Psychological Trauma, Disaster and Terrorism

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Psychological Trauma, Disaster and Terrorism

• Managing the Terror of Disaster and Terrorism
• Steven Berkowitz, MD
• Yale Child Study Center
• Yale Center for Public Health Preparedness

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• STRESS Actual or implied threat to the
  psychological and/or physiological integrity of
  an individual.

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What is Psychological Trauma? (Traumatic Stress)

• Overwhelming, unanticipated danger that cannot be
  mediated/processed in way that leads to fight or
  flight
• Immobilization of normal methods for decreasing
  danger and anxiety
• Neurophysiological dysregulation that compromises
  affective, cognitive and behavioral responses to
  stimuli

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Traumatic Stress

• Events are not traumatic, but they are
  potentially traumatogenic.
• There are types of events that are more likely to
  be traumatic than others
• However, the individuals subjective experience
  is likely the most salient factor

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Risk Factors (Event)

• How directly events affect their lives
• Physical proximity to event
• Emotional proximity to event (threat to child,
  parent versus stranger)
• Secondary effects-of primary importance (does
  event cause disruption in on-going life)

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Individual Risk Factors

• Genetic vulnerabilities and capacities
• Prior history (i.e. consistent stress or one or
  more stressful life experience/s)
• History of psychiatric disorder
• Familial health or psychopathology
• Family and social support
• Age and developmental level

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Peritraumatic Risk Factors

• Dissociation
• Acute Depression
• Extreme Hyperarousal
• Injury
• Loss/death

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DISASTER

• A severe disruption, ecological
• and psychosocial which greatly
• exceeds the coping capacity of the
• altered community
• WORLD HEALTH ORGANIZATION, 1992

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Disaster Event Factors

• Natural Disaster least traumatogenic
• Human error-next (Buffalo Creek)
• Violence and terrorism most

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Secondary Stressors of Primary Import

• Displacement
• Unemployment
• Separations from
• loved ones
• Fostering of
  dependency

• Closing of schools/work place
• Inactivity
• Loss of community
• and social supports
• Decreased food and water resources

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Physical Displacementand Social Disruption

• Physical displacement and social disruption has
  been found to be the highest correlated factor
  related to outcome after catastrophic events.
  (Laor, Wolmer, Cohen, 2001 Laor et al., 1997
  Laor, Wolmer, Mayes, Golomb, et al., 1996
  Lonigan et al., 1994)

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Inactivity and Dependency

• Leads to
• Depression
• Substance Abuse
• Increased criminality/delinquency

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PHASES OF RESPONSE TO DISASTER

• Impact (shock, disbelief, rage)
• Heroism
• Honeymoon
• Disillusionment
• Recovery/Restoration (hopefully)

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PERI-DISASTER

• HEROIC Occurs during and immediately after and
  is marked by the spectrum of acute stress
  responses.
• HONEYMOON The effective rescue operations
  resonate with a sense of calm that it is over.
• DISILLUSIONMENT The enormity of the
  ramifications of what has transpired and what is
  required.

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RECOVERY AND RESTORATION

• Community plans are formulated and implemented
• Federal, State and local tasks defined
• Recruit and train personnel
• Local, state, federal, ARC and FEMA coordinate
  intervention plans
• Deploy resources

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TERRORISM

• The unlawful use of or threat of use of force or
  violence against individuals or property, to
  governments or societies , often to achieve
  political, religious or ideological objectives
• Department of Defense, 1990

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PHASE RESPONSE TO TERRORISM (1 to 3 months)

• INCREASING GROUP SOLIDARITY
• PATRIOTISM
• AWARNESS OF LOSS AND THREAT
• ANGER/REVENGE
• MOBILIZATION
• SUSPICIOUSNESS
• EMOTIONAL/BEHAVIORAL PROBLEMS
• (Overlap with natural disasters)

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PHASE RESPONSE TO TERRORISM (3-12 months)

• INCREASING DISILLUSIONMENT/FEAR
• EMBITTERMENT BY THREATS/LOSSES
• LOSS/FRAGMENTATION OF COMMUNITY
• INDIVIDUALISM (I HAVE TO TAKE CARE OF MYSELF)
• LOSS OF IDEALISM (I DONT WANT TO SACRIFICE)
• DOUBTS REGARDING LEADERS
• GIVE THEM WANT THEY WANT

