Psychological and Behavioral Responses to Disasters Steve Bunney, MD Department of Psychiatry Yale School of Medicine

Psychological and Behavioral Psychological and Behavioral Responses to DisastersResponses to Disasters

Steve Bunney, MD Steve Bunney, MDDepartment of PsychiatryDepartment of PsychiatryYale School of MedicineYale School of Medicine

9-11-019-11-01

• Unique Disaster• First disaster in history

where in the aftermathpsychological repair wasmore important thanrepairing bodies orburying the dead

• Part of event waswatched live by millionsof people

Personal Experience Post 9-11Personal 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

PHASES of IMPACT and PHASES of IMPACT and RECOVERYRECOVERY

I. EMERGENCY/IMPACTSHOCK – first hours/daysHEROIC – first days/weeksII. EARLY POST-IMPACT

HONEYMOON – 1-3 Months DISILLUSIONMENT – 3-6 months

III. RESTORATION vs. BREAKDOWNRESTABILIZATION – 6-9 months

RECOVERY – 9-12 monthsPREPAREDNESS – 12+ months

What is Psychological What is Psychological Trauma?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

Psychological ShockPsychological 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.

Stress vs TraumaStress 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

Neurobiology of Severe StressNeurobiology 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

Neurobiology of Severe StressNeurobiology of Severe Stress(cont.)(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)

Neurobiology of Severe Stress Neurobiology of Severe Stress (cont.)(cont.)

Alarm: insula and amygdala coordinate body’s 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


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 provides mechanism for two types of long term memory of stressful events :

Hippocampus Explicit - verbalizable and recallable

Amygdala Implicit - unconscious changes in habit and conditioned

responses (e.g. fear response when exposed to cues relevant to traumatic event


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

Event Factors That Influence Event Factors That Influence Psychological ResponsesPsychological 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)

Individual Factors That Influence Individual Factors That Influence

Psychological ResponsePsychological 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

ChildrenChildren

Responses and TreatmentResponses and Treatment

Role of AdultsRole 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

Children’s Typical Initial ResponsesChildren’s Typical Initial ResponsesNormal reactions to abnormal situationsNormal reactions to abnormal situations

Emotional and SomaticEmotional 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

ToddlersRely on ParentsRegression

PreschoolersHighly ImaginativeConcerned About Safety

School AgeSocial DifficultiesConcerned About Right/Wrong (Revenge)

AdolescentsStruggling With IndependenceConflict With Authority FiguresMinimize or ExaggerateIncreased Risk TakingSubstance Use

Older Adolescents & Young AdultsConcerns About FutureSubstance Use

Spectrum of Developmentally Determined Responses

Implications of Neurobiological Implications of Neurobiological Development for TreatmentDevelopment for Treatment

Hippocampus not fully functional until 4-5 years old

Prefrontal cortex not fully functional until around age 10

Treatment and InterventionTreatment and InterventionIn the immediate aftermathIn 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

Treatment and InterventionTreatment and InterventionIn the immediate aftermath (cont.)In the immediate aftermath (cont.)

Criteria for Referral

Presence of DissociationDecreased motor functionBlunted affectAbsence 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

Acute Stress DisorderAcute 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

Treatment Issues 4-6 Months After Treatment Issues 4-6 Months After DisasterDisaster

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)

AdultsAdults

Responses and Treatment Responses and Treatment

Common FantasiesCommon 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)

Common Stress Reactions To DisasterCommon Stress Reactions To Disaster

Emotional EffectsShock

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”)

Physical EffectsFatigue

Insomnia

Sleep disturbance

Hyperarousal

Somatic complaints

Impaired immune response

Headaches

Gastrointestinal problems

Decreased appetite

Decreased libido

Startle response

Cognitive EffectsImpaired concentration

Impaired decision-making ability

Memory impairment

Disbelief

Confusion

Distortion

Decreased self-esteem

Decreased self-efficacy

Self-blame

Intrusive thoughts and memories

Worry

Interpersonal EffectsAlienation

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

Acute Stress DisorderAcute 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


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)


(cont.)(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

Key Principles of Immediate Key Principles of Immediate InterventionIntervention

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 they’re in and say

where they are Support: Confer control in therapeutic

contact

Key Principles of Immediate Key Principles of Immediate InterventionIntervention (cont.) (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

