Bioterrorism: Its all in your head

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Mental Health Aspects of Bioterrorism
Edward A. Walker, MD Professor and Vice Chair,
Department of Psychiatry and Behavioral
Sciences Chief, Psychiatric Services, University
of Washington Med Center
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Overview

• Emotional consequences of what has happened and
  what may still come
• Distinguishing normal and abnormal responses
• Psychiatric disorders that accompany trauma
  exposures
• Meeting needs of special populations
• Practical strategies for managing the emotional
  sequelae of trauma and anxiety in your practice
• Your cases and observations

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Labor Day Weekend 2001the last of the good old
days

• What were you doing that weekend?
• What was your world like?
• What were your assumptions about what was safe?
• What do now do differently?
• What do you no longer do?
• How did this tragedy change your world?

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Traumatic events

• Traumatic events are usually sudden and
  unexpected. Whether single brief events or
  chronically repeated, they overwhelm our ability
  to cope and adapt.
• Examples can include rape, mugging, assault, war,
  car accidents, disasters, viewing a friend being
  injured, and physical or sexual abuse.
• Children are more vulnerable than adults to
  traumas, because they have fewer skills and less
  experience with life. Adults can predict and
  avoid events that take kids by surprise.
• But adults can also be overwhelmed by situations
  or events that occur suddenly and are beyond
  their control.
• When this happens, a number of predictable
  reactions occur. These reactions to trauma are
  normal responses to abnormal events, and may
  produce Post Traumatic Stress Disorder

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Responses to traumatic events

• Each individual is unique
• degree of exposure
• nature of exposure
• developmental timing of exposure
• personal meaning of the event
• ability to understand what occurred
• available resources
• ability to cope
• degree of distress

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Coping cycle
stressor
coping strategy
appraisal
resources
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Once youve been sensitized dissecting the
terror in bioterrorism

• Before the next event
• Uncertainty what next, to whom, when, where,
  how?
• Changing the way you live to minimize exposure
• 1000 small wounds
• During the next event
• Degree of possible dramatic harm
• Direct effects to victims
• Vicarious trauma
• After the next event
• life disruption and fear of future events
• anxiety about repetition
• overcoming denial Im no longer safe

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What to look for in your clinic

• Fear
• Anxiety (its different from fear)
• Depression
• Medically unexplained symptoms
• Family and marital distress
• Occupational disability
• Substance and alcohol use
• Increased demand for sedative hypnotics
• Post Traumatic Stress Disorder symptoms

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• US News and World Report
• Title The Second Wave Author(s) Amanda
  Spake Marianne Szegedy-Maszak Issue Date
  OCTOBER 8, 2001 Words in article 1375 Lead
  Paragraph What would have been a simple
  diagnosis for doctors at Boston's Massachusetts
  General Hospital has suddenly become murky. Are
  the fatigue, respiratory distress, and insomnia
  symptoms of a viral infection that has been
  sending Bostonians to bed? That's what physicians
  would have assumed a month ago. But now it's
  equally plausible that these same symptoms are
  signs of the profound psychological stress people
  are feeling after the recent terrorist attacks.

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Relationship of terrorism to psychiatric disorders

• Consequences of direct exposure to a severe
  stressor Post Traumatic Stress Disorder
• New learned fear behaviors phobias
• Decompensation of any existing psychiatric
  disorder, especially depression and anxiety
• Increase in medically unexplained physical
  symptoms
• Increase risk for substance/Etoh use

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PTSD definition

• A. Exposure to a traumatic event in which both of
  the following were present
• The individual experienced, witnessed, or was
  confronted with an event of actual or threatened
  death or serious injury
• The event evoked a reaction of intense fear,
  helplessness or horror
• B. Persistent re-experiencing of the event
• Intrusive recollections
• Recurrent distressing dreams
• Acting or feeling as if the events were recurring
• Distress on exposure to cues that resemble event
• Physiological reactivity after exposure to cues

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• C. Persistent symptoms of avoidance and numbing
• Efforts to avoid thoughts, feelings, our
  conversations
• Efforts to avoid activities, places, or people
• Inability to recall important aspects of the
  trauma
• Diminished interest or participation in
  activities
• Feelings of detachment or estrangement
• Restricted range of affect
• Sense of foreshortened future
• D. Persistent symptoms of increased arousal
• Difficulty falling or staying asleep
• Irritability or outbursts of anger
• Difficulty concentrating
• Hypervigilance
• Exaggerated startle
• E. Duration of symptoms for more than 1 month
• F. Clinically significant distress and disability

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What is known about PTSD?

