Psychological and Behavioral Responses to Disasters Benjamin S. Bunney, MD Charles B.G. Murphy Professor and Chairman Department of Psychiatry Professor of Pharmacology Professor of Neurobiology Yale School of Medicine

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Psychological and Behavioral Responses to
DisastersBenjamin S. Bunney, MDCharles B.G.
Murphy Professor and ChairmanDepartment of
PsychiatryProfessor of PharmacologyProfessor of
NeurobiologyYale School of Medicine
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Taken in Part from aCenter for Trauma Response,
Recovery and Preparedness (CTRP) Presentation

• University of Connecticut School of Medicine
• Julian D. Ford, PhD
• Yale University School of Medicine
• Steven Berkowitz, MD
• Benjamin S. Bunney, MD
• Steven Marans, PhD
• Steve Southwick, MD
• CT Department of Mental Health and Addiction
  Services
• Arthur C. Evans, PhD
• Wayne Dailey, PhD
• James Siemnianowski, MSW
• CT Department of Children and Families
• Thomas Gilman, MSW

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(No Transcript)
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9-11-01

• Unique Disaster
• First disaster in history where in the aftermath
  psychological repair was more important than
  repairing bodies or burying the dead
• Part of event was watched live by millions of
  people

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Personal Experience Post 9-11

• Day 1
• Call from Walter Reed
• Activation of Emergency Response Plan
• Day 2
• Call from Service Union
• Day 7
• Call from business CEO
• Day 21
• Call from airline unions
• Day 30
• Call from insurance company

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PHASES of IMPACT and RECOVERY

• I. EMERGENCY/IMPACTSHOCK first
  hours/daysHEROIC first days/weeks
• II. EARLY POST-IMPACTHONEYMOON 1-3 Months
• DISILLUSIONMENT 3-6 months
• III. RESTORATION vs. BREAKDOWNRESTABILIZATION
  6-9 monthsRECOVERY 9-12 months
• PREPAREDNESS 12 months

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What is Psychological Trauma?

• 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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Psychological Shock

• Objective Exposure
• Exposure to threat of imminent/actual death
• Witnessing bodies and body parts
• Extreme exposure to fire, dust, exhaustion
• Subjective Survival Responses
• Terror fear, helplessness, impulsivity
• Horror disbelief, revulsion, guilt, shame, rage
• Numbing derealization, depersonalization, fugue,
  amnesia.

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Stress vs Trauma

• Dealing with Problems
• Heart Pounding
• Rapid Breathing
• Muscles Tense Up
• Fight or Flight
• Feel Excited or Worried
• Seeing/Thinking Clearly
• Acting Rapidly
• Feel in Control

• Trying to Survive
• Heart Feels Like Bursting
• Gasping, Feeling Smothered
• Muscles Feel Like Exploding
• Just Try to Get Through It
• Feel Terrified of Panicked
• Confused, Mentally Shut Down
• Automatic Reflexes or Freezing
• Feel Helpless or Out of Control

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Neurobiology of Severe Stress

• Responses are complex
• Biological defenses against a threat
• Mechanisms related to learning and adaptation
• Responses to social cues
• Reactions to loss and separation
• Effects of cognitive disarray and chaotic
  experience

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Neurobiology of Severe Stress (cont.)

• Thalamus registers whether sensory input is
  familiar or novel and a threat or not
• Threat triggers brain alarm system (amygdla) and
  release of corticosteroids and norepinephrine
• Fight-flight responses (autonomic nervous system,
  sympathetic branch)
• Peripheral resource conservation (autonomic
  nervous system, parasympathetic branch)

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Neurobiology of Severe Stress (cont.)

• Alarm insula and amygdala coordinate bodys
  mobilization in response to threat
• Attention norepinepherine release by locus
  ceruleus (brain stem area) promotes focused
  attention
• Reactivity corticosteroids promote instinctual
  survival rather than goal-directed reflection
• Information Processing Hippocampus inhibited in
  spatial orientation and categorization of sensory
  inputs
• Executive Decision Making prefrontal cortex
  receives confusing/chaotic alarm signals and is
  down-regulated

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Neurobiology of Severe Stress (cont.)

