PSYCHOSOCIAL CARE AFTER A BIOTERROR ATTACK

1
PSYCHOSOCIAL CARE AFTER A BIOTERROR ATTACK

• Marlene Rankin, Ph D, RN
• Clinical Associate Professor, College of Nursing
• Rutgers The State University of New Jersey
• College of Nursing
• Nursing Center for Bioterrorism and Infectious
• Disease Preparedness

2

• The format and information in this module
• focuses on psychosocial care after a bioterror
• attack. This module is designed to highlight
• important information about psychological
• responses and care after a bioterror attack.
• This module was supported in part by
• USDHHS, HRSA Grant No. T01HP01407.

3
Purpose

• Observations following conventional terrorist
  incidents and other trauma, including biological
  and nuclear accidents, suggest that a biochemical
  terrorist incident would have widespread public
  effects.
• Unlike in natural disasters or other situations
  resulting in mass casualties, nurses, health care
  workers and physicians would be most likely to
  identify the unfolding disaster associated with a
  biological attack.
• A bioterrorist attack would necessitate treatment
  of individuals and communities who experience
  psychological symptoms and syndromes.
• Recognizing the influence that psychological
  distress has on recovery and physical symptoms
  allows nurses and health care workers to more
  effectively treat patients.

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Purpose-2

• Initial psychosocial interventions include
  effective and accurate risk assessment,
  communication, management of acute abnormal
  psychological and somatic symptoms, and an
  environment that supports recovery and realistic
  client response outcomes.
• Factors that influence psychological outcome
  include interpersonal and environmental aspects.
• The long-term effects following a traumatic event
  are influenced by an individuals unique
  combination of health, developmental level,
  resources and experiences.
• The nurse must be cognizant of personal needs and
  self care during this crisis time.

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Individual Effects

• Individual effects of disaster trauma include the
  physical and psychological consequences of those
  injured or infected as well as psychological
  consequences of the injured persons loved ones.
• Individuals with no direct connection to the
  trauma, other than awareness, can experience
  psychological symptoms as well.
• In bioterrorism, where events often occur with no
  warning, individuals may experience random
  patterns of unpredictable and continuous fear
  (Braden, 2002).
• No one is safe and people can not within reason
  change their behavior to decrease risk.
• The victims who are killed, injured or even
  directly affected are rarely the primary target
  (Susser, 2002).
• Victims may include adults and children, both
  genders, and include multiple racial groups as
  occurred with the anthrax attacks.
• The risk of panic is heightened when individuals
  believe there is a small chance of escape or they
  are likely to become infected (Holloway (1997).

6
Community Effects

• Community physical resources are affected by
  bioterrorism as well as the behavior and cohesive
  nature of the community.
• A range of negative outcomes are possible
  including a vulnerable populations refusal to
  accept preventative measures or treatment regimes
  such as isolation and quarantine, social
  disruption, and civil violence.
• Beyond the human health toll, there is the damage
  inflicted by ethnic stereotyping, stigmatization,
  and finally staggering business and economic
  losses (Hall, 2003).
• There could be a disruption in the social
  infrastructure adversely affecting community,
  leadership and safety.

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• Most people pull together and function after a
  disaster, but their effectiveness is diminished.
• Biological weapons are especially effective at
  causing fear and horror

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Disaster Stress and Grief Reactions are Normal

• Stress and grief reactions are normal responses
  to an abnormal situation.
• Many emotional reactions of disaster survivors
  stem from problems of living brought about by the
  disaster.
• In a terror situation most people will experience
  some level of psychological distress including an
  altered sense of safety, sadness, anger, fear and
  decreased concentration.

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Disaster Stress and Grief Reactions are Normal-2

• Yet most individuals do not see themselves as
  needing mental health services following disaster
  and will not seek such services.
• Most individuals will function adequately, but a
  few will need psychological intervention.

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Disaster Stress and Grief Reactions are Normal-3

• Assessment considerations should include
  ethnocultural concerns that reflect ethnic
  heritage or cultural identity.
• Individuals may value their ethnic background but
  wish to avoid being stereotyped.
• Intrapersonal aspects must consider the patients
  developmental level and inner resilience.