• Prevalence rate of about 8 percent of general
  population (Kessler et al, NCS, 1995)
• Significantly higher in selected populations were
  risk of trauma is much higher
• Associated with increased numbers of medically
  unexplained symptoms and functional impairment.
• High comorbidity with other psychiatric disorders
  such as alcohol and substance abuse, affective
  disorders and other anxiety disorders
• little is known about the magnitude of health
  care costs and utilization that are specifically
  attributable to PTSD in medical settings

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PTSD Scores in 1225 Women HMO Members
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7
Walker EA, Katon W, Russo J, Ciechanowski P,
Newman E, Wagner AW Health Care Costs Associated
with Post Traumatic Stress Disorder Symptoms in
Women, Archives of General Psychiatry (in press)
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Functional Disability and PTSD
Walker EA, Russo J, Katon, Newman, E Adult
health status of women HMO members with PTSD
symptoms, Submitted, American Journal of
Psychiatry
Walker EA, Gelfand A, Katon W, Koss M, Von Korff
M, Bernstein D, Russo J Adult health status of
women HMO members with histories of childhood
abuse and neglect. Am J Med 1999107332-9.
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Physician coded ICD-9 diagnoses
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Unadjusted Health Care costs for 1225 Female
Group Health Members with PTSD symptoms
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Meeting special needs
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Who is affected?

• You
• Your family
• Your fellow providers
• Your health delivery system
• Direct victims
• Vulnerable patients
• Children

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You

• Physician heal thyself
• How do you feel?
• Are you distracted, worried about anything?
• Have you had a traumatic experience before?
• Do you know your limits?
• Can you ask for help from colleagues?
• Do you feel you have to be strong and a leader at
  all costs?

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Your family

• What do you think you family is feeling?
• Are you worried about them?
• What would you do if they became infected?
• Do you feel you can protect them while you work?
• Does anyone have a previous experience to a
  traumatic event?
• Are you worried about your children?

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Your fellow providers and staff

• Do you feel you have good team support?
• Have you figured out how to work as a team
  without fatiguing?
• Are you worried about any of them in particular?
• Have any of them had a previous traumatic
  experience?
• Do you know their vulnerabilities?
• Do you have a way of signaling distress to each
  other?
• Are you front line staff fearful or distracted?

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READ ME FIRST!   Dear colleague-   Before you
rush off to start doing anything else, please
take a few moments to orient yourself with this
note. It will help with everything else you do in
the next few hours. Youre facing a situation
where you and everyone around you will be
stressed. Youll be trying to meet the needs of
patients, colleagues, and family at a time when
youre worried about your loved ones. Its likely
that these needs will be unpredictable, somewhat
intense and competing with each other.   First,
stop and take a deep breath. You got this packet
because we know we can count on you to do a great
job. We, your co-workers and colleagues, have
confidence that you can contribute a great deal
to resolving this crisis, no matter what your job
is. Nothing you will do today is insignificant or
unimportant.   Before you turn to any patient
care or guidance of staff, think about yourself
first. What are you going to need to get through
the next few hours? You wont be able to help us
all if you dont relax a bit and take care of
yourself first. Youll need to pace yourself
take some breaks from time to time so you dont
burn out right away. After youve done some
initial triage of your area, contact your loved
ones and make sure theyre ok. Let them know
youll be with them as soon as you can, and stay
in touch with them throughout the crisis. If you
cant reach them right away you can ask Staff
Support Services to help you make contact.
  Watch those around you. They may not be as
skilled at meeting their own needs as you are.
Instead of doing everything yourself, delegate
some tasks and observe how others are doing. Do
you see anybody pushing too hard or nearing
burnout? Is there anyone appears distracted by a
family emergency who might benefit from Staff
Support Services? Ask how each of your colleagues
is doing from time to time. If anyone looks
stressed out, take that person aside and suggest
a break. Dont forget to ask yourself the same
question from time to time.   This is going to
be challenging for all of us, but were going to
get through this as a family the way we always
do. The UWMC is committed to keeping you informed
and up to date about whats happening and how it
affects you, you loved ones and your work. Thanks
for your dedication and commitment to our
patients, our staff and our mission.   Okay,
youre set. Put this note in your pocket and take
it out from time to time today. Well see you on
the front lines. Take care of yourself!     Your
friends and colleagues
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Your health delivery system

• Do you have confidence that your health care
  system will support your work?
• Is it ready for this emergency?
• Do you fear things might be hopeless?
• Is the leadership of your system ready?
• Will the system let you work effectively?
• Are you confident youll have what you need?

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Direct victims of trauma

• Can you deal with hysteria and panic?
• Are you confident in your ability to reassure and
  calm?
• Can you effectively help them deal with
  uncertainty?