• Delayed responses
• Cascade of neuronal and genomic events including
  increased synthesis of cortiotropin releasing
  hormone (CRH) and cortisol related receptors in
  areas of brain not directly in hormonal stress
  response
• Increased protein synthesis in memory areas
  hippocampus and amygdala - provides mechanism for
  two types of long term memory of stressful events
• Explicit - verbalizable and recallable
• Implicit - unconscious changes in habit and
  conditioned responses (e.g. fear response when
  exposed to cues relevelant to traumatic event

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Neurobiology of Severe Stress (cont.)

• Summary
• The early aftermath of a disaster is a critical
  time of increased neuronal plasticity.
• The perceived threat triggers intense bodily
  reactions that shape the mental traces of adverse
  events.
• Physiological and psychological factors can
  either concur to cause chronic stress disorders
  or adaptation and resilience.
• Early interventions may reduce the risk of
  chronicity

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Event Factors That Influence Psychological
Responses

• 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 Factors That Influence Psychological
Response

• 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
• Other Female, divorced or widowed, lower IQ,
  lower income, lower education level

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ChildrenResponses and Treatment
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Role of Adults

• For all children, especially younger children,
  experience and especially upsetting experience is
  mediated by adults.
• Adults emotional response often as important as
  the actual event

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Childrens Typical Initial ResponsesNormal
reactions to abnormal situations Cognitive

• Questions and concerns about safety and security
• Anger and thoughts of revenge
• Focus on frightening things or thoughts
• Continual playing or talking about the event

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Childrens Typical Initial ResponsesNormal
reactions to abnormal situations
(cont.)Emotional and Somatic

• Sleep disturbance (nightmares etc.)
• Decreased or increased appetite
• Sad or anxious mood (withdrawn or more quiet)
• Irritable, fussy or argumentative
• Loss of recently achieved milestones
• Clingy or wanting to be close to parents
• Difficulty paying attention
• Daydreaming or easily distractible

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Impact on the Childs Developing Self

• A childs interpretation of his own behavior
  after the traumatic event may transform the way
  he looks at himself, they include
• A sense of physical prowess or weakness, of
  passivity or activity, of cowardice, courage
  and heroism, of self enhancement or
  diminishment.

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Toddlers (18 months-3 years)

• Rely on parents and caretakers to understand the
  world and will take on the emotional response of
  adults around them
• Communicate stress through behavior and body
• Disturbances in eating, sleeping
• Decreased speaking, loss of bowel and bladder
  control
• Increase in tantrums, fussiness or defiance
• More Clingy

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Preschoolers

• More involved with peers and other adults, but
  continue to look to parents and primary
  caregivers to understand how to respond
• Highly imaginative. Also, often more fearful
• In addition to responses like those of toddlers
• Increased play related to the events, but
  worrisome if interferes with other activities
• Questions about who did it and why
• May be concerned about safety

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School Age

• More independent, peers and other adults such as
  teachers have greater influence
• Very concerned with right and wrong
• May be more defiant and aggressive
• Have more difficulty in school
• May be anxious or withdrawn
• Very concerned about revenge

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Adolescents

• Are struggling with independence, often moody and
  focused on themselves
• Conflicts with parents, teachers and other
  authorities are common
• Tendency to either minimize or exaggerate
  experiences

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Adolescents(cont.)

• May be overly preoccupied with events
• Angry, threatening and aggressive and defiant
• Appear distant and numb
• Increased risk taking
• New or increased substance use (alcohol,
  marijuana etc.)

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Older Adolescents and Young Adults

• Same range of responses as adults, but Increased
  concerns about the future,
• May be increased substance use (alcohol,
  marijuana and other drugs)

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Implications of Neurobiological Development for
Treatment

• Hippocampus not fully functional until 4-5 years
  old Prefrontal cortex not until around age 10
• Treatment of child trauma survivors thus
• Must facilitate developmentally-appropriate
  expression (e.g., drawing, play)
• Must focus on age-relevant categories/themes
  (i.e., basic schemata, e.g., safe-unsafe)
• Must not encourage premature closure/decisions or
  expose the child to information/affect overload

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Treatment and InterventionIn the immediate
aftermath

• Reunite children with important adults/ family
  members
• Interventions for children include interventions
  for caretakers. If adults can not attend to
  children, outcome will be poor
• Adults tend to underestimate impact on children
  or alternatively displace own feelings onto their
  children

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Treatment and InterventionIn the immediate
aftermath (cont.)

