Despite a generally positive sense we have around the term "community" - this one is traumatized, chaotic, poorly established, with fragmented access to information and services. Special and early attention must be payed to the dinamics of such a community.
Taking Care of Others
Disaster Mental Health
Whom Do You Ask for Help?
Priorities Facing an Individual Practitioner
A growing number of national and international organizations publish converging guidelines on disaster mental health today
Group for the Advancement of Psychiatry - http://ourgap.org - a national think tank
Disaster Psychiatry Outreach - www.disasterpsych.org
October 6th, 213 - 5th International Congress on Disaster Psychiatry, NYC, Bellevue Hospital - registration is now open!
Psychological First Aid Field Operations Guide from the The National Child Traumatic Stress Network and the National Center for PTSD (now in Second Edition).
Psychological First Aid is an evidence-informed approach for assisting children, adolescents, adults, and families in the aftermath of disaster and terrorism.
The Psychological First Aid Field Manual - http://www.ptsd.va.gov/professional/manuals/psych-first-aid.asp
www.disasterpsych.org
American Psychiatric Association
APA Committee on Psychiatric Dimensions of Disaster
http://www.psychiatry.org/practice/professional-interests/disaster-psychiatry
Self-Care Tips
"Our goal is to provide information and resources to professionals, the general public, States, territories, and local entities for emergency preparedness and disaster response." - http://www.samhsa.gov/Disaster/
Preparedness before the event, both at work and at home
Monitor your commitment of time and energy during the disaster
Take breaks
Don’t forget to eat, drink, sleep
Don’t ignore your own emotions
Stay in touch with family and friends
Consider means of peer support
Buddy system
- Taking care of own family
- Take care of professional obligations
- Taking care of self
- What do you need to know?
- What should you expect?
- How can you prepare?
- How can you help?
What Do You Need to Know?
Who May Ask for Your Help?
Basic Framework of
Understanding Disasters
Disaster
Stress, Trauma, Disaster
Stress…
Trauma….
Hurricane Katrina was a sudden event with prolonged consequences that inflicted widespread destruction, loss of life, and depleted community resources.
A complex emergency that is beyond the means of self-care of a particular community.
Trauma: A trauma is stress that overwhelms an individual’s capacity to respond and cope
Disaster: Trauma at the community level
Stress: An occurrence which disturbs someone’s usual sense of equilibrium but for which they have the coping abilities to restore that equilibrium.
Disaster Community
Dimensions of Disaster
Cycles of Disaster
Hurricane Katrina
Pre-disaster
- Baseline Functioning Community
- Social Problems may exist
- Prior Trauma may evidence self
Post-acute phase
Impact
- From 2 months and beyond
- New post-trauma balance is established
- An opportunity for growth
- 24-48 hours post impact
- Initial chaos with only primary safety needs at the forefront
- High adrenaline, lack of clarity
Cause: Natural vs. human-made
Location: Central vs. peripheral
Duration:
Severity:
Potential for recurrence: unpredictable vs. expected
Sense of Control over future occurrence and consequences
Epidemiologic Data of Pre-hurricane residents in Gulf States 5-8 months and then another year post-Katrina showed clear increases:
PTSD increases from 14.9% to 20.9%
Suicidal ideation 2.8% to 6.4%
Suicide plans 1.0% to 2.5%
Kessler et al., 2008
Courtesy of Marko Georgiev for the New York Times
Acute Phase
- Extends up to 2 months
- Community takes stock and forms initial response
disaster psychiatry outreach
(Berren, Beigel, & Ghertner, 1980)
(Taylor, 1987; Wright et al., 1990)
dpo
disaster psychiatry outreach
Acute Phase:
Common Reactions of Distress
Acute Phase:
Common Symptoms
Psychological Consequences of Concern
= a spectrum
Acute Psychological Responses
- May initially be adaptive and “normal” (i.e. “fight or flight reaction”)
- In contrast, persistence and functional impact help to gauge whether they are “abnormal”
“Stunned”
“Shocked”
Feeling abandoned
