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NJ Preparedness Training Consortium Psychological Aspects of Bioterrorism & Disaster Response For Nursing Professionals.

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Presentation on theme: "NJ Preparedness Training Consortium Psychological Aspects of Bioterrorism & Disaster Response For Nursing Professionals."— Presentation transcript:

1 NJ Preparedness Training Consortium Psychological Aspects of Bioterrorism & Disaster Response For Nursing Professionals

2 The Ultimate Tool of The Terrorist… Is not chemical, biological, nuclear or radiological……. It is psychological, Terror of Fear

3 Officials Must Consider the Possibility of…. Extreme fear and panic Blame and mistrust of authorities Mass Sociogenic Illness Misattribution of Normal Arousal

4 Understanding Terrorism The goal of terrorism is the creation of extreme fear, destroying the individual and communal sense of safety and security.

5 Assisting Victims of Terrorism Neighbor-Helping-Neighbor Approach

6 The Roll of Nursing in the Era of Bioterrorism As one of the most trusted professions in America, nurses are uniquely positioned to provide information regarding disaster preparedness to the community. November 14-16, 2003 CNN/USA Today/Gallup

7 The Roll of Nursing in the Era of Bioterrorism Nurses must have a personal and family disaster plan

8 How to Prepare for National Emergencies: What You Can Do There are three initial steps that families can take: 1)Assemble an emergency supply kit 2)Develop a family communication plan 3)Learn more about the different types of emergencies you could face

9 Emergency Kit Contents At least three days worth of water, including one gallon per person per day for drinking and sanitation purposes At least a three-day supply of non-perishable food Prescription medications, a first aid kit and a first aid manual One blanket, change of clothing and footwear per person Extra set of keys, a credit card, cash or traveler’s checks Flashlight and extra batteries/Battery-powered radio and extra batteries Important documents like birth certificates

10 Family Communication Plan Contact Name_______________________________ Telephone Numbers Work______________________ Home______________________ Cell______________________ Out of Town Contact__________________________ Telephone Numbers Work_____________________ Home______________________ Cell______________________ Neighborhood Meeting Place _________________ Meeting Place phone number___________________ Dial 9-1-1 for Emergencies

11 STRESS 43% of all adults suffer adverse health from stress. 75 to 90 % of all physician office visits are for stress-related. Stress is linked to the 6 leading causes of death– heart disease, cancer, lung ailments, accidents, cirrhosis of the liver, and suicide.

12 Medical Care/Nurse Police/Fire/EMS/Rescue Workers Individuals who traditionally work in stressful environments often develop various coping skills and strategies. Resilience & Recovery - Core Identity Development/Personality - Learned behavior & reactions - Typical response to difficult situations

13 Medical Care/Nurse Police/Fire/EMS/Rescue Workers Skills enable response to maintain a level of function, especially during difficult situations Approaches  can be considered healthy or positive. Approaches  can have a negative or unhealthy consequence.

14 Medical Care/Nurse Police/Fire/EMS/Rescue Workers They can be appropriate for the individuals involved. They may seem unusual or strange to an outsider.

15 People can use rituals to find comfort -Family -Friends -Activity -Religion/Spirituality

16 Even the most experienced and skilled professionals can be affected by their work.

17 Acute Stress Vs. PTSD Difference Long term impact

18 Symptoms of a Stress Reaction Can last –a few days –a few weeks –a few months –and occasionally longer Support and understanding of loved ones needed

19 Symptoms of a Stress Reaction Difficulty feeling love and intimacy Difficulty taking interest and pleasure in day-to- day activities

20 Symptoms of a Stress Reaction Professional assistance may be necessary

21 Types of Traumatic Events Natural Disasters Technological Disasters Disasters of Human Intention Other Interpersonal Violence Sudden Traumatic Loss Serious Medical Illness

22 What is a Traumatic Incident? A situation that is extraordinary and may overwhelm coping mechanisms

23 Traumatic Stress reactions can be broken down into 4 categories: Emotional Cognitive Behavioral Physical

24 Emotional Feelings of shock Anxiety Guilt Grief Severe panic Fear Intense anger Irritability Agitation Resentment Shame

25 Cognitive Blaming someone Confusion Heightened or lowered awareness Indecisiveness Self-blame Poor concentration Memory problems Nightmares Intrusive images

26 Behavioral Change in activity Change in speech patterns Withdrawal Emotional outbursts Change in sexual functioning Erratic movement Antisocial acts Suspiciousness/ paranoia

27 Physical Fatigue Nausea Muscle cramps Chest pain Difficulty breathing Elevated blood pressure Rapid heartbeat Thirst Headaches

28 TRAUMATIC STRESS Years ago, PTSD was commonly called “combat fatigue” “soldiers heart” or “shell shock.” Many people believed that only soldiers or other people who had been in a war could get PTSD.

