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Published on August 27, 2007

Author: The_Rock

Source: authorstream.com

Mitigating Disaster: Living in the Shadow of a Nuclear Power Plant in an Age of Terrorism :  Mitigating Disaster: Living in the Shadow of a Nuclear Power Plant in an Age of Terrorism Doug Smith, MD Medical Director, Northcoast Behavioral Healthcare Sridhar Jatla, MD Psychiatry Resident Case Western Reserve University- University Hospitals of Cleveland Disaster:  Disaster World Health Organization definition: 'a severe disruption, ecological and psychological, which greatly exceeds the coping capacity of the affected community.' Man-made Acts of omission- negligent handling of hazardous waste Acts of commission - terrorism Natural Trauma- defined well in the DSM-IV; a unique subjective experience by each exposed individual Acute Effects of Disaster:  Acute Effects of Disaster Physiological- fight or flight hyperarousal Anger Grief Physical comorbidity Psychosomatic (particularly if believe that event included toxic chemicals) Isolation Fear Slide4:  Acute Effects of Disaster:  Acute Effects of Disaster Acute Stress Disorder DSM-IV Exposure to traumatic event that included both Experienced, witnessed, or confronted with event(s) involving actual/threatened death/serious injury, or threat to physical integrity of self or others Person’s response involved fear, helplessness, or horror Acute Effects of Disaster:  Acute Effects of Disaster Acute Stress Disorder DSM-IV During or after the event, individual experiences 3 or more dissociative symptoms: Numbing, detachment, absence of emotional responsiveness Reduction of awareness of surroundings ('daze') Derealization Depersonalization Dissociative amnesia Acute Effects of Disaster:  Acute Effects of Disaster Acute Stress Disorder DSM-IV Event persistently re-experienced by at least one of: Recurrent images Thoughts Dreams Illusions Flashbacks Sense of re-living the experience Distress on exposure to reminders of traumatic event Acute Effects of Disaster:  Acute Effects of Disaster Acute Stress Disorder DSM-IV Marked avoidance of stimuli that arouse trauma recollection (people, places,etc.) Marked anxiety or increased arousal including poor sleep, hypervigilance, etc Clinically significant distress/impairment in some sphere of person’s life, functioning, or ability to obtain help Occurs within 4 weeks of the event Lasts 2 days to 4 weeks (maximum) Not due to prescribed drugs, illicit drugs, general medical condition, etc. Chronic Effects of Trauma:  Chronic Effects of Trauma Phobias Anxiety Disorders Sleep Disorders Major Depressive Disorder Substance Use Exacerbation of physical illness PTSD Slide10:  Chronic Effects of Trauma:  Chronic Effects of Trauma Posttraumatic Stress Disorder DSM-IV Exposure to traumatic event that included both Experienced, witnessed, or confronted with event(s) involving actual/threatened death/serious injury, or threat to physical integrity of self or others Person’s response involved fear, helplessness, or horror Same as for Acute Stress Disorder Chronic Effects of Trauma:  Chronic Effects of Trauma Posttraumatic Stress Disorder DSM-IV Event persistently re-experienced by one/more: Recurrent and distressing recollections of trauma Recurrent distressing dreams of trauma Acting/feeling as though event is recurring, including illusions, hallucinations, flashbacks, etc. Intense psychological distress from cues that symbolize/resemble an aspect of the event Physiological reactivity from cues that symbolize/resemble an aspect of the event Chronic Effects of Trauma:  Chronic Effects of Trauma Posttraumatic Stress Disorder DSM-IV Persistent avoidance of stimuli associated with trauma AND numbing of general responsiveness, shown by 3 or more of: Efforts to avoid feelings, thoughts, conversations associated with the trauma Efforts to avoid activities, places, people that arouse recollections of the trauma Inability to recall an important aspect of the event Markedly diminished interest or participation in significant activities Feeling of detachment/estrangement from others Restricted range of affect Sense of a foreshortened future Chronic Effects of Trauma:  Chronic Effects of Trauma Posttraumatic Stress Disorder DSM-IV Persistent symptoms of increased arousal (2+) Difficulty falling/staying asleep Irritability or outbursts of anger Difficulty concentrating Hypervigilance Exaggerated startle response Duration more than one month (andlt; 3 months acute, andgt; 3 months chronic)– can be delayed onset, occurring 6 months or more after the event Causes clinically significant distress or impairment in some important area of life or functioning Chronic Effects of Trauma:  Chronic Effects of Trauma PTSD likely to persist for many years After the 1988 6.9 magnitude earthquake in Armenia, individuals directly exposed who developed PTSD showed no significant remission between 1.5 years after and 4.5 years after the event. However, depressive symptoms subsided