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Psychological and Behavioral Responses to Disasters Steve Bunney, MD Department of Psychiatry Yale School of Medicine.

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Presentation on theme: "Psychological and Behavioral Responses to Disasters Steve Bunney, MD Department of Psychiatry Yale School of Medicine."— Presentation transcript:

1 Psychological and Behavioral Responses to Disasters Steve Bunney, MD Department of Psychiatry Yale School of Medicine

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4 Personal Experience Post 9-11  Day 1 – Call from Walter Reed – Activation of Emergency Response Plan  Day 2 – Call from Service Union  Day 7 – Call from business CEO  Day 21 – Call from airline unions  Day 30 – Call from insurance company

5 PHASES of IMPACT and RECOVERY I. EMERGENCY/IMPACT SHOCK – first hours/days HEROIC – first days/weeks II. EARLY POST-IMPACT HONEYMOON – 1-3 Months DISILLUSIONMENT – 3-6 months III. RESTORATION vs. BREAKDOWN RESTABILIZATION – 6-9 months RECOVERY – 9-12 months PREPAREDNESS – 12+ months

6 What is Psychological Trauma?  Overwhelming, unanticipated danger that cannot be mediated/processed in way that leads to fight or flight  Immobilization of normal methods for decreasing danger and anxiety  Neurophysiological dysregulation that compromises affective, cognitive and behavioral responses to stimuli

7 Psychological Shock  Objective Exposure  Exposure to threat of imminent/actual death  Witnessing bodies and body parts  Extreme exposure to fire, dust, exhaustion  Subjective Survival Responses  Terror: fear, helplessness, impulsivity  Horror: disbelief, revulsion, guilt, shame, rage  Numbing: derealization, depersonalization, fugue, amnesia.

8 Stress vs Trauma Dealing with Problems Heart Pounding Rapid Breathing Muscles Tense Up Fight or Flight Feel Excited or Worried Seeing/Thinking Clearly Acting Rapidly Feel in Control Trying to Survive Heart Feels Like Bursting Gasping, Feeling Smothered Muscles Feel Like Exploding Just Try to Get Through It Feel Terrified of Panicked Confused, Mentally Shut Down Automatic Reflexes or Freezing Feel Helpless or Out of Control

9 Neurobiology of Severe Stress  Responses are complex – Biological defenses against a threat – Mechanisms related to learning and adaptation – Responses to social cues – Reactions to loss and separation – Effects of cognitive disarray and chaotic experience

10 Neurobiology of Severe Stress (cont.)  Thalamus registers whether sensory input is familiar or novel and a threat or not  Threat triggers brain alarm system (amygdla) and release of corticosteroids and norepinephrine  Fight-flight responses (autonomic nervous system, sympathetic branch)  Peripheral resource conservation (autonomic nervous system, parasympathetic branch)

11 Neurobiology of Severe Stress (cont.)  Alarm: insula and amygdala coordinate body’s mobilization in response to threat  Attention: norepinepherine release by locus ceruleus (brain stem area) promotes focused attention  Reactivity: corticosteroids promote instinctual survival rather than goal-directed reflection  Information Processing: Hippocampus inhibited in spatial orientation and categorization of sensory inputs  Executive Decision Making: prefrontal cortex receives confusing/chaotic alarm signals and is down-regulated

12 Neurobiology of Severe Stress (cont.)  Delayed responses  Cascade of neuronal and genomic events including: Increased synthesis of cortiotropin releasing hormone (CRH) and cortisol related receptors in areas of brain not directly in hormonal stress response  Increased protein synthesis in memory areas provides mechanism for two types of long term memory of stressful events :  Hippocampus  Explicit - verbalizable and recallable  Amygdala  Implicit - unconscious changes in habit and conditioned responses (e.g. fear response when exposed to cues relevant to traumatic event

13 Neurobiology of Severe Stress (cont.)  Summary – The early aftermath of a disaster is a critical time of increased neuronal plasticity. – The perceived threat triggers intense bodily reactions that shape the mental traces of adverse events. – Physiological and psychological factors can either concur to cause chronic stress disorders or adaptation and resilience. – Early interventions may reduce the risk of chronicity

14 Event Factors That Influence Psychological Responses  How directly events affect their lives: Physical proximity to event Emotional proximity to event (threat to child, parent versus stranger) Secondary effects-of primary importance (does event cause disruption in on-going life)