29 Traumatic Stress Trauma is considered an event outside the normal range of experience.

30 Learning from Our Past Experience The mental fallout from the Oklahoma City bombings in 1995 didn’t peak until 12 to 18 months after the event.

31 Beyond the range of normal experience

32 The New York State Office of Alcoholism and Substance Abuse Services reports that demand for alcohol and drug treatment in New York City increased immediately after the World Trade Center attacks.

33 Phases of Disasters (Zunin/Myers) PREDISASTER HEROIC HONEYMOON DISILLUSIONMENT RECONSTRUCTION Trigger Events & Anniversary Reactions 1 to 3 Days TIME FRAME 1 to 3 Years

34 Who is at greatest risk for severe stress symptoms?

35 Groups Potentially Vulnerable to Terror-Related Issues Demartino 2001 Rescue workers Medical Personnel Leaders “Hero” Persons deemed responsible Media representatives Elderly Children Single parents Injured Bereaved

36 Who is at greatest risk for severe stress symptoms? Workers who directly experience or witness any of the following during or after the disaster are at greatest risk for severe stress symptoms and lasting readjustment problems

37 Who is at greatest risk for severe stress symptoms? Life threatening danger or physical harm (especially to children)

38 Who is at greatest risk for severe stress symptoms? Exposure to gruesome death, bodily injuries, and seriously injured persons.

39 Who is at greatest risk for severe stress symptoms? Extreme environmental or human violence or destruction

40 Who is at greatest risk for severe stress symptoms? Loss of home, valued possessions, neighborhood, or community

41 Who is at greatest risk for severe stress symptoms? Workers who experience: Loss of communication with or support from close relations

42 Who is at greatest risk for severe stress symptoms? Workers who experience: –Extreme fatigue –Weather exposure –Hunger –Sleep deprivation

43 Who is at greatest risk for severe stress symptoms? Workers who experience: –Intense emotional demands (such as searching for possibly dying survivors or interacting with bereaved family members)

44 Who is at greatest risk for severe stress symptoms? Extended exposure to danger, loss, emotional/physical strain

45 Who is at greatest risk for severe stress symptoms? Workers who experience: –Exposure to toxic contamination –Gas or fumes –Chemicals –Radioactivity

46 Risk Factors:Summary Life threatening danger/physical harm Exposure to gruesome death and bodily injury Extreme environmental/human violence or destruction Loss of home, possessions, community Loss of communication with, or support from, close relations

47 The psychological problems that may result from disaster experiences include: Physical reactions: –Tension –Fatigue –Edginess –Difficulty sleeping –Bodily aches or pain –Startling easily

48 Learning from Our Past Experience One year after the bombing, 3 times as many residents of Oklahoma City reported increased drinking as those in a control community (Indianapolis). Elevated rates of substance abuse, depression and suicide.

49 The psychological problems include interpersonal reactions in relationships at school, work, in friendships, interpersonal relationship, or as a parent: –Distrust –Irritability –Conflict –Withdrawal –Isolation –Feeling rejected or abandoned –Being distant –Judgemental –Over-controlling

50 What severe stress symptoms can result from disasters? Most disaster rescue workers only experience mild, normal stress reactions, and disaster experiences may even promote personal growth and strengthen relationships.

51 Development of PTSD 1 out of every three rescue workers experience some or all of the following severe stress symptoms,  Post Traumatic Stress Disorder (PTSD).