• Criteria for Referral
• Presence of Dissociation
• Decreased motor function
• Blunted affect
• Absence of speech
• Decreased responsiveness to external stimuli
• Presence of Hyperarousal (heart rate and often
  respiration increased)
• Avoidance/Withdrawal Symptoms
• Extreme Emotional Upset
• Symptoms of Acute Stress Disorder

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Acute Stress Disorder

• 3 of 5 Dissociative Sx (Detached, Dazed,
  Derealization, Depersonalization, Amnesia)
• Recurrent Unwanted Memories Awake/Asleep or
  Biopsychological Distress Due to Reminders
• Avoidance of Internal/External Reminders
• Hyperarousal (Anxious, Irritable, Insomnia, Poor
  Concentration, Hypervigilant, Reactive)
• Significant psychosocial/healthcare impairment
• Duration 2-30 days

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Treatment Issues 4-6 Months After Disaster

• Criteria For Referral
• Extreme emotional upset
• Sleep disturbances
• Somatization
• Hyper-vigilance
• Severe distractibility
• Regressive behavior
• Blunted emotions
• Regression in social functioning and play
• Oppositional and aggressive behaviors
• Classic PTSD not common in children but incidence
  increases with age (especially adolescents)

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Adults Responses and Treatment
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Common Fantasies

• to alter the precipitating event
• to interrupt the traumatic action
• to reverse the lethal or injurious consequences
• to gain safe retaliation (fantasies of revenge)
• to be able to anticipate or prevent future
  traumas
• to bring back lost loved ones, friends, places,
  activities, or states of mind (trust) or body
  (peace)

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Common Stress Reactions To Disaster

• Emotional Effects
• Shock
• Anger
• Despair
• Emotional numbing
• Terror
• Guilt
• Irritability
• Helplessness
• Loss of derived pleasure from regular activities
• Dissociation (e.g., perceptual experience seems
  dreamlike, tunnel vision, spacey, or on
  automatic pilot)

• Cognitive Effects
• Impaired concentration
• Impaired decision-making ability
• Memory impairment
• Disbelief
• Confusion
• Distortion
• Decreased self-esteem
• Decreased self-efficacy
• Self-blame
• Intrusive thoughts and memories
• Worry

Physical Effects Fatigue Insomnia Sleep
disturbance Hyperarousal Somatic
complaints Impaired immune response Headaches Gast
rointestinal problems Decreased
appetite Decreased libido Startle response
Interpersonal Effects Alienation Social
withdrawal Increased conflict within
relationships Vocational impairment School
impairment
Young, BH, et. al. Disaster Mental Health
Services A Guidebook For Clinicians and
Administrators. The National Center for
Post-Traumatic Stress Disorder, Department of
Veterans Affairs
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Acute Stress Disorder

• 3 of 5 Dissociative Sx (Detached, Dazed,
  Derealization, Depersonalization, Amnesia)
• Recurrent Unwanted Memories Awake/Asleep or
  Biopsychological Distress Due to Reminders
• Avoidance of Internal/External Reminders
• Hyperarousal (Anxious, Irritable, Insomnia, Poor
  Concentration, Hypervigilant, Reactive)
• Significant psychosocial/healthcare impairment
• Duration 2-30 days post traumatic event

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Treatment and InterventionIn the immediate
aftermath (cont.)

• There is no one approach to treatment that
  current research singles out as effective
• One time intervention models have been shown to
  be ineffective
• Critical Incident Stress Management (CISM) has no
  proven effectiveness in prevention of late onset
  psychological disorders (e.g. PTSD)

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Treatment and InterventionIn the immediate
aftermath (cont.)