Uncommon vulnerability
Intense love / altruism
Heroism / Industry
Bewilderment
Danger
Confusion
Impasse
Desperation
Apathy
Helplessness
Urgency
Discomfort
- Distress response – changes in how people think and feel
- Behavioral changes – changes in how people go about their life and do things
- Psychiatric illness – at the most extreme end of response and behavioral changes and include Post-Traumatic Stress Disorder or Major Depression
Intense, transient, & fluid
Physical
Palpitations, shortness of breath, dizziness, sweating, loss of appetite, chest pain
Cognitive
Distractibility, confusion, watchfulness, questions of meaning, expectation of harm, nightmares
Emotional
Fear, anxiety, depression, irritability, fatigue/exhaustion
Behavioral
Insomnia, interpersonal conflict, agitation, social withdrawal, social dependency, loss of routine, substance use
(Wolfenstein, 1957)
(Katz et al, 2002)
(Institute of Medicine, 2003)
(DPO Training Course, 2004)
Interventions
Risk Factors for Problems
Acute Phase:
Diagnoses
Common symptoms
Common Psychological Goals
Interventions
Psychological First Aid
Post-disaster problems are not the same as Post-Traumatic
Stress Disorder
Anxiety
Agitation
Insomnia
Mood symptoms
Psychosis
Dissociation
Somatic complaints
- Dose of trauma: Exposure to the event (death, agony, disfigurement)
- Prior psychiatric history
- Problems of living prior to the disaster/low socioeconomic status
- Lack of perceived or actual social supports after the event
- Presence of “secondary stresses”
- Female
- Middle age
- Ethnic minority
- PFA is the modality of choice for most brief field interventions
- Widely adopted by National and International Agencies
- "Evidence informed" - very nature of the disasters resists traditional research methods
- PFA Focuses is on providing basic safety and autonomy
- Community and individual centered approach - capitalizes on strengths and prior experience of coping
- Empathic, supportive, and practical
- Targeted mental health interventions addressing impairment, symptoms, acute issues, and referral
- Focusing on sustained local resources even if "imperfect" far more important than "gold standard" that cannot possibly be maintained.
- Comfort and support
- Promote mental health
- Accelerate recovery
- Prevent a disorder
- Treat a disorder
Although uncommon, some may develop new psychiatric illness during this time
More commonly, psychiatric illness will become an issue due to worsening or re-occurrence of prior such problems
- disruption of social and mental health networks
- lack of ready medication and care availability
- long term intstability - increase in hospitalizations for the severely mentally ill
disaster psychiatry outreach
Psychological First Aid:
Social Support
Psychological First Aid:
Education
Psychological First Aid:
High-Risk Populations
Pharmacotherapy
Communicating in a Crisis
- Avoid technical jargon but be consistent in use of terms
- Always indicate level of certainty about information and be honest in answering questions
- Avoid false reassurance or pleas not to panic
- Pre-event trainings & peri-event updates are crucial for hospital personnel
- Provide means of receiving information (TV, radio)
- Need areas of quiet as well
- Offered interventions should be voluntary, under one’s control, familiar, with clear benefits, conveyed by a trusted source
- Families should be kept together
- Quarantined patients should have access to information & should have the ability to communicate
- Setting up a system or linking with a municipal system for rapid locating of patients’ friends and relatives
- In the acute phase - the goal is to reduce symptoms that impede coping
- Provision of care for those with pre-existing conditions is of high value (strong evidence in increased hospitalizations long after the event)
- Adequate pain control (including opiates) likely to decrease later PTSD intensity and incidence
- Benzos - may be used judiciously - consider the same thoughtful selection as in every day practice
- Focusing on those who sustained a higher “dose” of the event can facilitate the provision of the services
- Physical proximity may be of a great predictive value.