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At-Risk Populations for Psychological Sequelae
Following a Bioterror Attack

• Those exposed to the dead and injured including
  eye witnesses, emergency first responders, those
  endangered by the event, and medical personnel
  caring for victims.
• The elderly and very young.
• Individuals, who because of the event are hungry,
  cannot drink clean water, are exposed to weather,
  or become extremely fatigued.
• Individuals who continue to be exposed to a toxic
  contamination.
• Individuals with a history of exposure to other
  traumas or with recent or major life stressors or
  emotional strain such as poverty, homelessness,
  unemployment, or discrimination.
• Patients with chronic medical or psychiatric
  diagnoses.

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Assess Normal Coping Behaviors of Patients

• The active process of using personal,
  psychological, social, and environmental
  resources to manage stress or anxiety.
• Enables the patient to discern problems to
  recognize possible solutions or strategies such
  as defense mechanisms.

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Assess Normal Coping Behaviors of Patients-2

• Factors Influencing Coping
• Fear of pain and discomfort.
• Fear of the unknown, based on experience and
  uncertainty about final outcome
• Fear of complications or loss of control
• Fear of disruption of life pattern
• The patients previous health care experiences,
  hospitalizations, and pre- and post-event
  treatment affect psychosocial functioning

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Coping Strategies Include

• Worrying
• Changes in physical activity, sleeping patterns,
  eating habits
• Seeking information
• Denial
• Repression
• Using drugs or alcohol
• Increased smoking

• Physical exercise
• Journal writing
• Relaxation tapes
• Reading books or magazines
• Talking the problem out
• Trusting in religious faith
• Relying on support from others

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Assess and Reinforce the Individuals Strengths

• The patients strengths represent an untapped
  energy source.
• Identifying the patients strengths will give
  perspective.
• Determine how the patient can use these strengths
  in this situation.
• Personal values and goals differ

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Mini Mental Status Examination

• Determine the significance and importance of the
  event to the patient, nature and degree of
  exposure.
• Assess the patients mood, orientation, affect,
  general appearance, and thought processes.
• Use open-ended questions, Tell me what is going
  on, It is often difficult to know where to
  begin.
• Discuss temporary loss of lifes routines and
  possible sexual restrictions.

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Mini Mental Status Examination-2

• Assess sleep patterns for possible sleep disorder
  or trauma.
• Examine patients perception of possible risks
  or permanent limitations from bioterror agent.
• Evaluate according to individuals developmental
  level.

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Additional Assessment Considerations

• The nurse must be cautious about conversations in
  the hospital because the patient may be able to
  hear what is going on but unable to clarify or
  interpret coherently.
• The hospital environment may alter the patients
  perception.
• A patient who has been medicated, receives IV
  sedation, or who is undergoing or emerging from a
  biological agent may be influenced by
• physical restraint
• sensory overload
• sensory deprivation due to edema, shock or
  medical emergency
• overheard conversation
• generalized and specific effects of drugs

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Additional Assessment Considerations-2

• The patient may have a transient psychological
  disturbance during the early assessment period
  due to
• personality structure
• change in appearance
• uncertainty about outcome of attack or prognosis
• attitudes and reactions of significant others

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Common Psychological Responses to a Biological
Attack

• Anxiety a universal unpleasant feeling of
  tension and apprehension, a normal response to
  stress accompanied by a variety of physical,
  affective, cognitive, and behavioral symptoms
  that have both positive and negative effects and
  range from mild to panic (see Table 1 next frame).

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Table 1. DSM-IV (1994) Criteria For Panic
Attack, Posttraumatic StressDisorder and Acute
Stress Disorder

• Panic Attack PTSD Acute
  Stress
• (4 or more symptoms (Symptoms can be
  (Symptoms occur
• present, sudden onset immediate or
  delayed immediately, end within
• peak in 10 minutes) for years,
  stressors 4 weeks 3 or more symp-
• trigger at least 3
  toms present for 2 days)
• symptoms)
• __________________________________________________
  ___________________________________
• Palpitations Experienced an
  Exposure to a traumatic
• Sweating event that
  caused event involving threat
• Trembling/Shaking severe threat to
  self to self
• Shortness of breath
• Feeling of choking Response of
  intense Response of intense
• Chest discomfort fear, helplessness,
  or fear, helplessness, or
• Nausea horror horror
• Feelings of unreality Hypervigilance
  Clinical distress
• Fear of losing control Recurrent
  thoughts
  Detachment/Daze
• Fear of dying or nightmares
  Depersonalization
• Numbness Flashbacks
  Recurrent dreams
• Chills Intense distress
  Flashbacks

