Mental Health Mental Health Aspects of Aspects of

BioterrorismBioterrorismEdward A. Walker, MD

Professor and Vice Chair, Department of Psychiatry and Behavioral Sciences

Chief, Psychiatric Services, University of Washington Med Center

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

Labor Day Weekend 2001:the 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?

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

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

Coping cycle

stressor

appraisal

resources

copingstrategy

Once you’ve 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: “I’m no longer safe”

What to look for in your clinic

• Fear• Anxiety (it’s 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

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.

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

PTSD definition

A. Exposure to a traumatic event in which both of the following were present:1. The individual experienced, witnessed, or was confronted with

an event of actual or threatened death or serious injury2. The event evoked a reaction of intense fear, helplessness or

horror

B. Persistent re-experiencing of the eventIntrusive recollectionsRecurrent distressing dreamsActing or feeling as if the events were recurringDistress on exposure to cues that resemble eventPhysiological reactivity after exposure to cues

C. Persistent symptoms of avoidance and numbingEfforts to avoid thoughts, feelings, our conversationsEfforts to avoid activities, places, or peopleInability to recall important aspects of the traumaDiminished interest or participation in activitiesFeelings of detachment or estrangementRestricted range of affectSense of foreshortened future

D. Persistent symptoms of increased arousalDifficulty falling or staying asleepIrritability or outbursts of angerDifficulty concentratingHypervigilanceExaggerated startle

E. Duration of symptoms for more than 1 monthF. Clinically significant distress and disability

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

PTSD score

HIGHMODERATELOW

Pe

rce

nt

80

60

40

20

0

PTSD Scores in 1225 Women HMO Members

71%

23%

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)

PTSD score

HIGHMODERATELOW

Me

an

100

90

80

70

60

50

40

30

20

PHYSICAL

ROLE

EMOTIONAL

SOCIAL

PAIN FREE

MENTAL HEALTH

VITALITY

HEALTH PERCEPTION

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 1999;107:332-9.

  LOW(n = 843)

MODERATE(n = 270)

HIGH(n = 83)

  

F(2,1145)

Total mean number of ICD-9 Diagnoses 

1.5 + 1.6 2.0 + 1.8 2.4 + 2.1 13.54p < .001

Number of minor infectious diseasesb

0.6 + 0.9 0.8 + 1.1 1.0 + 1.2 3.67p = .026

Number of pain disordersc

 

0.2 + 0.5 0.3 + 0.7 0.5 + 0.8 10.28p < .001

Number of mental health diagnosesd

0.2 + 0.5 0.3 + 0.6 0.4 + 0.6 15.41p < .001

Number of other diseasese

 

0.3 + 0.6 0.4 + 0.7 0.4 + 0.7 1.44p = .24

Physician coded ICD-9 diagnoses

Unadjusted Health Care costs for 1225 Female Group Health Members with PTSD symptoms

  LOW MODERATE HIGH

  N=843 N=270 N=83

Primary Care   

337 + 396(237)

432 + 494(319)

 

510 + 485(405)

Specialty Care 

267 + 584(0) 

261 + 512(0)

355 + 615(108)

Emergency Care  

18 + 134(0)

31 + 161(0)

110 + 445(0)

Pharmacy 

160 + 406(66)

 

240 + 393(112)

331 + 578(128)

Mental Health  

35 + 190(0) 

150 + 394(0)

162 + 502(0)

Total Outpatient  

1352 + 3236(609)

1590 + 2112(829)

2603 + 4939(1283)

 Inpatient 294 ± 2032(0)

189 ± 1130(0)

457 ± 1750(0)

Total Costs 1646 ± 5156(609)

 

1779 ± 3008(829)

3060 ± 6381(1283)

Meeting special needs

Who is affected?

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

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?

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?

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?

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. You’re facing a situation where you and everyone around you will be stressed. You’ll be trying to meet the needs of patients, colleagues, and family at a time when you’re worried about your loved ones. It’s 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 won’t be able to help us all if you don’t relax a bit and take care of yourself first. You’ll need to pace yourself – take some breaks from time to time so you don’t burn out right away. After you’ve done some initial triage of your area, contact your loved ones and make sure they’re ok. Let them know you’ll be with them as soon as you can, and stay in touch with them throughout the crisis. If you can’t 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. Don’t forget to ask yourself the same question from time to time.

 This is going to be challenging for all of us, but we’re 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 what’s 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, you’re set. Put this note in your pocket and take it out from time to time today. We’ll see you on the front lines.

Take care of yourself!  Your friends and colleagues

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 you’ll have what you need?

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?

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

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

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 wasn’t present earlier– Decreased school performance– Increased dependence and clinginess, sometimes

regression

Practical management strategies

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)

Model

PredisposingFactors

PrecipitatingFactors

PerpetuatingFactors

Case Example

Mary is a 42 year-old woman who visits you on August 20, 2001 to establish care at your practice. Currently, she is in no distress, and would like her yearly gynecological examination. The visit is pleasant and unremarkable.

Predisposing Factors

During the review of systems she reports aprevious history of persistent diarrhea and joint pain,currently inactive. Her family medical history isremarkable for a history of alcoholism in her father andmother which sometimes led to occasional emotional andphysical abuse. You get the sense that her self-esteemis on the low side, and you realize that you had somedifficulty establishing a warm doctor-patient relationship.She leaves the visit with no planned follow-up.

Precipitating Factors

On September 25 she presents in acute distress, stating that she is anxious and upset. She and her husband had a major fight last night. He has been abstinent from alcohol for 5 years now, but came home drunk every night for the past week after finding out that he is being activated by the National Guard. He has become increasingly emotionally abusive. Last night he struck her. She is now very upset and presents with signs and symptoms of diarrhea and joint pain. As you work up her physical complaints, you also begin to make her aware of your belief that her physical problems may be related to her marital distress. You find her somewhat defensive and angry and she fails to appear for several appointments.

Perpetuating Factors Over the next month, on her own, she sees several specialists who label her physical symptoms as “colitis” and “fibromyalgia”. The specialists confirm her belief in the organic foundation of her symptoms. She now is being seen on a regular basis by a gastroenterologist, a gynecologist and a rheumatologist. By the end of the year she has had a negative diagnostic laparoscopy, increasing fatigue and functional disability, and is now applying for Social Security disability assistance for her chronic medical problems. Her marriage has failed. She avidly follows the internet self-help groups on fibromyalgia and chronic fatigue. You find yourself increasingly unable to influence this vicious cycle of disability and somatization.

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

Precipitating Factors

• medical disease

• psychiatric disorder

• social, fiscal or occupational stress

• changes in social support

• re-experienced trauma

• dietary factors

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)

The Plan: Work Backwards

• get control of perpetuating factors– tertiary prevention

• limit precipitating factors– secondary prevention

• decrease power of predisposing factors– primary prevention

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

Controlling Perpetuating Factors (cont’d)

• deal with reinforcers (gain)– emotional, financial

• stop re-creations of trauma– consultation referral– deal with interpersonal problems– use of opiates– recurrent medical procedures/surgeries

Limiting Precipitating Factors

• treat comorbid medical/psychiatric diseases• stress management

– change what can change, accept what can’t– appraisal, resources, coping (activation)

• increase social support• decrease exposures to trauma• focus on wellness (exercise, diet)• decrease chronic social stress

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

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

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

• 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

Keeping things in perspective