• Psychotherapeutic interventions in the the
  absence of structure and organization will not be
  effective.
• Provide real and concrete information about
  event, explain actions of authorities
• Provide basic necessities

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Treatment and InterventionIn the immediate
aftermath (cont.)

• Psychotherapeutic interventions in the the
  absence of structure and organization will not be
  effective.
• Provide real and concrete information about
  event, explain actions of authorities
• Provide basic necessities

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Key Principles of Immediate Intervention

• Engagement Empathic, non directive inquiry( not
  what happened?, but, how are you feeling?,
  delving into detail can retraumatize)
• Manage Overwhelming Feelings agitation,
  pressured speech, uncontrollable crying, out of
  touch with reality
• Request person to look at you and listen to what
  you are telling them
• Hold their attention, talk about positive or
  non-emotional topics
• Ask them to describe the place theyre in and say
  where they are
• Support Confer control in therapeutic contact

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Key Principles of Immediate Intervention (cont.)

• Affect Identify, label and link to ideation and
  somatic experience (noting differences from
  beginning to end of contact and with reports
  about pre-morbid functioning)
• Cognition Assess quality and nature of thought
  processes and link to affective impact of event
  and associated ideas

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Key Principles of Immediate Intervention (cont.)

• Psycho-education Explain the normal
  post-traumatic response (what to expect, what is
  normal and when additional support/intervention
  is needed)
• Follow-up Arrange for series of contacts to
  assess symptoms and adaptive functioning

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4-6 Months After Disaster

• Persistent physical, mental, relational, and work
  problems are taking a toll
• Helping professionals (behavioral health,
  medical/nursing, human services, clergy) and
  natural helpers are frayed and feeling the burden
  of answering the unanswerable
• Delayed psychiatric sequel are emerging
  (unresolved bereavement, depression, PTSD,
  anxiety disorders, addictions)

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Target Groups At Risk for Persistent
Post-Traumatic Sequelae

• On-Site Survivors
• Terror Exposure to threat of imminent/actual
  death
• Horror Witnessing death, destruction, terror
  shock
• Physical Insult injury, exhaustion, exacerbation
  or precipitation of chronic medical illness,
  pain, disability
• Traumatic Reactivation (e.g., return to or loss
  of work)
• Bereaved Families/Primary Relationships
• Traumatic Grief
• Unresolved Bereavement
• Social Intrusion and Isolation

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Target Groups At Risk for Persistent
Post-Traumatic Sequelae

• On-Site Rescue/Recovery Workers
• Terror Exposure to threat of imminent/actual
  death
• Horror Witnessing death, destruction, terror
  shock
• Physical Insult injury, exhaustion, toxic
  exposure
• Isolation and Amplified In-Group Cohesion
  Post-traumatic detachment and numbing increase
  sense of separation
• Traumatic Reactivation (past subsequent crisis
  work)
• Separation/Detachment from Family and Community
• Peer Endorsement of Substance Use Risk Taking

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Target Groups At Risk for Persistent
Post-Traumatic Sequelae

• Helpers Caring for Survivors, the Bereaved,
  Workers (e.g., Behavioral Health, EAP, Health
  Care, Clergy)
• Vicarious Shock Exposure to terror,
  helplessness, grief
• Vicarious Horror Witness descriptions of
  horrifying events
• Physical/Workload Strain Ascribed responsibility
  exceeds actual knowledge, training, or
  personal/professional limits
• Traumatic Reactivation Unresolved
  direct/vicarious trauma
• Heightened Role Responsibilities Unprecedented
  crisis demands, Idealized role model, Answer the
  unanswerable

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Target Groups At Risk for Persistent
Post-Traumatic Sequelae

• Family/Community Members Living and Working with
  Survivors, the Bereaved, Rescue Workers Helpers
• Vicarious Shock Exposure to terror,
  helplessness, grief
• Uncertainty Wanting to help but not knowing
  when/how
• Physical/Workload Strain Carrying the added load
  while others are focused on coping with
  impairment or recovery
• Loss Disconnection from traumatized significant
  others
• Traumatic Reactivation Unresolved
  direct/vicarious trauma