52 Severe stress symptoms Disassociation (feeling completely unreal or outside yourself, like in a dream; having “blank” periods of time you cannot remember)

53 Severe stress symptoms Intrusive re-experiencing –Terrifying memories –Nightmares –Flashbacks

54 Severe stress symptoms Extreme attempts to avoid disturbing memories (such as through substance use)

55 Severe stress symptoms Extreme emotional numbing (completely unable to feel emotion, as if empty)

56 Hyper-arousal Panic attacks Rage Extreme irritability Intense agitation

57 Severe anxiety Paralyzing worry Extreme helplessness Compulsions or obsessions

58 Severe depression Complete loss of –Hope –Self-worth –Motivation –Purpose in life


60 How is Terrorism Different? Terrorism wins only if you respond to it in the way the terrorist wants you to… You can control the fate of the terrorist act in terms of your response to it. Psychologically speaking, the impact is up to you and not to the terrorist. Adopted from DeMartino 11/15/01and his interpretation of Franklin 1975

61 Psychodynamics of Chemical, Biological, Nuclear, or Radiological Disasters(CBNR)  Referred to as “silent disasters”.  Dimension of “future orientation”:  delayed medical illnesses and the risk of birth defects and other forms of genetic transmission.

62 Psychodynamics of CBNR Disasters Disrobing in public. Wash-downs in chemical solutions (smells, tastes, tactile experience, etc). Periods of isolation and observation The sight of responders in protective suits. General confusion or lack of information shared with victims.

63 Terror Producing Aspects of CBNR Events Potential for high number of casualties Limited availability of treatments Uncertainty about effectiveness of treatments Contagion Dispersion of biological casualties Silent Disasters… Odorless, Invisible, Quiet

64 Long-Term Response to CBNR Disasters Long-term reactions include: Apathy. Resignation. Decrease tolerance to additional stressors. Irritability, hostility, aggression. These reactions are more common than classic PTSD-type responses. (Vyner, 1987)

65 Behavioral and Cognitive Reactions to CBNR Disasters Following toxic exposures to CBNR agents, victims often report: Feeling trapped in their own bodies. Social isolation, being avoided by others. Obsessive thinking about the event. Damaged and helplessness.

66 Reactions to CBNR Terrorism Unusual physical complaints Overwhelming fear and anxiety. Greater anger and mistrust. Higher ratio of psychiatric:medical casualties. High levels of healthcare-seeking behavior.

67 Panic, Hysteria and Sociogenic Illness Panic is a group phenomena characterized by an intense, contagious fear. Panicked individuals think only of their own needs or survival.

68 Panic, Hysteria and Sociogenic Illness Panic is related to the perception that there is a limited opportunity for escape, a high-risk of being injured or killed, or that help will only be available to the very first people who seek it..

69 Hysteria and Sociogenic Illness Epidemic Hysteria or Mass Sociogenic (Psychogenic) illness refer to the social phenomena of two or more people experiencing a cluster of symptoms for which there is no apparent medical cause.

70 The Psychological Reaction to the Tokyo Sarin Attack 6 Months after the attack: 32% reported overwhelming fear. 28% with insomnia. 16% with depression. 10% fear us using the subway again. Short Term Response

71 The Psychological Reaction to the Tokyo Sarin Attack 72% habitually used sleeping pills. 57% complained of nightmares and flashbacks. 77% used alcohol to calm their nerves. Long Term Response In 1999 survey of 1,247 respondents, more than ½ stated that they still suffered mental and physical effects.

72 Psychological First Aid Long established principle of “buddy-care” in U.S. military. Growing body of empirical evidence demonstrating relationship between physiological arousal and PTSD development following crises. Recommended by the National Academy of Sciences-Institute of Medicine and National Center for PTSD.

73 Working Definition “Psychological first aid (PFA) refers to a ser of skills identified to limited the distress and negative behaviors that can increase fear and arousal.” (National Academy of Science, 2003)

74 Psychological First Aid is… Psychological first aid (PFA) is as natural, necessary and accessible as medical first aid. Psychological first aid means nothing more complicated than assisting people with emotional distress resulting from an accident, injury or sudden shocking event.

75 PFA Can… Reduce physiological arousal. Mobilize support for those who are most distressed. Facilitate reunion with loved ones and keep families together. Provide education about available resources and coping strategies. Incorporate effect risk communication techniques.

76 Where to use PFA On the Frontline of a disaster. Points of Dispensing (POD’s). ER’s and medical emergencies. First Response activities.