15 Individual Factors That Influence Psychological Response  Genetic vulnerabilities and capacities  Prior history (i.e. consistent stress or one or more stressful life experience/s)  History of psychiatric disorder  Familial health or psychopathology  Family and social support  Age and developmental level  Other: Female, divorced or widowed, lower IQ, lower income, lower education level

16 Children Responses and Treatment

17 Role of Adults  For all children, especially younger children, experience and especially upsetting experience is mediated by adults.  Adults emotional response often as important as the actual event

18 Children’s Typical Initial Responses Normal reactions to abnormal situations Emotional and Somatic  Sleep disturbance (nightmares etc.)  Decreased or increased appetite  Sad or anxious mood (withdrawn or more quiet)  Irritable, fussy or argumentative  Loss of recently achieved milestones  Clingy or wanting to be close to parents  Difficulty paying attention  Daydreaming or easily distractible

19 Toddlers  Rely on Parents  Regression Preschoolers  Highly Imaginative  Concerned About Safety School Age  Social Difficulties  Concerned About Right/Wrong (Revenge) Adolescents  Struggling With Independence  Conflict With Authority Figures  Minimize or Exaggerate  Increased Risk Taking  Substance Use Older Adolescents & Young Adults  Concerns About Future  Substance Use Spectrum of Developmentally Determined Responses

20 Implications of Neurobiological Development for Treatment  Hippocampus not fully functional until 4-5 years old  Prefrontal cortex not fully functional until around age 10

21 Treatment and Intervention In the immediate aftermath  Reunite children with important adults/ family members  Interventions for children include interventions for caretakers. If adults can not attend to children, outcome will be poor  Adults tend to underestimate impact on children or alternatively displace own feelings onto their children

22 Treatment and Intervention In the immediate aftermath (cont.) Criteria for Referral  Presence of Dissociation Decreased motor function Blunted affect Absence of speech Decreased responsiveness to external stimuli  Presence of Hyperarousal (heart rate and often respiration increased)  Avoidance/Withdrawal Symptoms  Extreme Emotional Upset  Symptoms of Acute Stress Disorder

23 Acute Stress Disorder  3+ of 5 Dissociative Sx (Detached, Dazed, Derealization, Depersonalization, Amnesia)  Recurrent Unwanted Memories Awake/Asleep or Biopsychological Distress Due to Reminders  Avoidance of Internal/External Reminders  Hyperarousal (Anxious, Irritable, Insomnia, Poor Concentration, Hypervigilant, Reactive)  Significant psychosocial/healthcare impairment  Duration 2-30 days

24 Treatment Issues 4-6 Months After Disaster Criteria For Referral  Extreme emotional upset  Sleep disturbances  Somatization  Hyper-vigilance  Severe distractibility  Regressive behavior  Blunted emotions  Regression in social functioning and play  Oppositional and aggressive behaviors Classic PTSD not common in children but incidence increases with age (especially adolescents)

25 Adults Responses and Treatment

26 Common Fantasies  to alter the precipitating event  to interrupt the traumatic action  to reverse the lethal or injurious consequences  to gain safe retaliation (fantasies of revenge)  to be able to anticipate or prevent future traumas  to bring back lost loved ones, friends, places, activities, or states of mind (trust) or body (peace)

27 Common Stress Reactions To Disaster Emotional Effects Shock Anger Despair Emotional numbing Terror Guilt Irritability Helplessness Loss of derived pleasure from regular activities Dissociation (e.g., perceptual experience seems “dreamlike, “tunnel vision,” “spacey,” or on “automatic pilot”) Physical Effects Fatigue Insomnia Sleep disturbance Hyperarousal Somatic complaints Impaired immune response Headaches Gastrointestinal problems Decreased appetite Decreased libido Startle response Cognitive Effects Impaired concentration Impaired decision-making ability Memory impairment Disbelief Confusion Distortion Decreased self-esteem Decreased self-efficacy Self-blame Intrusive thoughts and memories Worry Interpersonal Effects Alienation Social withdrawal Increased conflict within relationships Vocational impairment School impairment Young, BH, et. al. Disaster Mental Health Services: A Guidebook For Clinicians and Administrators. The National Center for Post-Traumatic Stress Disorder, Department of Veterans Affairs