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Common Psychological Responses to a Biological
Attack-2

• Mild anxiety is reflected as verbal expression of
  concerns, restlessness, irritability, agitation,
  or crying. Often times there are repeated
  questions and an inability to focus
• Moderate levels of anxiety may include periods of
  shortness of breath, gastric symptoms such as
  butterflies in the stomach, selective
  inattention, facial twitches and trembling lips,
  and irritability.

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Common Psychological Responses to a Biological
Attack-3

• Interventions include distraction techniques such
  as listening to music, reading a book, talking to
  a friend, playing a game, or counting backward by
  threes.
• Rationale Distraction techniques allow people to
  remain in control when experiencing moderate
  levels of anxiety, the brain
• cannot hold two thoughts at
• the same time (Fontaine,
• Kneisl, Trigoboff, 2004).

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Panic

• Panic level of anxiety is associated with awe,
  dread, and terror.
• The person experiences a loss of control and is
  unable to do things even with direction and
  results in increased motor activity, decreased
  ability to relate to others, distorted
  perceptions, and loss of rational thought.
• This level of anxiety is incompatible with life
  death and exhaustion will occur if it continues
  for a long period (Stuart and Laraia, 2005).

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Panic-2

• Specific clinical cues include
• shortness of breath, choking smothering sensation
• hypotension, dizziness, chest pain or pressure,
  palpitations
• nausea
• hot flashes
• agitation, poor motor coordination, body
  trembling
• facial expression of terror
• fear of losing control, fear of dying
• completely disrupted perceptual field

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Interventions for Panic Attacks

• Use a calm approach, stay with the patient and
  give directions using simple, short sentences.
• Keep the patient focused on the present.
• Suggest deep breathing and tensing and relaxing
  muscles of hands and feet. Rationale Staying
  with a patient promotes safety and reduces fear,
  deep breathing helps patients feel connected to
  the environment and reduces the physical
  excitement phase (Fontaine, Kneisl, Trigoboff,
  2004).
• Often panic attacks mimic myocardial infarctions.

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Depressive Episode

• The patient reports a depressed mood or the loss
  of interest or pleasure in nearly all activities.
  
• In children and adolescents the mood may be
  irritable rather than sad.
• Appetite is usually reduced but in some cases
  individuals crave sweets or carbohydrates.
• Decreased energy, tiredness, and fatigue are
  common with even the smallest tasks requiring a
  substantial effort.
• There is a sense of worthlessness or guilt that
  may include negativity or unworthiness.
• Many patients report impaired ability to think,
  concentrate, and make decisions.
• Children may reflect poor academic performance
  and have recurrent thoughts of dying young
  (DSM-IV, 1994).
• Patients do not have hallucinations or delusions!

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Depressive Episode-2

• Symptoms include
• Sadness
• Demoralization
• Isolation/withdrawal
• Impaired concentration
• Sleep and appetite disturbances

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Somatization Disorder

• The patient has reported physical symptoms with
  no clinical findings to support subjective
  complaints.
• The DSM-IV (1994) includes the following
  criteria
• A history of many physical complaints that begins
  to interfere with social, occupational and other
  important areas of functioning.
• This disorder may occur in patients undergoing
  serious life stressors, and whose coping patterns
  and defense mechanisms are failing.

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Somatization Disorder-2

• Symptoms may include
• Fatigue
• Weakness
• Malaise
• GI complaints
• Headache
• Impaired balance
• Skin rashes

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Post Traumatic Stress Disorder (PTSD)

• The patient has experienced a traumatic event
  (bioterrorism) that threatens serious injury,
  death or is a threat to ones own physical
  integrity.
• The patient reacts with horror, extreme fright,
  or helplessness and repeatedly re-experiences the
  event or avoids anything that evokes memories of
  it.
• These patients tend to be easily startled,
  anxious, and tense and the full symptom picture
  must be present for more than one month.