77 PFA for Fear-based Reactions Typical traumatic stress reactions are characterized by: Arousal. Avoidance. Re-experiencing. Early-phase (threat-present) reactions are characterized by: Fear

78 Key Elements of Early Intervention Preparation. Provision for Basic Needs. Psychological First Aid. Needs Assessment. Monitoring of the Rescue and Recovery Environment.

79 Continued Outreach and Information Dissemination. Technical Assistance, Consultation and Training. Fostering Resilience/Recovery. Triage. Treatment.

80 Recommendations for Early-intervention Reduce high arousal. Increase social support. Enhance coping with event and reactions Decrease fear of symptoms. Increase understanding of traumatic stress reactions and grief.

81 Continued Prevent maladaptive coping. Avoidance, rumination, substance abuse, isolation. Prevent “loss of resources” Later (3 weeks – year): Reframe negative cognitions. Increase therapeutic exposure. Facilitate emotional processing.

82 Psychological First Aid Early assistance provided b those first on-scene. Initial assessment of emotional impact of event Stabilization of immediate emotional wounds Prevention of further exposure of emotional injury

83 Psychological First Aid Maintenance of emotional status until professional mental health care is available Facilitate transition to trained mental health professional when necessary Promote quicker and better emotional recovery

84 Psychological First Aid is not Debriefing Counseling Psychotherapy Mental health treatment.

85 The PFA Skill Set Supportive Communication. Assisted Coping. Verbal De-escalation. Screening and referral to higher level of care.

86 Fear vs. Exercise-induced Arousal Fear-induced arousal: SNS-driven. Elevates heart rate, BP, respiration, etc. Results in vasoconstriction. Is linked to the development of PTSD. Grossman, D. 2004

87 Exercise-induced arousal: Non-SNS driven. Elevates heart rate, BP, respiration, etc. Results in vasodilatation. Helps trigger PNS/Relaxation Is not linked to PTSD. Grossman, D. 2004

88 The Heart Rate-Traumatic Memory Connection “ Psychological arousal during traumatic events may trigger the neurobiological processes that lead to posttraumatic stress disorder (PTSD).” Shalev, et al, 1998 “

89 The Psychophysiology of Fear Normal resting heart rate= 60-80 bpm 115-145 bpm Hypervigilance begins. Fine motor skills deteriorates. Problem solving diminished Numbing opioid response begins. Vasoconstriction begins. Depersonalization begins. Grossman, D., 2004

90 The Psychophysiology of Fear Normal resting heart rate= 60-80 bpm Above 145 bpm Breathing becomes fast and shallow Sweat production reduces heat. Conscious thought diminishes further Auto-response mode begins. Vasoconstriction advances. Grossman, D., 2004

91 The Psychophysiology of Fear Normal resting heart rate= 60-80 bpm Above 175 bpm Breathing is fast and shallow Shut down complex motor skills Higher cognitive functions shut down Advanced vasoconstriction Irrational fighting or feeling: freezing “Autopilot” behavior Submissive behaviors Grossman, D., 2004

92 The Formation of traumatic Memories Both the hippocampus and cortex have disproportionate number of glutamate receptors.

93 Supportive Communication Verbal & Non-verbal Communication Skills. Active Listening & Responding. Providing Supportive Feedback. Knowing When to Refer and more

94 Assisted Coping Autogenic Breathing Exercises. Guided Relaxation techniques. Managing Fear. Reducing Emotional and Physiological Reactivity. and more

95 Autogenic Techniques Autogenic techniques include: Breathing exercises Progressive muscle relaxation Guided imagery others

96 Screening and Referral Physical Chest pain Respiratory trouble Loss of consciousness Cardiac arrhythmias/palpitations Affective Suicidal ideation Homicidal ideation Catatonia mania

97 Screening and Referral Cognitive Pervasive disorientation Blackouts Psychotic symptoms amnesia Behavioral Self-injurious acts Total lack of self-care Dangerousness to self, others, property

98 Complication Variables in Delivering Mental health Service Delivery Travel may be greatly restricted during the initial impact and decontamination stages of recovery delaying psychological support. Exposed individuals may be isolated for observation and treatment thus preventing contact with family, friends or counselors.

