1. Psychological and Behavioral Responses to Disasters Psychological and Behavioral Responses to Disasters Benjamin S. Bunney, MD Charles B.G. Murphy Professor and Chairman Department of Psychiatry Professor of Pharmacology Professor of Neurobiology Yale School of Medicine

2. 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 Siemnianowski, MSW CT Department of Children and Families Thomas Gilman, MSW

4. 9-11-01 Unique Disaster First disaster in history where in the aftermath psychological repair was more important than repairing bodies or burying the dead Part of event was watched live by millions of people

5. 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

6. 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

7. 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

8. 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.

9. 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

10. 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

11. 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)

12. 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

13. 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: hippocampus and amygdala - provides mechanism for two types of long term memory of stressful events Explicit - verbalizable and recallable Implicit - unconscious changes in habit and conditioned responses (e.g. fear response when exposed to cues relevelant to traumatic event

14. 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

15. 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)

16. 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

17. Children Responses and Treatment

18. 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

19. Children’s Typical Initial Responses Normal reactions to abnormal situations Cognitive Questions and concerns about safety and security Anger and thoughts of revenge Focus on frightening things or thoughts Continual playing or talking about the event

20. Children’s Typical Initial Responses Normal reactions to abnormal situations Emotional and Somatic Children’s Typical Initial Responses Normal reactions to abnormal situations (cont.) 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

21. Impact on the Child’s Developing Self A child’s interpretation of his own behavior after the traumatic event may transform the way he looks at himself, they include: A sense of physical prowess or weakness, of passivity or activity, of cowardice, courage and heroism, of self enhancement or diminishment.

22. Toddlers (18 months-3 years) Rely on parents and caretakers to understand the world and will take on the emotional response of adults around them Communicate stress through behavior and body: –Disturbances in eating, sleeping –Decreased speaking, loss of bowel and bladder control –Increase in tantrums, fussiness or defiance –More Clingy

23. Preschoolers More involved with peers and other adults, but continue to look to parents and primary caregivers to understand how to respond Highly imaginative. Also, often more fearful In addition to responses like those of toddlers: –Increased play related to the events, but worrisome if interferes with other activities –Questions about who did it and why –May be concerned about safety

24. School Age More independent, peers and other adults such as teachers have greater influence –Very concerned with right and wrong –May be more defiant and aggressive –Have more difficulty in school –May be anxious or withdrawn –Very concerned about revenge

25. Adolescents Are struggling with independence, often moody and focused on themselves Conflicts with parents, teachers and other authorities are common Tendency to either minimize or exaggerate experiences

26. Adolescents (cont.) May be overly preoccupied with events Angry, threatening and aggressive and defiant Appear distant and numb Increased risk taking New or increased substance use (alcohol, marijuana etc.)

27. Older Adolescents and Young Adults Same range of responses as adults, but Increased concerns about the future, May be increased substance use (alcohol, marijuana and other drugs)

28. Implications of Neurobiological Development for Treatment Hippocampus not fully functional until 4-5 years old + Prefrontal cortex not until around age 10 Treatment of child trauma survivors thus: Must facilitate developmentally-appropriate expression (e.g., drawing, play) Must focus on age-relevant categories/themes (i.e., basic schemata, e.g., safe-unsafe) Must not encourage premature closure/decisions or expose the child to information/affect overload

29. 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

30. 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

31. 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

32. 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)

33. Adults Responses and Treatment

34. 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)

35. 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”) 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 Physical Effects Fatigue Insomnia Sleep disturbance Hyperarousal Somatic complaints Impaired immune response Headaches Gastrointestinal problems Decreased appetite Decreased libido Startle response 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

36. 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

37. Treatment and Intervention In the immediate aftermath (cont.) 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)

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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)

44. Target Groups At Risk for Persistent Post-Traumatic Sequelae On-Site Survivors Terror: Exposure to threat of imminent/actual death Horror: Witnessing death, destruction, terror & shock Physical Insult: injury, exhaustion, exacerbation or precipitation of chronic medical illness, pain, disability Traumatic Reactivation (e.g., return to or loss of work) Bereaved Families/Primary Relationships Traumatic Grief Unresolved Bereavement Social Intrusion and Isolation

45. Target Groups At Risk for Persistent Post-Traumatic Sequelae 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 Isolation and Amplified In-Group Cohesion: Post-traumatic detachment and numbing increase sense of separation Traumatic Reactivation (past & subsequent crisis work) Separation/Detachment from Family and Community Peer Endorsement of Substance Use & Risk Taking