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Target Groups At Risk for Persistent
Post-Traumatic Sequelae

• People in Recovery from Behavioral Health
  Disorders
• Shock Media exposure to terror, helplessness,
  grief
• Traumatic Reactivation Unresolved
  direct/vicarious trauma
• Post-Traumatic Coping Denial, numbing,
  dissociation
• Heightened Risk of Relapse or Decompensation
• Isolation Withdrawal from recovery community
  treatment
• Resilience Opportunity to use recovery
  skills/commitments

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Target Groups At Risk for Persistent
Post-Traumatic Sequelae

• Vulnerable Groups
• (e.g., children, elders, disenfranchised)
• Shock Media exposure to terror, helplessness,
  grief
• Traumatic Reactivation Unresolved
  direct/vicarious trauma
• Interrupted Attachments Reduced access to or
  reliability of caregivers, primary relationships,
  and support groups
• Resource Loss Reduced access to or reliability
  of key economic, educational, housing, family
  support services
• Isolation Increased risk of stigmatization
  marginalization
• Resilience Developmental and experiential
  strengths

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Treatment Issues 4-6 Months Later Traumatic
Shock

• Intrusive Re-experiencing Overwhelming memories
• Numbing Feeling stunned, empty, dead inside
• Hypervigilance Prolonged Survival Alarm State
• Dissociation Disconnection from Alarm Awareness
• Affect Dysregulation Overwhelming emotions
• Somatization Bodily exhaustion and breakdown
• Alienation Loss of sustaining perceptions of
  future attachments
• Defeat Loss of personal/spiritual trust goals

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Treatment Issues 4-6 Months Later Reactivation
of Chronic Post-Traumatic Impairment

• Concurrent Treatment Sequelae of Acute
  Traumatization and Complex PTSD
• Emotion Dysregulation Extreme lability/numbing
• Dangerous/Impulsive Risk Taking/Addiction
• Suicidality and Self-Harm
• Pathological Dissociation
• Somataform Disorders
• Existential and Spiritual Alienation

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Post Traumatic Disorders Not Automatic More
than PTSD

• Most adults and children recover without a
  lasting post-traumatic psychiatric disorder
• 10-20 develop depression or PTSD (often both)
• Alcohol/substance use disorders not prevalent
• Subclinical depression or substance use common

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Posttraumatic Stress Disorder (PTSD)

• Recurrent Unwanted Memories Awake/Asleep or
  Biopsychological Distress to Reminders
• Avoidance of Internal/External Reminders,
  Emotional Numbing, Social Detachment, Amnesia
• Hyperarousal (Anxious, Irritable, Insomnia, Poor
  Concentration, Hypervigilant, Reactive)
• Significant psychosocial/healthcare impairment
• Duration 30 days (may be delayed or chronic)

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Patterns of Risk for PTSD

• Temporal
• Traumatic Shock Acute Stress in first month
• Traumatic Grief PTSD in subsequent months
• Individual
• Extent and Nature of Exposure or Loss
• Gender Females gt Males
• Sociocultural
• Children Caregiver Contagion, older age
• Socioeconomic or Ethnocultural Adversity

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Stress Activates The Bodys Alarm System
Normal Stress PTSD Dealing with
Problems Trying to Survive

Clear Memories Memory Like a
Broken Puzzle Creating Solutions
Making a Mess of Your Life -Work,
Family, Friendships Feel Angry or Scared
Feel Hopeless or Doomed Feel in
Control Feel Helpless or
Out of Control Feel Good About Yourself
Feel Worthless, like a Failure
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Issues to be Assessed in the Treatment of
Traumatic Sequelae of Disaster

• Differential diagnosis(es)?
• What is the individuals developmental level?
• What was pre-event/premorbid functioning? What
  is it now?
• History of psychiatric disorders or problems?
• What are the current stressors/ or reminders?
• (loss, disruption, displacement, financial
  issues)
• What are current resources/resiliency factors?
• How are caregivers coping?
• Is there alcohol and drug use?
• Are there frequent episodes of anger and/or
  aggression?
• Are there symptoms present of depression,
  disordered bereavement (functioning impaired
  severely for at least two months after loss or no
  improvement in six months), PTSD, panic attacks?