28 Acute Stress Disorder  3+ of 5 Dissociative Sx (Detached, Dazed, Derealization, Depersonalization, Amnesia)  Recurrent Unwanted Memories Awake/Asleep or Biopsychological Distress Due to Reminders  Avoidance of Internal/External Reminders  Hyperarousal (Anxious, Irritable, Insomnia, Poor Concentration, Hypervigilant, Reactive)  Significant psychosocial/healthcare impairment  Duration 2-30 days post traumatic event

29 Treatment and Intervention In the immediate aftermath  There is no one approach to treatment that current research singles out as effective  One time intervention models have been shown to be ineffective  Critical Incident Stress Management (CISM) has no proven effectiveness in prevention of late onset psychological disorders (e.g. PTSD)

30 Treatment and Intervention In the immediate aftermath (cont.)  Psychotherapeutic interventions in the the absence of structure and organization will not be effective.  Provide real and concrete information about event, explain actions of authorities  Provide basic necessities

31 Key Principles of Immediate Intervention  Engagement: Empathic, non directive inquiry( not what happened?, but, how are you feeling?, delving into detail can retraumatize)  Manage Overwhelming Feelings: agitation, pressured speech, uncontrollable crying, out of touch with reality  Request person to look at you and listen to what you are telling them  Hold their attention, talk about positive or non- emotional topics  Ask them to describe the place they’re in and say where they are  Support: Confer control in therapeutic contact

32 Key Principles of Immediate Intervention (cont.)  Affect: Identify, label and link to ideation and somatic experience (noting differences from beginning to end of contact and with reports about pre-morbid functioning)  Cognition: Assess quality and nature of thought processes and link to affective impact of event and associated ideas

33 Key Principles of Immediate Intervention (cont.)  Psycho-education: Explain the normal post-traumatic response (what to expect, what is normal and when additional support/intervention is needed)  Follow-up: Arrange for series of contacts to assess symptoms and adaptive functioning

34 4-6 Months After Disaster  Persistent physical, mental, relational, and work problems are taking a toll  Helping professionals (behavioral health, medical/nursing, human services, clergy) and natural helpers are frayed and feeling the burden of answering the unanswerable  Delayed psychiatric sequel are emerging (unresolved bereavement, depression, PTSD, anxiety disorders, addictions)

35 Target Groups At Risk for Persistent Post-Traumatic Sequelae On-Site Survivors Bereaved Families/Primary Relationships On-Site Rescue/Recovery Workers  Terror: Exposure to threat of imminent/actual death  Horror: Witnessing death, destruction, terror & shock  Physical Insult: injury, exhaustion, toxic exposure  Traumatic Reactivation (past & subsequent crisis work)  Separation/Detachment from Family and Community

36 Target Groups At Risk for Persistent Post-Traumatic Sequelae Helpers Caring for Survivors, the Bereaved, Workers (e.g., Behavioral Health, EAP, Health Care, Clergy) Family/Community Members Living and Working with Survivors, the Bereaved & Rescue Workers  Vicarious Shock: Exposure to terror, helplessness, grief  Uncertainty: Wanting to help but not knowing when/how  Physical/Workload Strain: Carrying the added load while others are focused on coping with impairment or recovery  Loss: Disconnection from traumatized significant others  Traumatic Reactivation: Unresolved direct/vicarious trauma

37 Target Groups At Risk for Persistent Post-Traumatic Sequelae People in Recovery from Behavioral Health Disorders Vulnerable Groups (e.g., children, elders, disenfranchised)

38 Treatment Issues 4-6 Months Later:  Intrusive Re-experiencing: Overwhelming memories  Numbing: Feeling stunned, empty, dead inside  Hypervigilance: Prolonged Survival Alarm State  Dissociation: Disconnection from Alarm Awareness  Affect Dysregulation: Overwhelming emotions  Somatization: Bodily exhaustion and breakdown  Alienation: Loss of sustaining perceptions of future & attachments  Defeat: Loss of personal/spiritual trust & goals

39 Post Traumatic Disorders: Not Automatic & More than PTSD  Most adults and children recover without a lasting post-traumatic psychiatric disorder  10-20% develop depression or PTSD (often both)  Alcohol/substance use disorders not prevalent  Subclinical depression or substance use common

