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Psychological and Behavioral Responses to Disasters


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									Psychological and Behavioral
  Responses to Disasters

       Steve Bunney, MD
    Department of Psychiatry
    Yale School of Medicine
•   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
     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
         SHOCK – first hours/days
       HEROIC – first days/weeks
       HONEYMOON – 1-3 Months
    DISILLUSIONMENT – 3-6 months
     RESTABILIZATION – 6-9 months
        RECOVERY – 9-12 months
    PREPAREDNESS – 12+ months
      What is Psychological
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
         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,
                   Stress vs Trauma

Dealing with Problems      Trying to Survive

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

 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)
         Neurobiology of Severe Stress

   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
Neurobiology of Severe Stress

   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
Neurobiology of Severe Stress

   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
 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)
     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
Responses and Treatment
            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
   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
Spectrum of Developmentally Determined Responses

   Rely on Parents
   Highly Imaginative
   Concerned About Safety
School Age
   Social Difficulties
   Concerned About Right/Wrong (Revenge)
   Struggling With Independence
   Conflict With Authority Figures
   Minimize or Exaggerate
   Increased Risk Taking
   Substance Use
Older Adolescents & Young Adults
   Concerns About Future
   Substance Use
  Implications of Neurobiological
    Development for Treatment

 Hippocampus not fully functional until 4-5 years
 Prefrontal cortex not fully functional until around
  age 10
  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
         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
       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
    Treatment Issues 4-6 Months After
                   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)
Responses and Treatment
          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)
    Common Stress Reactions To Disaster
Emotional Effects                                             Cognitive Effects
Shock                                                         Impaired concentration
Anger                                                         Impaired decision-making ability
Despair                                                       Memory impairment
Emotional numbing                                             Disbelief
Terror                                                        Confusion
Guilt                                                         Distortion
Irritability                                                  Decreased self-esteem
Helplessness                                                  Decreased self-efficacy
Loss of derived pleasure from regular activities              Self-blame
Dissociation (e.g., perceptual experience seems “dreamlike,   Intrusive thoughts and memories
       “tunnel vision,” “spacey,” or on “automatic pilot”)    Worry
Physical Effects                                              Interpersonal Effects
Fatigue                                                       Alienation
Insomnia                                                      Social withdrawal
Sleep disturbance                                             Increased conflict within relationships
Hyperarousal                                                  Vocational impairment
Somatic complaints                                            School impairment
Impaired immune response
Gastrointestinal problems
Decreased appetite
Decreased libido
Startle response

  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
        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
   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.
   Treatment and Intervention
          In the immediate aftermath

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
      Key Principles of Immediate

 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
  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
 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
     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)
 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
 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
     Target Groups At Risk for
Persistent Post-Traumatic Sequelae

People in Recovery from Behavioral Health Disorders

                 Vulnerable Groups
       (e.g., children, elders, disenfranchised)
  Treatment Issues 4-6 Months
 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 &
 Defeat: Loss of personal/spiritual trust & goals
   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
  Posttraumatic Stress Disorder
 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)
   Issues to be Assessed in the
Treatment of Traumatic Sequelae of
               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
   Poor or absent social supports
    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
       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
          Tell them what you are doing to cope
A State Mental Health Care
 System Response to 9-11
 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
     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
    www.ctrp.org and www.clearinghouse.org
      Linking Behavioral Health to the OEM & DPH
            Disaster/Crisis Response System
         Local Incident                    Statewide,
           Command                       Regional, Local
            System                         Behavioral
        Municipal officials,             Health System
        public health, fire,              BH Agencies +
        police, emergency                 Professionals+
          management,                     Natural Helpers
        EMS, health care,
          schools, social
         service agencies
                                       Local Behavioral
                                       Health Response
OEM - Office of Emergency Management
DPH - Department of Public Health
BH - Behavioral Health
      How does the state behavioral health
     system support local crisis responses?
  RC = Regional                                     Gov = Governor
 Behavioral Health                Gov/OEM/DPH
   Coordinators                                     OEM = Office of Emergency Mgmt

 DMHAS = Dept of              DMHAS/DCF             DPH = Dept of Public Health
  Mental Health &                                   CTRP = Ctr. for Trauma
   Addiction Svs                    CTRP            Response/Recovery & Preparedness
                                                    DCF = Dept of Children & Families

         RC              RC           RC         RC                RC

     T        T      T        T      T     T    T        T       T        T

 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
          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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