- Focus on the most vulnerable - medically compromised elderly, children, isolated minorities
Education regarding basic coping skills and methods must be both effective and timely - may help prevent pathology
- Breathe calmly
- Avoid making major decisions
- Focus on high-priority activities
- Resume routines
- Avoid alcohol / drugs
- Talk honestly with & involve children
- Seek help and counseling
- If a hospital visit – provide this information upon discharge; prepared sheets are helpful
- Disaster Psychiatry Outreach
- American Red Cross
- American Psychiatric Association
- Medical Reserve Corps
- NVOAD
- Local Religious and Civic Organizations
- Your own clinic, hospital, neighborhood
Substance Abuse and Mental Health Services Administration
Acute diagnoses
Urgent Triage
Acute Stress Disorder
Major Depression
Reactivated PTSD
Acute Bereavement
Adjustment Disorder
Culturally codified phenomena
Panic Attacks
Personality disorder coping problems
Brief Psychotic Disorder
Substance Abuse
Delirium
- Suicide / self-harm
- Homicide / harm to others
- Inability to care for self
Anti-psychotic medications
Psychotherapy
Pharmacotherapy:
General Principles
Acute Pharmacotherapy – Secondary Prevention
Medications - Experience
Anti-Depressants
- Mental Health providers should not assume that all survivors will need psychotherapy
- Appropriate needs assessment and triage should help identify those at most risk (proximity, direct injury, pre-existing diagnosis etc.)
- Individual preference - should only be a guide, secondary traumatization must be avoided in group modalities
"Although SSRIs are effective in chronic PTSD, there is yet no evidence base for their use in the acute disaster setting. Without adequate follow up, SSRIs may provoke mania or even suicidal ideation and therefore are best used only in the post-acute stage."
- Always review current medications, medical problems, and allergies
- Emphasis on short-term regimen
- Attention to prescriber’s motivations
- benzodiazepines - useful and ubiquitous and do not appear harmful as was initially thought
- hypnotic agents - commonly requested, when possible explore the etiology of the sleep disturbance and utilize CBT
- anti-psychotics - may be useful for excessive anxiety and certainly for psychosis
- Antipsychotics should be used for management of acute symptoms of psychosis and mania
- Provider should be thoughtful of verifying availability of the specific antipsychotics and continue previous meds whenever verification is possible
- Antipsychotics do not seem to have any specific use or special value beyond traditional use
Example:
Propranolol
Hydrocortisone
SSRI, SNRI, TCA
Benzodiazepines
Morphine
Antagonist/agonists
(Bennett et al. 2007)
Disaster Psychiatry: Readiness, Evaluation, and Treatment 2011
dpo
disaster psychiatry outreach
Psychological First Aid
Eye-Movement Desensitization and Re-processing (EMDR)
Psychological Debriefing
Psychotherapeutic Techniques
- Contact and engagement
- Provide for basic needs
- Protect from further harm
- Reduce agitation & arousal, support those in most distress
- Keep families together and provide social support
- Provide information, foster communication & education via effective risk communication techniques
- Orient to available services
- Provide information on coping
In vitro exposure and cognitive therapy accompanied by rapid eye movements
Increasing evidence for benefits in PTSD
Still unclear what elements are necessary of this structured approach
Little studied in the acute setting
Opportunities to share one’s story and experience may be helpful
Opportunities for psychoeducation and informal assessment
Avoid strict models
Never should be mandatory
but
Heterogeneous groups can expose members to new traumas
Debriefing during ongoing trauma can worsen the trauma exposure
Confusion of grieving individuals with traumatized individuals
One time intervention is highly desirable but elusive
Cognitive-Behavioral
Prolonged exposure
Traumatic bereavement
Psychodynamic
Group
Family
Post-Acute Phase
Diagnoses
Aftercare
Post-Acute
Return to “everyday life”
Removed from immediate threat
Re-establish contacts, work, and homes
- Options for follow-up should be known prior to clinical intervention
- Linkages with local services
- Clinicians should not self-refer
Most symptoms will have resolved, but a substantial minority will experience the maturation of symptoms from the acute phase
PTSD
Major Depressive Disorder
Anxiety
Substance abuse/dependence
Complicated grief
Adjustment Disorder
Disorders due to medical conditions or unusual medical presentations
Post Disaster PTSD Prevalence
Direct victims: 30-40%
Rescue workers: 10-20%
General population: 5-10%
(Neria et al. 2008)
Resilience and Special Populations
Resilience – Positive Outlook
Resilience – Exercise
Resilience
Resilience – Active Coping
- Positive outlook - Using cognitive-behavioral strategies to enhance optimism and decrease pessimism;
- Embracing humor – this may seem trivial but makes a major difference
- Navy Seals training now utilizes “self-talk” to decrease drop-out rates and maintain resilience.
