Mental Health in a Time of Terror

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Mental Health in a Time of Terror

• Robert K. Schneider, MD
• Assistant Professor
• Departments of Psychiatry,
• Internal Medicine and Family Practice
• Virginia Commonwealth University
• The Medical College of Virginia Campus

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Outline

• Review Studies of Terror
• Disease Model
• Health Model
• What can we do?

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Models of Coping

• Disease Model
• Trauma/Stressor Person Disease
• Health Model
• Trauma/Stressor Person Health

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Disease Model

• PTSD Posttraumatic Stress Disorder
• Reexperiences
• Hyperarousability
• Avoidance

• Major Depression
• Depression
• Anhedonia

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Oklahoma City BombingNorth et. al. JAMA 1999

• April 19, 1995
• 167 dead
• 684 injured
• the most severe incident of terrorism ever
  experienced on American soil

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Oklahoma City BombingNorth et. al. JAMA 1999

• 45 postdisaster psychiatric disorder
• 34.5 PTSD
• 22.5 Major Depression
• 9.4 Alcohol Use Disorder

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Oklahoma City BombingNorth et. al. JAMA 1999

• Predictors
• Any predisaster diagnosis 66
• Female sex 55 vs. 34
• 94 of PTSD had early avoidance and numbing
  symptoms

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SCUD Missile Attacks Israel, 1991 Gulf WarLaor
et. al. Am J Psychiatry 2001

• 107 families exposed
• Half of the families displaced
• Mothers functioning and Childrens Symptoms
• 3 studies 6 and 30 months and 5 years

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SCUD Missile Attacks

• Over time symptoms decrease in residentially
  stable children
• Mothers reaction correlated with young
  childrens symptoms most
• Family cohesion highly correlated with childrens
  well being

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SCUD Missile Attacks

• Mothers functioning
• Ability to relate to child
• Coping skills
• Symptoms
• Childrens symptoms
• PTSD symptoms
• Avoidance

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SCUD Missile Attacks

• Younger children highly correlated with mothers
  symptoms
• Displaced families had more symptoms (longer
  time more problems)
• Family functioning impacted displaced more than
  residentially stable children
• Mothers coping with adaptive defenses correlated
  with resolution of childrens symptoms

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PTSD in the Community Breslau et. al. Arch Gen
Psychiatry 1998

• 90 one or more traumas
• Most prevalent trauma unexpected death of a
  loved one

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Categories traumatic events

• Personally experienced assaultive violence
• 37.7
• Other personally experienced injury or shocking
  experience
• 59.8
• Learning about traumas to others
• 62.4
• Sudden unexpected death of a loved one
• 60.0

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Conditional Risk

• Rape 40-60
• Combat 35
• Violent Assault 20
• Sudden death of a loved one 14
• Witnessing a traumatic event 7
• Learning about trauma to others 1-2

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Rick Factors for PTSDBrewin et al J Consult
Clinical Psych 2000

• Meta analysis Civilian and Military
• (Weighted averages)
• Lack of Social Support 0.40
• Post trauma life stresses 0.32
• Trauma Severity 0.23

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Health Model

• No predisaster disorder (OCB)
• 70 remained without disorder
• Stability and High Functioning (SMA)
• No children had symptoms at five years

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Health Model DefensesAdaptive Coping

• Self-assertion
• Self-observation
• Sublimation
• Suppression

• Anticipation
• Affiliation
• Altruism
• Humor

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Adaptive CopingSCUD Missile Attacks

• Mothers capacity to control mental images had a
  direct effect on her symptoms

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Health Model DefensesMaladaptive Coping

• Acting Out
• Omnipotence
• Apathy
• Complaining

• Devaluation
• Denial
• Dissociation
• Displacement

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What can we do?

• Self
• Family
• Community

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What can we do?SELF

• We are in a time of stress and transition
• Use our adaptive defenses
• Avoid our maladaptive defenses
• Regulate our exposure to potentially traumatic
  information
• Television, Internet, Newspaper
• Be where you need to be

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What can we do?FAMILY

• Model adaptive behavior
• Be present and available
• Maintain Boundaries
• Clarity
• Rules
• Monitor

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What can we do?Community

• Model adaptive behavior
• Be present and available
• Maintain Boundaries
• Clarity
• Rules
• Monitor

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Conclusions

• We are living in a time of stress and transition
• Diseases to prevent include PTSD and Major
  Depression
• Young children are particularly vulnerable
• Coping is an active, conscious process that
  occurs on multiple levels

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