1. ® BDLS is a registered trademark of the American Medical Association V 2.9 04/07 ® 1 “Preparing Our Communities” Welcome!

2. V 2.9 04/07 2 Faculty Disclosure For Continuing Medical Education (CME) purposes as required by the American Medical Association (AMA) and other continuing education credit authorizing organizations:For Continuing Medical Education (CME) purposes as required by the American Medical Association (AMA) and other continuing education credit authorizing organizations: –In order to assure the highest quality of CME programming, the AMA requires that faculty disclose any information relating to a conflict of interest or potential conflict of interest prior to the start of an educational activity. –The teaching faculty for the BDLS course offered today have no relationships / affiliations relating to a possible conflict of interest to disclose. Nor will there be any discussion of off label usage during this course.

3. ® BDLS is a registered trademark of the American Medical Association V 2.9 04/07 ® 3 Psycho-Social Aspects of Terrorism and Disaster Chapter 7

4. V 2.9 04/07 4 Mission of Terrorism….

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9. 9 D-I-S-A-S-T-E-R for Psychological Issues Detect Prevalence of Effects and…Detect Prevalence of Effects and… Anticipate Resources Required to Mitigate Anticipate Resources Required to Mitigate Incident CommandIncident Command Security and SafetySecurity and Safety Assessment of Psychological HazardsAssessment of Psychological Hazards Support from State & Federal AssetsSupport from State & Federal Assets Triage and TreatmentTriage and Treatment Evacuation / DispositionEvacuation / Disposition Recovery & ResilienceRecovery & Resilience

10. V 2.9 04/07 10 Detection in Butler, Panzer, Goldfrank, 2003

11. V 2.9 04/07 11 Magnitude of Problem vs. Availability of Resources Magnitude of Problem vs. Availability of Resources Transient Distress Symptoms > 50%Transient Distress Symptoms > 50% Behavior Changes / Substance Abuse 10-25%Behavior Changes / Substance Abuse 10-25% Anxiety Disorders in “Exposed” PersonsAnxiety Disorders in “Exposed” Persons Children: Children: Prevalence of War-Related PTSD in 12- 60% Prevalence of War-Related PTSD in 12- 60% Adults: Adults: Disaster-Related PTSD in 5 - 80% Disaster-Related PTSD in 5 - 80% Military: Military: “Combat Stress Response” in 10 - 30% “Combat Stress Response” in 10 - 30%

12. V 2.9 04/07 12 Risk Factors Risk Factors Degree of ExposureDegree of Exposure ExhaustionExhaustion Factors Increasing Rate of Psychosocial Problems: Physical HarmPhysical Harm Loss of Someone CloseLoss of Someone Close History of Mental DisorderHistory of Mental Disorder …Associated with Depression / Suicide

13. V 2.9 04/07 13 Incident Command Incident Command Need Formally-Designated Leader, Accountable for Coordination andNeed Formally-Designated Leader, Accountable for Coordination and Communication among Potential Providers Need Training and PracticeNeed Training and Practice Need Integration of VolunteersNeed Integration of Volunteers Therefore, Need a Prospective PlanTherefore, Need a Prospective Plan Integrated with State/Local Plans Integrated with State/Local Plans

14. V 2.9 04/07 14 Volunteers Volunteers Need to Address… Credentialing Credentialing “Just-in-Time” Training“Just-in-Time” Training Management: logistics, supervision, transportation, medical & other care needs Management: logistics, supervision, transportation, medical & other care needs Well-Meaning Volunteers Can… Overwhelm, Interfere, Confuse, Burden & Even EndangerWell-Meaning Volunteers Can… Overwhelm, Interfere, Confuse, Burden & Even Endanger

15. V 2.9 04/07 15 Security and Safety of Responders Security and Safety of Responders Responders Can Have Same Psychological Responses as OthersResponders Can Have Same Psychological Responses as Others Exposure to the Trauma of Disasters Often Worse than Past ExperiencesExposure to the Trauma of Disasters Often Worse than Past Experiences Even “Veteran” Responders Affected… esp. If Co-Workers Become VictimsEven “Veteran” Responders Affected… esp. If Co-Workers Become Victims Acute & Subsequent Post-Traumatic Stress Disorders Both CommonAcute & Subsequent Post-Traumatic Stress Disorders Both Common