overall. (Goenjian et al., 2000) 45-50 years after WWII, 84% of POWs held by the Japanese met criteria for PTSD and 59% met current criteria. (Engdahl et al., 1997) Effects of “Vicarious” Trauma/Disaster:  Effects of 'Vicarious' Trauma/Disaster 555 Residents of NY Chinatown surveyed (Chen et al, 2003) Immediately after 9/11 with family/friend safe 59% reported 4 or more emotional symptoms Immediately after 9/11 with family/friend loss 90% reported 4 or more emotional symptoms 5 months after 9/11 with family/friend safe 17% reported 4 or more emotional symptoms 50% reported one persistent emotional symptom 5 months after 9/11 with family/friend loss 35% reported 4 or more emotional symptoms Effects of “Vicarious” Trauma/Disaster:  Effects of 'Vicarious' Trauma/Disaster Random phone survey of 569 American adults within 5 days of 9/11 (Schuster et al., 2001) 44% reported at least one substantial stress symptom 98% coped by talking with others 90% coped by turning to religion 60% coped by participating in group activities 36% coped by making donations 85% spoke with their children andgt; 1 hour about 9/11 34% restricted children’s TV viewing 35% of children had one or more stress symptoms 47% worried about their/loved one’s safety Effects of “Vicarious” Trauma/Disaster:  Effects of 'Vicarious' Trauma/Disaster 308 outpatients living 150-200 miles from 9/11 attacks given questionnaires 2-3 weeks after 9/11 (Franklin et al., 2002) 33% of psychiatric outpatients reported symptoms meeting criteria for PTSD 13% of medical outpatients reported symptoms meeting criteria for PTSD No difference in learning about the attacks No difference in personal involvement with victims Effects of “Vicarious” Trauma/Disaster:  Effects of 'Vicarious' Trauma/Disaster Random telephone survey 1 month after 9/11(Galea et al, 2002) 57% reported at least one PTSD symptom 7.5% had probable PTSD Increase in cigarette use by 4% Increase in alcohol use by 18% Increase in marijuana use by 2% Increase in all 3 by 7% Effects of “Vicarious” Trauma/Disaster:  Effects of 'Vicarious' Trauma/Disaster Internet survey of 2729 Americans completed within 23 days of 9/11, then repeated with 933 at 2 months, and 787 at 6 months (Silver et al., 2002) 17% reported symptoms of posttraumatic stress at 2 months 5.8% reported symptoms of posttraumatic stress at 6 months Global distress was increased with a denial coping strategy versus decreased with an active coping strategy. When coping behavior was adjusted for statistically, the effect of vicarious exposure from TV was no longer significant. Effects of “Vicarious” Trauma/Disaster:  Effects of 'Vicarious' Trauma/Disaster Random telephone survey 6 months after 9/11 (Vlahov et al., 2004) by same research group PTSD in 1.5 % (much lower than at 1 month) Increase in cigarette use by 3% Increase in alcohol use by 16% Increase in marijuana use by 3% Increase in all 3 by 6% Finding of sustained increases in substance use shows potential for longer-term health effects of trauma. Effects of “Vicarious” Trauma/Disaster- Television:  Effects of 'Vicarious' Trauma/Disaster- Television Oklahoma City Bombing (Pfefferbaum et al., 1999) 2/3 of a large group of grade 6-12 children reported most TV watched for 7 weeks after event was about the bombing Children who watched more TV reported more PTSD symptoms 9/11 (Schuster et al., 2001) Random phone survey 3-5 days after showed increased hours of viewing associated with substantial stress reaction using 5 posttraumatic stress symptoms Implications for Mental Health Providers:  Implications for Mental Health Providers Intervention necessary for those directly exposed to traumatic events Intervention necessary for many exposed vicariously, even over long distances Education for parents to intervene with their children in a preventive fashion. Slide24:  Disaster Preparedness: Working With Medical Providers:  Disaster Preparedness: Working With Medical Providers Consultation to primary care providers and disaster agencies is helpful. Consultation can reduce the number of individuals who go on to develop psychiatric morbidity. Providers should ensure a hospital’s disaster response plan includes psychiatric considerations. Norwood AE et al. Disaster Psychiatry: Principles and Practice. Psychiatric Quarterly. 2000; 71(3): 207-226. Disaster Preparedness: Working With the Community:  Disaster Preparedness: Working With the Community Mental health providers can speak at non-medical venues. Child psychiatrists could speak to school officials. Psychosocial programs embedded within other programs can reach more people. Barron RA. International Disaster Mental Health. Psychiatric Clinics of North America. 