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

Anthony.ng@mannainhealthcare.orgAnthony.ng@mannainhealthcare.org

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

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

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

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

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

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

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)

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

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

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

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

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

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

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

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?

Disasters and PsychopathologyDisasters and Psychopathology

ButBut…………....

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

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

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

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

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

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

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 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.

Disaster EffectsDisaster Effects

Perceived SafetyPerceived Safety

Change in BehaviorChange in Behavior

StigmatizationStigmatization

Confidence in GovernmentConfidence in Government

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

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

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%

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%

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

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

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

Cycle of Disaster Mental Health Cycle of Disaster Mental Health

Acute Response

Post-Disaster

Pre-Disaster

Planning and preparednessPlanning and preparednessEducationEducationMitigationMitigationResponseResponseRecoveryRecovery

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

Private Sector SystemsPrivate Sector Systems

Human services Human services providersprovidersWorkplaceWorkplace--Employee Assistance Employee Assistance ProgramsProgramsPrimary CarePrimary CareFaithFaith--basedbasedLocal providersLocal providers

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

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

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

PhysicalPhysicalEmotionalEmotionalCognitiveCognitiveBehavioralBehavioralSpiritualSpiritual

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

Kessler et al , 2006

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

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

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

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

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

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

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

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

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

General PrinciplesGeneral Principles

Challenges in assessmentChallenges in assessment

Vulnerability to side effectsVulnerability to side effects

Clarification of goalsClarification of goals

What do you see?What do you see?

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

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

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 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

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

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

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

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.

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.

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

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

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

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))

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

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

Other Forms of Other Forms of ““InterventionIntervention””

FamilyFamilyFriendsFriendsPeers/colleaguesPeers/colleaguesChurch/spiritualChurch/spiritual

Primary Care Primary Care Physician Physician Exercises/sportsExercises/sportsRoutinesRoutinesAlternative Alternative medicinemedicine

Think Outside of the BoxThink Outside of the Box

Before Disasters:Before Disasters:

During Disasters:During Disasters:

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

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

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””

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

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

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