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PTSD-2

• Most patients complain of insomnia and they
  struggle with concentration.
• Major depression is common in delayed reactions.
  
• Many patients will use alcohol or sleeping
  medications.
• Children will have scary nightmare and think they
  will die young.

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PTSD-3The DSM-IV (1994) lists the following
cluster of symptoms

• Re-experiencing
• Efforts to avoid thoughts, feelings associated
  with the trauma
• Shock
• Fear
• Panic
• Numbing
• Inability to recall an important aspect of the
  trauma

• Hyperarousal or hypervigilance
• Anger
• Difficulty concentrating
• Irritability
• Detachment
• Estrangement from others
• Nightmares
• Distressing dreams
• Flashbacks
• Reawakening

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Treatment for PTSD

• Most patients suffer some form of PTSD initially
  and in the majority of cases it will diminish
  over two months.
• However, referral to a mental health clinic is
  appropriate for patients who have symptoms of
  PTSD after three months for treatment and usually
  includes cognitive and behavioral therapies.
• Medication such as fluoxetine (Prozac) has been
  effective in controlled clinical trials.

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Treatment for PTSD-2

• After the World Trade Center 9/11 attack, the
  estimated prevalence of PTSD in Manhattan was 20
  (Hall et al. 2003).
• Unfortunately, PTSD is rarely a patients only
  psychiatric diagnosis and it is sometimes
  difficult to distinguish overlapping independent
  symptoms from effects of the trauma.
• Nearly half of all people with PTSD also suffer
  from major depression and more than a third from
  phobias and alcoholism.
• PTSD is a highly prevalent and impairing
  condition (Moore Jefferson, 2004).

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Psychological Responses to Bioterror Trauma in
Children and Adolescents

• Pre-school age
• depressed or irritable mood,
• temper tantrums,
• clinginess,
• increased dependency,
• changes in appetite,
• sleep disturbances and somatic complaints.
• After any disaster, children are most afraid that
  the event will happen again or they will be
  separated from their family and left alone.

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Psychological Responses to Bioterror Trauma in
Children and Adolescents-2

• School Age Children
• separation anxiety,
• avoidance,
• regressive symptoms,
• fear of the dark,
• decrease in school performance,
• re-enactment through traumatic play,
• withdrawal from friends,
• depression,
• aggressive behavior at home or school, and
• hyperactivity that was not present earlier.

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Psychological Responses to Bioterror Trauma in
Children and Adolescents-3

• Adolescents
• increased risk taking behavior,
• drug or alcohol abuse,
• decline in previous
• responsible behavior,
• social withdrawal,
• apathy,
• depression,
• rebellion at home or at school, and
• increased sexual acting out.

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Helping Children Cope After A Traumatic Event

• Younger children under the age of 5 will
  understand the disaster in more general terms.
• Eight to eleven year olds will be more concrete
  in their understanding and ask for more details.
  
• Teenagers will understand all the implications
  and feel increasingly unsafe.
• The child may feel responsible in some way- do
  not allow them to feel accountable for events
  that they have no control over.

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Helping Children Cope After A Traumatic Event-2

• Talk with them openly at their developmental
  level, focus on the future and what they can do
  going forward.
• Looking toward the future will empower the child
  and give a sense of control.
• Focusing on the past will increase feelings of
  helplessness and anxiety.
• Ask what they think has happened and about their
  fears
• Emphasize the normal routine, going to school,
  sports, and activities.
• Limit media re-exposure.
• Allow expression in private ways storytelling,
  art, pictures, play, journal writing.

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General Crisis Intervention Principles

• Establish a trusting nurse/patient relationship
  during the outreach stage.
• Focus on communication between the nurse and the
  patient/victim.
• Demonstrate a positive, nonjudgmental attitude.
• Focus on the patients verbal messages, gestures,
  facial expressions, along with listening to the
  patient.