2004: 27 (3). Debriefing:  Debriefing It is a group process for those who have experienced a disaster. This is supposed to help an individual cognitively restructure an event. This process remains controversial. People who undergo a debriefing often express discomfort. Some researchers believe it worsens people’s responses. Supportive Techniques:  Supportive Techniques These identify and strengthen people’s ego function. Goals can include helping people obtain housing and encouraging them to return to school or work. Intervention can 'normalize' people’s response to an event, meaning their responses are 'normal responses following abnormal events.' Norwood AE et al. Disaster Psychiatry: Principles and Practice. Psychiatric Quarterly. 2000; 71(3): 207-226. Cognitive-behavioral Techniques: The Theory:  Cognitive-behavioral Techniques: The Theory The techniques address distortions in people’s views of themselves, their world, and their future. Education is given about benefits and downsides of anxiety and what constitutes an abnormal response. Techniques address lack of control and unpredictability. Cognitive-behavioral Therapy: The Practice:  Cognitive-behavioral Therapy: The Practice CBT was compared with systematic desensitization in a study. This study was among immediate and delayed treatment-seeking rape victims. Both interventions were associated with improvement in various measures. Case reports support efficacy of CBT in treating PTSD after 1993 World Trade Center bombing. Frank E et al: Efficacy of cognitive behavior therapy and systematic desensitization in the treatment of rape trauma. Behavior Therapy. 1988; 19, 403-420. Difede J et al: Acute psychiatric responses to the explosion at the World Trade Center: a case series. Journal of Nervous and Mental Disease. 1997; 185, 519-522. Psychodynamic Psychotherapy Techniques:  Psychodynamic Psychotherapy Techniques These focus on defenses, the unconscious, and transference analysis to augment other interventions. The principles can be applied on a short-term basis. These techniques can reduce symptoms by helping a person explore how an ongoing threat resonates with unconscious issues. Group Therapy:  Group Therapy Studies have examined various types of group therapy for women who have suffered trauma. Therapies have included cognitive-behavioral, process-oriented, and time-limited group therapies. Therapies show promise, but generalizability is limited. Group therapies can increase efficiency and improve social cohesion and support. Due to the chaotic nature of disaster, this requires a mental health provider to be creative and persistent. Herman J et al: Time-limited group therapy for women with a history of incest. International Journal of Group Psychotherapy. 1984; 34: 605-616. Hazzard A et al: Factors affecting group therapy outcome for adult sexual abuse survivors. International Journal of Group Psychotherapy. 1993; 43: 453-468. Treatment for Children:  Treatment for Children Several individual and group therapies have been described. There was a significant reduction in trauma-related symptoms in school-aged children after a four-session group or individual psychotherapy two years after a hurricane. After the 1988 Armenian earthquake, adolescents who had psychotherapy had reduction of PTSD symptoms. Chemtob CM et al: Psychosocial intervention for postdisaster trauma symptoms in elementary school Children Archives of Pediatric and Adolescent Medicine. 2002; 156: 211-216. Goenjian AK et al: Outcome of psychotherapy among early adolescents aftertrauma. American Journal of Psychiatry. 1997; 154: 536-542. Additional Ways for Mental Health Providers to Help:  Additional Ways for Mental Health Providers to Help Providers can be helpful in the immediate aftermath of a terrorist incident. Therapists could become knowledgeable about the different biological, chemical, and nuclear threats. Mental health providers can address patients’ anxiety about exposure. The providers can help differentiate between cases of exposure and psychosomatic reactions. Providers can act as liaisons to the news media. Garakani A et al: General disaster psychiatry. Psychiatric Clinics of North America. 2004; 27 (3). Guidelines for Cultural Competence:  Guidelines for Cultural Competence Recognize importance of culture and respect diversity. Provide cultural competence training to disaster mental-health staff. Recognize role of customs, traditions, and natural support networks. Try to recruit disaster workers who are representative of the service area. Silove D: Translating compassion into psychosocial aid after the tsunami. Lancet. 2005; 365 (9456): 269-71. Pharmacotherapy:  Pharmacotherapy There is some debate, but short-term medications can be used for symptom relief. Studies show mixed results. No difference was seen in PTSD or anxiety scores of trauma survivors after treatment with a benzodiazepine or placebo. In fifteen acute burn victims given citalopram, none developed PTSD, compared to half of untreated controls. Gelpin E et al: Treatment of recent trauma survivors with benzodiazepines: a prospective study. Journal of ClinicalPsychiatry. 1996; 57: 390-394. Blaha J et al: Therapeutical aspects of using citalopram in burns. Acta Chirurgiae Plasticae. 1999; 41: 25-32. Slide37: 

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