46. Target Groups At Risk for Persistent Post-Traumatic Sequelae Helpers Caring for Survivors, the Bereaved, Workers (e.g., Behavioral Health, EAP, Health Care, Clergy) Vicarious Shock: Exposure to terror, helplessness, grief Vicarious Horror: Witness descriptions of horrifying events Physical/Workload Strain: Ascribed responsibility exceeds actual knowledge, training, or personal/professional limits Traumatic Reactivation: Unresolved direct/vicarious trauma Heightened Role Responsibilities: Unprecedented crisis demands, Idealized role model, Answer the unanswerable

47. Target Groups At Risk for Persistent Post-Traumatic Sequelae Family/Community Members Living and Working with Survivors, the Bereaved, Rescue Workers & Helpers 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

48. Target Groups At Risk for Persistent Post-Traumatic Sequelae People in Recovery from Behavioral Health Disorders Shock: Media exposure to terror, helplessness, grief Traumatic Reactivation: Unresolved direct/vicarious trauma Post-Traumatic Coping: Denial, numbing, dissociation Heightened Risk of Relapse or Decompensation Isolation: Withdrawal from recovery community & treatment Resilience: Opportunity to use recovery skills/commitments

49. Target Groups At Risk for Persistent Post-Traumatic Sequelae Vulnerable Groups (e.g., children, elders, disenfranchised) Shock: Media exposure to terror, helplessness, grief Traumatic Reactivation: Unresolved direct/vicarious trauma Interrupted Attachments: Reduced access to or reliability of caregivers, primary relationships, and support groups Resource Loss: Reduced access to or reliability of key economic, educational, housing, family support services Isolation: Increased risk of stigmatization & marginalization Resilience: Developmental and experiential strengths

50. Treatment Issues 4-6 Months Later: Traumatic Shock 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

51. Treatment Issues 4-6 Months Later: Reactivation of Chronic Post-Traumatic Impairment Concurrent Treatment: Sequelae of Acute Traumatization and Complex PTSD Emotion Dysregulation: Extreme lability/numbing Dangerous/Impulsive Risk Taking/Addiction Suicidality and Self-Harm Pathological Dissociation Somataform Disorders Existential and Spiritual Alienation

52. 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

53. 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)

54. Patterns of Risk for PTSD Temporal Traumatic Shock + Acute Stress in first month Traumatic Grief + PTSD in subsequent months Individual Extent and Nature of Exposure or Loss Gender: Females > Males Sociocultural Children: Caregiver Contagion, older age Socioeconomic or Ethnocultural Adversity

55. Stress Activates The Body’s Alarm System Stress Activates The Body’s Alarm System Clear Memories Memory Like a Broken Puzzle Creating Solutions Making a Mess of Your Life -Work, Family, Friendships Feel Angry or Scared Feel Hopeless or Doomed Feel in Control Feel Helpless or Out of Control Feel Good About Yourself Feel Worthless, like a Failure Normal Stress = PTSD = Dealing with Problems Trying to Survive

56. Issues to be Assessed in the Treatment of Traumatic Sequelae of Disaster Differential diagnosis(es)? What is the individual’s developmental level? What was pre-event/premorbid functioning? What is it now? History of psychiatric disorders or problems? What are the current stressors/ or reminders? (loss, disruption, displacement, financial issues) What are current resources/resiliency factors? How are caregivers coping? Is there alcohol and drug use? Are there frequent episodes of anger and/or aggression? Are there symptoms present of depression, “disordered” bereavement (functioning impaired severely for at least two months after loss or no improvement in six months), PTSD, panic attacks?

57. Issues to be Assessed in the Treatment of Traumatic Sequelae of Disaster (cont.) 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

58. 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

59. Issues to be Assessed in the Treatment of Traumatic Sequelae of Disaster (cont.) Self report can be misleading or incorrect due to: Denial (person cannot admit to self that he/she has a problem) A tough guy, macho image “needs” to be maintained Peer culture (e.g. policeman or fireman), country of origin culture, family culture or belief in patriotic duty may necessitate a “stiff upper lip” demeanor

60. Issues to be Assessed in the Treatment of Traumatic Sequelae of Disaster (cont.) Self report can be misleading or incorrect due to: Denial (person cannot admit to self that he/she has a problem) A tough guy, macho image “needs” to be maintained Peer culture (e.g. policeman or fireman), country of origin culture, family culture or belief in patriotic duty may necessitate a “stiff upper lip” demeanor

61. 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

62. A State Mental Health Care System Response to 9-11

63. 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. Department of Mental Health and Addiction Services Arthur C. Evans, Ph.D. James Siemnianowski, 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

64. 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

65. 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