40 Posttraumatic Stress Disorder (PTSD)  Recurrent Unwanted Memories Awake/Asleep or Biopsychological Distress to Reminders  Avoidance of Internal/External Reminders, Emotional Numbing, Social Detachment, Amnesia  Hyperarousal (Anxious, Irritable, Insomnia, Poor Concentration, Hypervigilant, Reactive)  Significant psychosocial/healthcare impairment  Duration 30+ days (may be delayed or chronic)

41 Issues to be Assessed in the Treatment of Traumatic Sequelae of Disaster Criteria for Referral  Presence of depression, PTSD, panic attacks, disabling grief of six months duration and no improvement over time  Worsening of prior psychological problems  Memories of prior traumatic experiences are now causing distress  Presence of sustained psychological or physical stress  Poor or absent social supports

42 Issues to be Assessed in the Treatment of Traumatic Sequelae of Disaster (cont.) Criteria for Immediate Referral  Suicidal thoughts with a plan and/or means  Excessive substance use causing person or others to be placed at risk  Poor functioning to the point that individual’s (or dependent’s) safety/welfare is in danger

43 Issues to be Assessed in the Treatment of Traumatic Sequelae of Disaster (cont.) Major Issues in Making Referrals  Stigma  Explain feelings and behavior (note: not called symptoms) are normal under these circumstances and so is getting some help to deal with them  Take the “shrink” out of counseling  Explain you are sending them for information and potential support  Explain they will get help in problem solving and coping  Tell them what you are doing to cope

44 A State Mental Health Care System Response to 9-11

45 A Statewide Network of Local Behavioral Health Teams: Helping Communities with the Stress of Disasters or Public Health Crises Center for Trauma Response, Recovery, and Preparedness University of Connecticut Health Center Julian D. Ford, Ph.D. CT Department of Mental Health and Addiction Services Arthur C. Evans, Ph.D. James Siemianowski, MSW Wayne Dailey, PhD Center for Trauma Response, Recovery and Preparedness Yale University School of Medicine, Dept. of Psychiatry Steven Berkowitz, MD Steve Bunney, M.D Steven Marans, PhD. Steve Southwick, MD CT Department of Children and Families Thomas Gilman, MSW

46 What have we done since 9/11? A Statewide Behavioral Health Preparedness Plan  800+ professionals trained to serve as volunteers on local behavioral health crisis response teams  150+ prevention providers and natural helpers trained as resources for community preparedness  50+ behavioral health consumer advocates trained to help communities support people in recovery  Local volunteer teams receiving ongoing technical assistance to prepare them for disaster response  Planning for mobilization and activation of these teams in the event of a major disaster  Behavioral health resources disseminated via and

47 Linking Behavioral Health to the OEM & DPH Disaster/Crisis Response System Statewide, Local Incident Command System Municipal officials, public health, fire, police, emergency management, EMS, health care, schools, social service agencies Statewide, Regional, Local Behavioral Health System BH Agencies + Professionals+ Natural Helpers Local Behavioral Health Response Teams OEM - Office of Emergency Management DPH - Department of Public Health BH - Behavioral Health

48 How does the state behavioral health system support local crisis responses? Gov/OEM/DPH DMHAS/DCF CTRP TTTTTTTTTT Local teams comprised of specially trained state staff, Private Non-Profit and private volunteers, work closely with municipal and community leaders, public health department directors, EMS, clergy, school officials, employers RC = Regional Behavioral Health Coordinators DMHAS = Dept of Mental Health & Addiction Svs RC Gov = Governor OEM = Office of Emergency Mgmt DPH = Dept of Public Health CTRP = Ctr. for Trauma Response/Recovery & Preparedness DCF = Dept of Children & Families

49 Taken in Part from a Center for Trauma Response, Recovery and Preparedness (CTRP) Presentation  University of Connecticut School of Medicine  Julian D. Ford, PhD  Yale University School of Medicine  Steven Berkowitz, MD  Benjamin S. Bunney, MD  Steven Marans, PhD  Steve Southwick, MD  CT Department of Mental Health and Addiction Services  Arthur C. Evans, PhD  Wayne Dailey, PhD  James Siemianowski, MSW  CT Department of Children and Families  Thomas Gilman, MSW


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