99 Complication Variables in Delivering Mental health Service Delivery In the instance of extreme illness or death of an exposed person, families may not e able to “say good bay”, see or touch their loved ones. Rituals, such as funerals and special treatment of the body may be disrupted causing further emotional distress for loved ones.

100 Mental Health Service Delivery Methods Outreach when life-safety issues are fully addressed. Anticipate home-based counseling needs. Community consultation and training.

101 Service Delivery Methods Individual, group and public education Online, web-base resources Hot lines and tele-counseling Bi-lingual and bi-cultural staff

102 On Site Trauma Response

103 Stabilizing Individual Assess the survivors for injury and shock. Get uninjured people involved in helping. Provide support by: –Listening –Empathizing Help survivors connect with natural support systems

104 Avoid Saying… “I understand.” “Don’t feel bad.” “You’re strong/You’ll get through this.” “Don’t cry.” “It’s God’s will.” “It could be worse” or “At least you still have…”

105 Emergency Mental Health and Traumatic Stress Most people who are coping with the aftermath of a disaster have normal reactions as they struggle with the disruption and loss caused by the disaster.

106 “Traditional” Mental Health Practice Is often office based. Focuses on diagnosis and treatment of a mental illness. Attempts to impact the baseline of personality and functioning. Examines content. Encourages insight into past life experiences and their influence on current problems. Has a psycho-therapeutic focus. Is primarily home and community based. Focuses on assessment of strengths, adaptation of existing coping skills and development of new ones. Seeks to restore people to pre- disaster levels of functioning. Accepts content at face value. Validates the appropriateness of reactions to the event and its aftermath and normalizes the experience. Has a psycho-educational focus. Crisis Counseling

107 COMMON CRISIS COUNSELING SERVICES Information Education Outreach Counseling Supportive listening Referrals Training Collaboration with other programs

108 Disaster Stress Interventions Individual stress management training Social support and creating a supportive organization

109 Disaster Stress Interventions Social support is one of the most important and powerful stress reducers.

110 Managing Stress During Disaster On scene briefings for incoming responders Develop a “buddy” system Watch out for each other

111 Managing Stress During Disaster Take care of yourself physically Take frequent rest breaks Drink plenty of fluids Eat healthy foods

112 Managing Stress During Disaster Take breaks away from the work area Give yourself permission to feel rotten

113 Fatigue as a Health Hazard Stress –Causes a lack on concentration, memory loss and errors in judgment Depression –May be caused by extended periods of stress –Can be caused when workers experience high demands and low levels of control over their work Burnout (Work Exhaustion) –When workers undergo extended periods of high demanding & high stress situations coupled with long hours & work overload The Health Effects of Working Long Hours

114 Helping Children Feel Better Carry out daily routines and outings (when possible)

115 Helping Children Feel Better Encourage children to talk and ask questions

116 Helping Children Feel Better Reassure children they are safe

117 Helping Children Feel Better Screen TV

118 KISS = Keep It Simple Silly Remember you are dealing with a very stressful situation and its aftermath –TALK – especially to others who relate to your situation –DON’T make major decision’s alone –LIMIT – Expectations on self and others

119 HALT Avoid Being Hungry Angry Lonely Tired

120 REMEMBER Take care of yourself. Take care of family.

121 Available Resources Nursing Peer Assistance 24 Hour Hotline 1-800-662-0108 Referral, information, education and fees: (609) 883-5335 ext. 34 Confidential email:

122 Disaster Nursing and Emergency Preparedness for Chemical, Biological, Radiological Terrorism and Other Hazards By Tener Goodwin Veenema, PhD, MPH, MS, CPNP, Editor Recipient of 2 “AJN Book of the Year Awards”

123 Acknowledgements National Centers for Posttraumatic Stress Disorders Dept of Veterans Affairs American Psychological Association American Psychiatric Association American Health Association The American Academy of Experts in Traumatic Stress FEMA CDC NIDA, NIH, NIAAA Jamie F. Becker of the Laborers’ Health and Safety Fund of North America Steven M. Crimando MA, BCETS, Extreme Behavioral Risk Management Deborah J. DeWolfe PHD, MSPH Training Manual for Mental Health and Human Service Workers in Major Disaster. SAMHSA Publication

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