Mental Health in a Time of Terror

Robert K. Schneider, MDAssistant ProfessorDepartments of Psychiatry, Internal Medicine and Family PracticeVirginia Commonwealth UniversityThe Medical College of Virginia Campus

Outline

• Review Studies of Terror • Disease Model• Health Model• What can we do?

Models of Coping

Disease ModelTrauma/Stressor + Person = Disease

Health Model:Trauma/Stressor + Person = Health

Disease Model

PTSD: Posttraumatic Stress DisorderReexperiencesHyperarousabilityAvoidance

Major DepressionDepressionAnhedonia

Oklahoma City BombingNorth et. al. JAMA 1999

April 19, 1995167 dead684 injured“the most severe incident of terrorism

ever experienced on American soil”

Oklahoma City BombingNorth et. al. JAMA 1999

• 45% postdisaster psychiatric disorder34.5% PTSD22.5% Major Depression9.4% Alcohol Use Disorder

Oklahoma City BombingNorth et. al. JAMA 1999

• Predictors–Any predisaster diagnosis: 66%–Female sex: 55% vs. 34%–94% of PTSD had early avoidance

and numbing symptoms

SCUD Missile Attacks Israel, 1991 Gulf WarLaor et. al. Am J Psychiatry 2001

• 107 families exposed• Half of the families displaced• Mother’s functioning and Children’s

Symptoms • 3 studies: 6 and 30 months and 5 years

SCUD Missile Attacks

• Over time symptoms decrease in residentially stable children

• Mothers’ reaction correlated with young children’s symptoms most

• Family cohesion highly correlated with children’s well being

SCUD Missile Attacks

• Mother’s functioning:– Ability to relate to child– Coping skills– Symptoms

• Children’s symptoms– PTSD symptoms– Avoidance

SCUD Missile Attacks• Younger children highly correlated with

mother’s symptoms• Displaced families had more symptoms

(longer time: more problems)• Family functioning impacted displaced more

than residentially stable children • Mothers coping with adaptive defenses

correlated with resolution of children’s symptoms

PTSD in the Community Breslau et. al. Arch Gen Psychiatry 1998

• 90%: one or more traumas

• Most prevalent trauma: unexpected death of a loved one

Categories: traumatic events• Personally experienced assaultive violence

– 37.7%• Other personally experienced injury or

shocking experience – 59.8%

• Learning about traumas to others– 62.4%

• Sudden unexpected death of a loved one – 60.0%

Conditional Risk• Rape 40-60%• Combat 35%• Violent Assault 20%• Sudden death of a loved one 14%• Witnessing a traumatic event 7%• Learning about trauma to others 1-2%

Rick Factors for PTSDBrewin et al J Consult Clinical Psych 2000

Meta analysis Civilian and Military(Weighted averages)–Lack of Social Support: 0.40–Post trauma life stresses: 0.32–Trauma Severity: 0.23

Health Model

• No predisaster disorder (OCB)–70% remained without disorder

• Stability and High Functioning (SMA)–No children had symptoms at five

years

Health Model – DefensesAdaptive Coping

AnticipationAffiliationAltruismHumor

Self-assertionSelf-observationSublimationSuppression

Adaptive CopingSCUD Missile Attacks

• “Mother’s capacity to control mental images had a direct effect on her symptoms”

Health Model – DefensesMaladaptive Coping

DevaluationDenialDissociationDisplacement

Acting OutOmnipotenceApathyComplaining

What can we do?

SelfFamilyCommunity

What can we do?SELF

• We are in a time of stress and transition• Use our adaptive defenses• Avoid our maladaptive defenses• Regulate our exposure to potentially

traumatic information:– Television, Internet, Newspaper

• Be where you need to be

What can we do?FAMILY

• Model adaptive behavior• Be present and available• Maintain Boundaries

– Clarity– Rules

• Monitor

What can we do?Community

• Model adaptive behavior• Be present and available• Maintain Boundaries

– Clarity– Rules

• Monitor

Conclusions• We are living in a time of stress and

transition• Diseases to prevent include PTSD

and Major Depression• Young children are particularly

vulnerable• Coping is an active, conscious

process that occurs on multiple levels