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Issues to be Assessed in the Treatment of
Traumatic Sequelae of Disaster (cont.)

• Criteria for Referral
• Presence of depression, PTSD, panic attacks,
  disabling grief of six months duration and no
  improvement over time
• Worsening of prior psychological problems
• Memories of prior traumatic experiences are now
  causing distress
• Presence of sustained psychological or physical
  stress
• Poor or absent social supports

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Issues to be Assessed in the Treatment of
Traumatic Sequelae of Disaster (cont.)

• Criteria for Immediate Referral
• Suicidal thoughts with a plan and/or means
• Excessive substance use causing person or others
  to be placed at risk
• Poor functioning to the point that individuals
  (or dependents) safety/welfare is in danger

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Issues to be Assessed in the Treatment of
Traumatic Sequelae of Disaster (cont.)

• Self report can be misleading or incorrect due
  to
• Denial (person cannot admit to self that he/she
  has a problem)
• A tough guy, macho image needs to be maintained
• Peer culture (e.g. policeman or fireman),
  country of origin culture, family culture or
  belief in patriotic duty may necessitate a stiff
  upper lip demeanor

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Issues to be Assessed in the Treatment of
Traumatic Sequelae of Disaster (cont.)

• Self report can be misleading or incorrect due
  to
• Denial (person cannot admit to self that he/she
  has a problem)
• A tough guy, macho image needs to be maintained
• Peer culture (e.g. policeman or fireman),
  country of origin culture, family culture or
  belief in patriotic duty may necessitate a stiff
  upper lip demeanor

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Issues to be Assessed in the Treatment of
Traumatic Sequelae of Disaster (cont.)

• Major Issues in Making Referrals
• Stigma
• Explain feelings and behavior (note not called
  symptoms) are normal under these circumstances
  and so is getting some help to deal with them
• Take the shrink out of counseling
• Explain you are sending them for information and
  potential support
• Explain they will get help in problem solving and
  coping
• Tell them what you are doing to cope

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A State Mental Health Care System Response to 9-11
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A Statewide Network of Local Behavioral Health
Teams Helping Communities with the Stress of
Disasters or Public Health Crises

• Center for Trauma Response, Recovery, and
  Preparedness
• University of Connecticut Health Center
• Julian D. Ford, Ph.D.
• Department of Mental Health and Addiction
  Services
• Arthur C. Evans, Ph.D.
• James Siemnianowski, MSW
• Wayne Dailey, PhD
• Center for Trauma Response, Recovery and
  Preparedness
• Yale University School of Medicine, Dept. of
  Psychiatry
• Steven Berkowitz, MD
• Steve Bunney, M.D
• Steven Marans, PhD.
• Steve Southwick, MD
• CT Department of Children and Families
• Thomas Gilman, MSW

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Linking Behavioral Health to the OEM DPH
Disaster/Crisis Response System
Statewide, Local Incident Command
System Municipal officials, public health, fire,
police, emergency management, EMS, health care,
schools, social service agencies
Statewide, Regional, Local Behavioral Health
System BH Agencies Professionals Natural
Helpers
Local Behavioral Health Response Teams
OEM - Office of Emergency Management DPH -
Department of Public Health BH - Behavioral Health
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How does the state behavioral health system
support local crisis responses?
Gov Governor OEM Office of Emergency Mgmt DPH
Dept of Public Health CTRP Ctr. for Trauma
Response/Recovery Preparedness DCF Dept of
Children Families
RC Regional Behavioral Health
Coordinators DMHAS Dept of Mental Health
Addiction Svs
Gov/OEM/DPH
DMHAS/DCF
CTRP
RC
RC
RC
RC
RC
T
T
T
T
T
T
T
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T
T
Local teams comprised of specially trained state
staff, Private Non-Profit and private volunteers,
work closely with municipal and community
leaders, public health department directors, EMS,
clergy, school officials, employers