16. ® BDLS is a registered trademark of the American Medical Association V 2.9 04/07 ® 16 Post-Disaster Counseling Services

17. V 2.9 04/07 17 Interventions for Responders Refer Identified Affected Responders to Professionals Trained in Both Cognitive-Behavioral & Pharmacological TherapiesRefer Identified Affected Responders to Professionals Trained in Both Cognitive-Behavioral & Pharmacological Therapies Therapies Are Not Be the Domain of Non- Professional VolunteersTherapies Are Not Be the Domain of Non- Professional Volunteers

18. V 2.9 04/07 18 Haddon Matrix in Butler, Panzer, Goldfrank, 2003

19. V 2.9 04/07 19 Triage/Treatment Efficient Triage of Persons with Normal vs. Abnormal ResponsesEfficient Triage of Persons with Normal vs. Abnormal Responses and those with symptoms from co-morbid conditions Treat Within Scope of Competency & ResourcesTreat Within Scope of Competency & Resources Identify High-Risk Persons for Immediate Referral and TreatmentIdentify High-Risk Persons for Immediate Referral and Treatment

20. V 2.9 04/07 20 Normal Responses A Threat Normally Induces…. A Threat Normally Induces…. A Sense of Apprehension, Worry, Edginess & Difficulty Concentrating A Sense of Apprehension, Worry, Edginess & Difficulty Concentrating Rational (and Irrational) Attempts to Remove the Threat or Escape It Rational (and Irrational) Attempts to Remove the Threat or Escape It On a Social Scale…Altruistic Behaviors Intended to Ameliorate the Situation On a Social Scale…Altruistic Behaviors Intended to Ameliorate the Situation

21. V 2.9 04/07 21 Normal Responses

22. V 2.9 04/07 22 Normal Responses A Disaster Normally Induces…. A Disaster Normally Induces…. GuiltGuilt Manifested in Many WaysManifested in Many Ways Results in Zealous VolunteerismResults in Zealous Volunteerism

23. V 2.9 04/07 23 Prevalent Syndromes Prevalent Syndromes Sub-Diagnostic Distress (“worried well”) Sub-Diagnostic Distress (“worried well”) Some Symptoms of DistressSome Symptoms of Distress Multiple Concerns / AnxiousMultiple Concerns / Anxious Somatization (physical complaints)Somatization (physical complaints) Do Not Meet Diagnostic “Thresholds” for Psychiatric Disorders Do Not Meet Diagnostic “Thresholds” for Psychiatric Disorders

24. V 2.9 04/07 24 Treatment of Sub-Diagnostic Distress Treatment of Sub-Diagnostic Distress Normalize Responses (reassurances) While Empathizing with DistressNormalize Responses (reassurances) While Empathizing with Distress Supportive Counseling & Sx Reduction Through Relaxation TechniquesSupportive Counseling & Sx Reduction Through Relaxation Techniques If Symptoms Such as Insomnia are Debilitating, Treat SymptomaticallyIf Symptoms Such as Insomnia are Debilitating, Treat Symptomatically Generally, Role of Anxiolytics is SlightGenerally, Role of Anxiolytics is Slight Monitor for Persistence / DissociationMonitor for Persistence / Dissociation

25. V 2.9 04/07 25 Psychological First Aid Protect Survivors from Further HarmProtect Survivors from Further Harm Reduce Physiological ArousalReduce Physiological Arousal Get Support for Most DistressedGet Support for Most Distressed Keep Families TogetherKeep Families Together Facilitate Reunions of Family / FriendsFacilitate Reunions of Family / Friends Provide Reassurance & Education with Effective Risk Communication MethodsProvide Reassurance & Education with Effective Risk Communication Methods