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Vulnerable patients

• Previous exposures to trauma
• Rape
• Military service
• Accident trauma
• Murder, civil violence
• Violent crime exposures
• Domestic violence
• Early childhood abuse or neglect
• Poor caretaking, limited trust
• Difficult to establish and maintain therapeutic
  alliances

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Children

• After any disaster children are most afraid that
  
• the event will happen again.
• someone will be injured or killed.
• they will be separated from the family
• they will be left alone.
• Helping them cope
• Assume that they know that a disaster has
  occurred
• Talk with them calmly and openly at their level
• Ask what they think has happened and about their
  fears
• Limit media re-exposure
• Share your own fears and reassure
• Allow expression in private ways (e.g., drawing,
  journals, legos)
• Emphasize normal routine
• Continue to monitor over time stay involved in
  their recovery

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Children

• Symptoms of distress in children
• Depressed or irritable mood
• Sleep disturbances, including increased sleeping,
  difficulty falling asleep, nightmares, or
  night-time wakening
• Changes in appetite, either increased or
  decreased
• Social withdrawal
• Obsessional play drawing or talking about the
  events that interferes with normal activities
• Hyperactivity that wasnt present earlier
• Decreased school performance
• Increased dependence and clinginess, sometimes
  regression

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Practical management strategies
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Model

• Predisposing factors
• biopsychosocial patient characteristics which set
  the stage (the fire trap)
• Precipitating factors
• establish the illness process (the match)
• Perpetuating factors
• maintain the illness process (additional fuel)

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Model
Predisposing Factors
Precipitating Factors
Perpetuating Factors
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Case Example
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Predisposing Factors
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Precipitating Factors
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Perpetuating Factors
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Predisposing Factors

• biological diatheses (e.g. motility)
• pre-existing exposure to illness or disease
• previous maltreatment or exposure to trauma
• low resilience, poor coping ability
• low social support
• chronic social stress
• comorbid medical disease
• low psychological mindedness

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Precipitating Factors

• medical disease
• psychiatric disorder
• social, fiscal or occupational stress
• changes in social support
• re-experienced trauma
• dietary factors

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Perpetuating Factors

• disability-induced vicious cycles
• decreased self confidence
• decreased activation, wellness
• chronic somatization
• social isolation
• primary gain (intrapsychic)
• secondary gain (interpersonal)
• tertiary gain (interpersonal)

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The Plan Work Backwards

• get control of perpetuating factors
• tertiary prevention
• limit precipitating factors
• secondary prevention
• decrease power of predisposing factors
• primary prevention

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Controlling Perpetuating Factors

• decrease functional disability
• symptom reduction a better endpoint than cure
• increase positive activities, social contacts
• medications
• decrease chronic somatization
• deal with illness beliefs (figure-ground issue)
• regular medical visits
• your job is to fix me
• doctor patient collaboration

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Controlling Perpetuating Factors (contd)

• deal with reinforcers (gain)
• emotional, financial
• stop re-creations of trauma
• consultation referral
• deal with interpersonal problems
• use of opiates
• recurrent medical procedures/surgeries

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Limiting Precipitating Factors

• treat comorbid medical/psychiatric diseases
• stress management
• change what can change, accept what cant
• appraisal, resources, coping (activation)
• increase social support
• decrease exposures to trauma
• focus on wellness (exercise, diet)
• decrease chronic social stress

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Decreasing Power of Predisposing Factors

• accepting biological diatheses as given
• assessing previous reactions to illness
• awareness of previous maltreatment
• teaching new coping skills
• increasing social support
• treating comorbid medical disease
• practical one day at a time plans
• consultation for psychotherapy / meds

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Behavioral support

• Media abstinence
• CNN All anthrax, all the time
• Breaking news! This just in.
• Value of print journalism (e.g., Newsweek)
• Facilitated discussion groups
• Becoming informed vs. obsessional
• Defining safe areas
• Cognitive therapies
• exposure, problem solving and cognitive-behavioral
  
• Behavioral extinction as a therapeutic process
• Supporting grieving

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Pharmacological Support

• Proper diagnosis
• Panic disorder, major depression, PTSD
• Anxious personalities and generalized anxiety
• Resuming control of substance and alcohol abuse
• Observe for relapse of previously stable
  disorders
• Limited and selective use of anxiolytics
• Role for Buspar?
• Antidepressants and main approach
• Short term hypnotics

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Keeping things in perspective

• Risk of being struck by lightning in any given
  year - 1 in 750,000.
• Risk of dying from an earthquake or volcano - 1
  in 11 million
• Risk of having a car accident 1 in 8
• Risk of dying from dog bite - 1 in 20 million
• Risk of dying from snakebite - 1 in 36 million
• Risk for African for contracting Ebola Virus - 1
  in 14 million
• Risk of adolescent dying in car accident - 1 in
  3500
• Risk of adolescent dying from suicide - 1 in
  7700
• Risk of being murdered - 1 in 11,000
• Risk of being robbed - 1 in 400
• Risk of being burglarized - 1 in 50
• Risk of being wiped out by a comet or meteor
  impact - 1 in 20,000