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General Crisis Intervention Principles-2

• Discuss tests and procedures with the patient and
  significant others.
• Provide an opportunity for questions and answers
  if possible and if patient is coherent.
• Never assume they cannot hear or understand!
• Allow the patient to verbalize any concerns or
  fears.
• Providing consistent emotional support and
  information in a nonthreatening manner increases
  emotional safety.
• Place importance on understanding the personal
  meaning of the patients words, behaviors, and
  feelings.

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Priority Nursing Interventions

• The first priority is to assess the lethality of
  the bioterror event and to provide for the safety
  needs of the victim.
• Normal patterns of response and coping mechanisms
  are inadequate, and extra resources from within
  the patient, family, and health care team are
  necessary (Aguilera, 1998).
• Knowing and understanding the nature of the
  threat/attack.
• Assessing the patients perception of the threat.
• Identifying and reinforcing positive coping
  behaviors.
• Providing assistance for significant others.
• Coordinating care.
• Serving as a patient advocate.
• Mobilizing community resources as appropriate.
• Psychopharmacology (anti-anxiety agents) as
  ordered.

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Priority Nursing Interventions-2

• Provide the patient with specific instructions,
  such as
• written literature and educational materials
• teaching activities
• verbal reassurance, expression of concern
• emergency phone number and pager instructions
• Provide your full attention when you are with the
  patient.

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Priority Nursing Interventions-3

• Reassure patient that the nurse is present and
  available
• do what you say you will do
• answer patients questions clearly and precisely
• help patient verbalize feelings
• touch patient when he/she needs comfort

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Clinical Application Depression

• Many losses may be associated with a bioterror
  attack such as bereavement following the death of
  loved ones, finances, occupational changes and
  social withdrawal.
• Patients may be depressed, with suicidal thoughts
  present.
• Many experience survivor guilt ( Stuart
  Laraia, 2005).

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Nursing Interventions for Depression

• Assess for suicidal thoughts and plans. A high
  percentage of patients who are depressed commit
  suicide, the first priority of care is prevention
  and patient safety.
• Has the patient made any verbal suicide threats?
• Has the patient communicated nonverbally by
  giving away prized possessions or revised a will?
• Referral for psychopharmacological evaluation.
• Evidence supports that selective serotonin
  reuptake inhibitors (SSRIs) are effective for the
  treatment of depression.
• Patients thoughts are slowed down, give extra
  time to process questions and respond to
  messages.
• Use reality testing to help patients identify
  irrational beliefs and thoughts.

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Nursing Interventions for Depression-2

• Set limits on amount of time patient spends
  discussing bioterror event and trauma.
• Rumination may intensify guilt and feelings of
  helplessness.
• Encourage some form of physical exercise such as
  walking.
• The literature gives evidence that even walking
  for 20 minutes three times per week improves
  depressive symptoms.
• Facilitate patients use of coping strategies that
  improve functioning prayer, journal writing,
  meditation, yoga, and relaxation techniques.

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Clinical Application Altered Body Image

• When the bioterror attack involves an agent such
  as smallpox or disfiguring germs, many patients
  may have a diagnosis of disfigured or altered
  body image.
• There will be a severe psychological disconnect
  between the individuals perception of how his or
  her body was and the modified new body or
  disfigurement (Stuart Laraia, 2005).

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Nursing Interventions for Altered Body Image

• Recognize the stages of grief and encourage
  patients to utilize appropriate coping mechanisms
  to work through reintegration of body image
  changes.
• Discuss with patient perceptions of changed
  appearance. The patient will feel depersonalized
  and have a feeling of unreality and alienation
  from the self.
• Provide incremental exposure to social
  environments and support the patient in his/her
  rehearsal of useful coping strategies.
• Focus on the patient as a whole.
• Emphasize the acknowledgment and utilization of
  what remains, rather than focusing on what was
  lost.

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Nursing Interventions for Altered Body Image-2

• Assist patient in coping with temporary changes
  such as bruising and edema.
• Provide patient opportunities for privacy to
  reflect on what has happened and what the body
  changes mean, and to experiment with approaches
  to deal with body image alterations.
• Although body image contains elements of reality
  and the ideal, the nurse should emphasize reality.

