If “yes”, thenIf “yes”, then CAGECAGE::

–Have You Felt You Should Have You Felt You Should CCut Down ut Down on Your Drinking?on Your Drinking?

–Have People Have People AAnnoyed You by nnoyed You by Criticizing Your Drinking?Criticizing Your Drinking?

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–Have You Felt You Should Have You Felt You Should CCut Down ut Down on Your Drinking?on Your Drinking?

–Have People Have People AAnnoyed You by nnoyed You by Criticizing Your Drinking?Criticizing Your Drinking?

–Have You Felt Have You Felt GGuilty About Drinking?uilty About Drinking?

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– Have You Felt You Should Have You Felt You Should CCut Down ut Down on Your Drinking?on Your Drinking?

– Have People Have People AAnnoyed You by nnoyed You by Criticizing Your Drinking?Criticizing Your Drinking?

– Have You Felt Have You Felt GGuilty About Drinking?uilty About Drinking?– Have You Had to Drink Have You Had to Drink in thein the Morning to Get Morning to Get

Rid of a Hangover Rid of a Hangover (“(“EEye-opener”) ye-opener”) ??

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EEvacuationvacuation

• Pre-Event Pre-Event Hazards Assessment:Hazards Assessment:–Can Capacity of Infrastructure Can Capacity of Infrastructure

Accommodate Demand Surges ?Accommodate Demand Surges ?• Transportation, communication, healthcare, etcTransportation, communication, healthcare, etc

– Is Public Confident with Respect to Pre-Is Public Confident with Respect to Pre-Event and Event-Related Security and Event and Event-Related Security and Capacity of Infrastructure ?Capacity of Infrastructure ?

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Event & Post-Event:Event & Post-Event:

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Event & Post-Event:Event & Post-Event: Care/Control Care/Control ofof Persons Who Panic Persons Who Panic

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Care of Displaced PersonsCare of Displaced Persons

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Care of Displaced PersonsCare of Displaced Persons

Coordination with Red Cross and Coordination with Red Cross and Clinical Triage/Treatment TeamsClinical Triage/Treatment Teams

chapter7 psychological

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