26. V 2.9 04/07 26 Abnormal Responses A Substantial Problem Exists if Symptoms are Greater in: A Substantial Problem Exists if Symptoms are Greater in: Intensity and Duration Intensity and Duration Resulting Impairment or Disability Resulting Impairment or Disability Avoidance of Certain Situations or Objects, Impairing Daily Life Avoidance of Certain Situations or Objects, Impairing Daily Life An Unusual and Significant Pattern of Symptoms An Unusual and Significant Pattern of Symptoms

27. V 2.9 04/07 27 Prevalent Disorders Anxiety DisordersAnxiety Disorders Acute Stress DisorderAcute Stress Disorder Post-Traumatic Stress DisorderPost-Traumatic Stress Disorder Affective DisordersAffective Disorders Major Depressive DisorderMajor Depressive Disorder Dysthymic DisorderDysthymic Disorder Bereavement Evolves into Major Persistent DepressionBereavement Evolves into Major Persistent Depression Substance Dependence and / or Related Mood & Anxiety DisordersSubstance Dependence and / or Related Mood & Anxiety Disorders

28. V 2.9 04/07 28 Medical Community Re-Focuses…

29. V 2.9 04/07 29 Anxiety Disorders due to General Medical Conditions Anxiety Disorders due to General Medical Conditions Interruption of Care for Chronic ConditionsInterruption of Care for Chronic Conditions –Inability to Get Medications –Change in Priorities (for Physicians and Patients) –Lack of Monitoring and Communications –Lack of Access to Emergent Care Affects on Undiagnosed Medical ConditionsAffects on Undiagnosed Medical Conditions –Hyperthyroid States and Angina –Parental Relationships –Irritable Bowel Syndrome

30. V 2.9 04/07 30 Reactions of Children Ages < 5 : Separation FearsSeparation Fears NightmaresNightmares Regression of BehaviorRegression of Behavior Ages 6 – 11: Atypical Disruptive BehaviorsAtypical Disruptive Behaviors Withdraw from People, Daily ActivitiesWithdraw from People, Daily Activities Irritability and Difficulty ConcentratingIrritability and Difficulty Concentrating Lower Grades at SchoolLower Grades at School Adolescents Similar to Adults

31. V 2.9 04/07 31 Common Stress Disorders Common Stress Disorders Re-Experiencing Events (nightmares, flashbacks, intrusive thoughts)Re-Experiencing Events (nightmares, flashbacks, intrusive thoughts) Emotional NumbingEmotional Numbing (depersonalization, derealization, disoriented) AvoidanceAvoidance (negative conditioning to event- related stimuli) Autonomic ArousalAutonomic Arousal Disruptions of LifeDisruptions of Life

32. V 2.9 04/07 32 Temporal Pattern of Stress Disorders Acute Stress Acute PTSD PTSDChronic Onset Within Within 28 days 28 days Immediate (or Anytime Thereafter)

33. V 2.9 04/07 33 Temporal Pattern of Stress Disorders Acute Stress Acute PTSD PTSDChronic Onset Within Within 28 days 28 days Immediate (or Anytime Thereafter) Duration 2-28 days 2-28 days Up to Up to 3 Months 3 Months Greater Greater than than 3 Months 3 Months

34. V 2.9 04/07 34 Screening with SNAP StartleStartle NumbnessNumbness Arousal / AvoidanceArousal / Avoidance PersistencePersistence Derived from Davidson et al, J Nerv Mental Dis 1989

35. V 2.9 04/07 35 Screening for Depression Screening for Depression Screening Question: “In the past two weeks…. “In the past two weeks…. Have You Had a Depressed Mood Most of the Day ?Have You Had a Depressed Mood Most of the Day ?

36. V 2.9 04/07 36 Screening for Depression Screening for Depression Screening Questions: Screening Questions: “In the past two weeks…. “In the past two weeks…. Have You Had a Depressed Mood Most of the Day?Have You Had a Depressed Mood Most of the Day? Have You Had a Loss of Interest or Pleasure in Most Activities?”Have You Had a Loss of Interest or Pleasure in Most Activities?”