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Nursing Interventions for Altered Body Image-3

• Sensory input is vital to body image
  reintegration, especially when body boundaries
  need to be reestablished (e.g., loss of limb).
• Provide sensory stimulation to damaged areas to
  renew and reinforce previous responses and
  mobilize forgotten sensations and functions.
• Facilitate body image reintegration by
  encouraging the patient to look at and touch the
  site, face, limb while exploring questions and
  feelings about appearance and/or function.

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Stress Management and Self Care of Nurses

• Nurses need to be aware of their own stress
  responses, especially if they are providing
  direct care to victims.
• Psychological preparation can reduce
  psychological risk in first responders.
• The more exposure to trauma the more the nurse is
  at risk.
• It is cumulative!
• Experience is not necessarily protective, intense
  feelings occur while confronting beliefs about
  personal safety, trust and control.

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Stress Management and Self Care of Nurses-2

• Many nurses feel burdened by responsibility and
  expectations.
• Fears and frustrations may be transferred to
  patients, thus compounding their problems.
• The nature of the emergency creates fracturing
  across organizations and may lead to
  miscommunication, disengagement, escape or
  refusal to work.
• Loyalties between taking care of ones own family
  and ones professional patients will be a
  challenge that needs to be addressed.

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Common Stress Responses of Nurses

• High degree of burnout related to increased work
  load and organizational stress
• Feelings of rage, guilt, helplessness, fear,
  shame, and a fearful or evil world view.
• Emotions such as anxiety, sadness, anger or feel
  overwhelmed.

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Practical Suggestions to Decrease Stress

• Practice relaxation techniques, deep breathing,
  yoga, journal writing, spirituality breaks, and
  guided imagery to clarify feelings and reduce
  anxiety
• Attend exercise sessions, short walks in the hall
  
• Regular scheduled breaks from tending to
  patients.
• Establish a break area for nurses and health care
  providers to talk and receive support from
  colleagues.

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Practical Suggestions to Decrease Stress-2

• Encourage frequent contact with loved ones
  through telephone interactions or e-mails
• Progressive relaxation exercises reduce internal
  anxiety and promote blood flow to body organs
• Complements serve as powerful motivators.
• Hold department or hospital meetings to keep
  people informed of plans and events.

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Summary of Psychological Principles After A
Bioterror Attack

• The most useful attitude for the nurse to possess
  is to view the patient as a person coping,
  perhaps in a most inadequate way, with a
  situation that is overwhelming and frightening.
• Patients are sensitive to the nurses feelings
  and attitudes as evidenced by touch, handling of
  the patients body, willingness to talk and
  listen, and in discussion of the changes that
  have occurred in the body and through trauma the
  patient has suffered through.
• Patients who perceive their nurses as concerned
  and caring are better prepared to deal with the
  stress the recovery phase.

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Summary of Psychological Principles After A
Bioterror Attack-2

• They report fewer vague complaints, feelings of
  disappointment, expressions of anger and
  hostility, and are more satisfied with their
  outcomes.
• Encourage sufficient rest and sleep, normalizing
  eat-sleep-work cycles, limiting exposure to media
  reports and traumatizing images and sounds are
  all measures that facilitate coping and recovery.
• Survivors experience profound grief, anguish,
  anger, guilt and sadness.

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Summary of Psychological Principles After A
Bioterror Attack-3

• Talking through ones emotions is an important
  part of the recovery process for both patients
  and providers.
• Refer patients with abnormal stress responses to
  psychiatric treatment team.
• Anxiety responses are most likely following a BT
  attack, but depressive symptoms, PTSD and
  substance abuse may also occur.
• Encourage re-entry into social roles when
  possible and appropriate.

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Web Resources

• American Academy of Experts in Traumatic Stress
• www.aaets.org
• American Association of Suicidology
• www.suicidology.org
• Center for Disease Control and Prevention
• www.bt.cdc.gov/emcontact/index.asp
• Disaster Relief
• www.diasterrelief.org
• FBI Terror
• www.fbi.gov.terrorism/terrorism/htm
• Mail security
• www.usps.com
• National Institutes of Mental Health
• www.nimh.nih.gov
• Substance Abuse and Mental Health Administration
• www.samhsa.gov
• Federal Emergency Management Agency
• www.fema.gov