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Psychological Casualties

• More people suffer from chronic emotional
  difficulties post disaster than from physical
  difficulties
• Psychological sequalae correlate with a number of
  factors
• Different experiences related to the event can
  trigger psychological symptoms
• Cumulative effect of stress may cause emotional
  dysfunction

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RANGE OF PSYCHOLOGICAL CASUALTIES

• Psychiatric patients who lose access to
  medications
• Patients whose fragile adaptation is compromised
• Individuals with acute stress reactions
• Individuals with enduring psychological effects
  from the traumatic experience
• Secondary and tertiary victims

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Disasters Require Integrated and Coordinated
Responses

• At every step of a disaster response,
  psychological interventions take place that may
  limit or intensify post traumatic responses
• External Structure and containment support
  individual restabilization
• Governmental Authority Messaging and
• Public information
• First Responders
• Sheltering and provision of basic needs
• Transition to semi-permanent status

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Levels of Intervention

• Governmental
• Pre-event planning
• Worse time to begin coordinating is during a
  crisis
• ICS should include Crisis mental health response
  plan
• Prepare for worst and hope for best
• Clear and unambiguous messages about
• Nature and reality of event
• Plans in place
• Directions for citizens

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First Responders

• First responders ability to authoritatively, but
  respectively and supportively address victims
  needs can decrease stress reactions
• Recognition that psychological injury is as
  important as physical injury
• Supportive structure aids individuals ability to
  respond as needed
• Orient individuals when needed
• May prevent surge of overwhelmed individuals

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THE MENTAL HEALTH REPONSE TO DISASTER

• DISASTER REQUIRES INTERVENTION
• Acute and enduring medical and psychological
  consequences

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PREPARATION

• Coordination of responsible agencies
• Develop intervention strategies
• Train and educate first-line responders
• Execute mass cal exercises
• Work with media to prepare communication
  packaging

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PSYCHOSOCIAL INTERVENTIONS

• Prevention of group panic
• Effective Risk Communication
• Rapid evaluation/treatment
• Control of symptoms of emotional arousal
• Management of misattribution of symptoms
• Mobilize family and social supports
• Restoration of social/vocational roles

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Shelters and Outreach The Role of Mental Health
Providers

• In addition to assessment and direct
  psychological interventions, MHP should
  facilitate activities that are enhance protective
  factors
• social and familial support pro-social activities
• Recognition, promote previous relationships and
  community connections
• Engage individuals in rebuilding

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Early Interventions

• Provide a sense of safety
• Opportunities for emoting
• Reconstruct the individuals narrative of what
  happened
• Clarify reality
• Inventory of stressors
• Family and social supports
• Assess for psychological morbidity

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Crisis Interventions

• Rapid, accurate triage and effective treatment or
  immunization
• Distinguish hyperarousal acute stress response
  from disease
• Implementation of a coordinated and well planned
  community strategy

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Basic Measures

• Grounding for disoriented individuals
• Deep Breathing, PMR for tension, anxiety and
  hyperarousal
• Sleep hygiene, sedatives may be useful (alpha
  agonists?)

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Basic Measures

• Step 1 Slow Down (Take a time out Calm your
  body One thought at a time)
• Step 2 Orient Yourself (Bring your mind body
  back to the present time/place)
• Step 3 Self Check (How much distress? How much
  control? The worst ever?)

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Early Intervention Rationale

• Psychoeducation
• Engagement and Assessment
• Monitoring
• Intervention/Treatment

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Treatment Specific Measures

• Cognitive behavioral interventions for
  symptomatic individuals (PTS)
• Trauma focused CBT
• EMDR (eye movement not necessary)
• Prolonged Exposure only when needed
• Careful not to be premature or intrusive
• If not timed correctly can interrupt normal
  processing and coping capacity

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Specific Measures

• Group treatments must be done carefully
• Homogeneity of members is essential
• Developmental level (children of similar ages
  should be grouped together)
• Symptom intensity (asymptomatic or mildly
  symptomatic individuals may worsen if exposed to
  severely compromised patients)