37. V 2.9 04/07 37 Screening for Suicide Screening Questions: “Have You had Recent Thoughts that Life is Not Worth Living or That You’d Be Better Off Dead?” “This Past Week… Have You Had Thoughts about Hurting Yourself or Even Killing Yourself?”“This Past Week… Have You Had Thoughts about Hurting Yourself or Even Killing Yourself?” If Answer is “Yes”….If Answer is “Yes”…. “What Have You Thought About?” “Have You Actually Done Anything to Hurt Yourself?

38. V 2.9 04/07 38 …But I Badly Need a Drink I Know It’s Still Morning…

39. V 2.9 04/07 39 Screening for Alcohol and Substance Abuse Screening for Alcohol and Substance Abuse Have You Ever Had a Problem with Drugs?Have You Ever Had a Problem with Drugs? Do You Drink Alcohol? If “yes”, then CAGE:Do You Drink Alcohol? If “yes”, then CAGE:

40. V 2.9 04/07 40 Screening for Alcohol and Substance Abuse Screening for Alcohol and Substance Abuse Have You Ever Had a Problem with Drugs?Have You Ever Had a Problem with Drugs? Do You Drink Alcohol? If “yes”, then CAGE:Do You Drink Alcohol? If “yes”, then CAGE: –Have You Felt You Should Cut Down on Your Drinking?

41. V 2.9 04/07 41 Screening for Alcohol and Substance Abuse Screening for Alcohol and Substance Abuse Have You Ever Had a Problem with Drugs?Have You Ever Had a Problem with Drugs? Do You Drink Alcohol? If “yes”, then CAGE:Do You Drink Alcohol? If “yes”, then CAGE: –Have You Felt You Should Cut Down on Your Drinking? –Have People Annoyed You by Criticizing Your Drinking?

42. V 2.9 04/07 42 Screening for Alcohol and Substance Abuse Screening for Alcohol and Substance Abuse Have You Ever Had a Problem with Drugs?Have You Ever Had a Problem with Drugs? Do You Drink Alcohol? If “yes”, then CAGE:Do You Drink Alcohol? If “yes”, then CAGE: –Have You Felt You Should Cut Down on Your Drinking? –Have People Annoyed You by Criticizing Your Drinking? –Have You Felt Guilty About Drinking?

43. V 2.9 04/07 43 Screening for Alcohol and Substance Abuse Screening for Alcohol and Substance Abuse Have You Ever Had a Problem with Drugs?Have You Ever Had a Problem with Drugs? Do You Drink Alcohol? If “yes”, then CAGE:Do You Drink Alcohol? If “yes”, then CAGE: –Have You Felt You Should Cut Down on Your Drinking? –Have People Annoyed You by Criticizing Your Drinking? –Have You Felt Guilty About Drinking? –Have You Had to Drink in the Morning to Get Rid of a Hangover (“ E ye-opener”) ?

44. V 2.9 04/07 44 Evacuation Pre-Event Hazards Assessment:Pre-Event Hazards Assessment: –Can Capacity of Infrastructure Accommodate Demand Surges ? Transportation, communication, healthcare, etcTransportation, communication, healthcare, etc –Is Public Confident with Respect to Pre- Event and Event-Related Security and Capacity of Infrastructure ?

45. V 2.9 04/07 45 Evacuation Evacuation Event & Post-Event: Event & Post-Event:

46. V 2.9 04/07 46 Evacuation Evacuation Event & Post-Event: Event & Post-Event: Care/Control of Persons Who Panic Care/Control of Persons Who Panic

47. V 2.9 04/07 47 Evacuation Evacuation Event & Post-Event: Event & Post-Event: Care/Control of Persons Who Panic Care/Control of Persons Who Panic Care of Displaced Persons Care of Displaced Persons

48. V 2.9 04/07 48 Evacuation Evacuation Event & Post-Event: Event & Post-Event: Care/Control of Persons Who Panic Care/Control of Persons Who Panic Care of Displaced Persons Care of Displaced Persons Coordination with Red Cross and Clinical Triage/Treatment Teams Coordination with Red Cross and Clinical Triage/Treatment Teams