Active Coping Style
Physical Exercise
Positive Outlook
Moral Compass
Social Support
Cognitive Flexibility
- Physical exercise - Engaging in physical activity to improve mood and health is key – this is easily available and gives immediate positive feedback to your body and mind that you are in fact in control.
- At least 30 minutes of cardio exercise as tolerated – at least 3 times weekly.
- Active coping style - Problem-solving and managing emotions that accompany stress; learning to face fears – in other words – deal with problems as they come.
- The significant majority of those effected will walk away with passing symptoms.
- Identifying resources in the community is an important step to recovery
Adopted from “6 Keys to Resilience for PTSD and every day stress, Margaret Haglund, BA, Current Psychiatry,
Resilience – Moral Compass
Resilience – Cognitive Flexibility
Resilience – Social Support
Moral compass - Developing and living by meaningful principles;
Putting them into action through altruism/heroism.
Relying on religion to find meaning can be helpful for some.
- Cognitive flexibility - finding good in adverse situations
- Remaining flexible in one’s approach to solving problems
- Accepting solutions that may have come from someone else and may not be ideal – but “would do”
- Social support - Developing and nurturing friendships; seeking resilient role models and learning from them
- age and life experience can often serve a protective role
- seek out those you trust and have relied upon in previous crisis to get the reliable and reassuring support.
- Remember, you have been thru other stressful events in your life and you have come through and came out on the other side. You’ll come through again.
Elderly
Children and Disasters
Children
Changes in sleep
Apathetic behavior
Regressive behavior
Changes in relationships with family or peers
Worsening of grades in school
Fears and worries
- Once basic safety is provided - older individuals can be an important pillar of stability for families and community
- Life experience can be an example of resilience and recovery
- Rapid and safe involvement in routine and provision for medical needs is key
Unique psychological experiences partly shaped by alterations in routine and parental reactions
Age-dependent reactions
Infants
Pre-school
School-age
Adolescents
(Substance Abuse and Mental Health Services Administration, Washington DC)
Substance Abuse and Mental Health Services Administration
Intense, transient, & fluid
Physical - Palpitations, shortness of breath, dizziness, sweating, loss of appetite, chest pain
Cognitive - Distractibility, confusion, watchfulness, questions of meaning, expectation of harm, nightmares
Emotional - Fear, anxiety, depression, irritability, fatigue/exhaustion
Behavioral - Insomnia, interpersonal conflict, agitation, social withdrawal, social dependency, loss of routine, substance use
Local Mental Health Services
1-800-LIFENET: a 24-hour/day hotline funded by the Department of Health and Mental Hygiene to provide mental health referrals appropriate to patient’s geography and ability to pay
311: A New York City hotline for all other inquiries, including social services
Piotr Redlinski for The New York Times
Dr. Hirschowitz during his daily training routine in Central Park.
Disaster Mental Health Basics
Dr. Sander Koyfman
Disaster Psychiatry Outreach
Kings County Hospital