Key Principles of Immediate Key Principles of Immediate Intervention Intervention (cont.)(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

4-6 Months After Disaster4-6 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)

Target Groups At Risk for Persistent Target Groups At Risk for Persistent Post-Traumatic SequelaePost-Traumatic Sequelae

On-Site Survivors

Bereaved Families/Primary Relationships

On-Site Rescue/Recovery Workers

Terror: Exposure to threat of imminent/actual death Horror: Witnessing death, destruction, terror & shockPhysical Insult: injury, exhaustion, toxic exposureTraumatic Reactivation (past & subsequent crisis work)Separation/Detachment from Family and Community

Target Groups At Risk for Persistent Target Groups At Risk for Persistent Post-Traumatic SequelaePost-Traumatic Sequelae

Helpers Caring for Survivors, the Bereaved, Workers (e.g., Behavioral Health, EAP, Health Care, Clergy)

Family/Community Members Living and Working with Survivors, the Bereaved & Rescue Workers

Vicarious Shock: Exposure to terror, helplessness, grief Uncertainty: Wanting to help but not knowing when/howPhysical/Workload Strain: Carrying the added load while

others are focused on coping with impairment or recoveryLoss: Disconnection from traumatized significant othersTraumatic Reactivation: Unresolved direct/vicarious trauma

Target Groups At Risk for Target Groups At Risk for Persistent Post-Traumatic SequelaePersistent Post-Traumatic Sequelae

People in Recovery from Behavioral Health Disorders

Vulnerable Groups

(e.g., children, elders, disenfranchised)

Treatment Issues 4-6 Months Treatment Issues 4-6 Months Later:Later:

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

Post Traumatic Disorders: Not Post Traumatic Disorders: Not Automatic & More than PTSDAutomatic & 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

Posttraumatic Stress Disorder Posttraumatic Stress Disorder (PTSD)(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)

Issues to be Assessed in the Issues to be Assessed in the Treatment of Traumatic Sequelae of Treatment of Traumatic Sequelae of

DisasterDisaster

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


Disaster (cont.)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 individual’s

(or dependent’s) safety/welfare is in danger


Disaster (cont.)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

A State Mental Health CareSystem Response to 9-11

A Statewide Network of Local Behavioral A Statewide Network of Local Behavioral Health Teams: Helping Communities with the Health Teams: Helping Communities with the

Stress of Disasters or Public Health CrisesStress of Disasters or Public Health CrisesCenter for Trauma Response, Recovery, and Preparedness

University of Connecticut Health Center

Julian D. Ford, Ph.D.CT Department of Mental Health and Addiction Services

Arthur C. Evans, Ph.D.James Siemianowski, MSW

Wayne Dailey, PhDCenter for Trauma Response, Recovery and PreparednessYale University School of Medicine, Dept. of Psychiatry

Steven Berkowitz, MDSteve Bunney, M.D

Steven Marans, PhD.Steve Southwick, MD

CT Department of Children and FamiliesThomas Gilman, MSW

What have we done since 9/11?What have we done since 9/11?

A Statewide Behavioral Health A Statewide Behavioral Health Preparedness PlanPreparedness Plan

800+ professionals trained to serve as volunteers on local behavioral health crisis response teams

150+ prevention providers and natural helpers trained as resources for community preparedness

50+ behavioral health consumer advocates trained to help communities support people in recovery

Local volunteer teams receiving ongoing technical assistance to prepare them for disaster response

Planning for mobilization and activation of these teams in the event of a major disaster

Behavioral health resources disseminated via www.ctrp.org and www.clearinghouse.org

Linking Behavioral Health to the OEM & DPH Linking Behavioral Health to the OEM & DPH Disaster/Crisis Response SystemDisaster/Crisis Response System

Statewide, Local

Incident Command

SystemMunicipal

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 ManagementDPH - Department of Public HealthBH - Behavioral Health

How does the state behavioral health How does the state behavioral health system support local crisis responses?system support local crisis responses?

Gov/OEM/DPH

DMHAS/DCF

CTRP

T T T TTTT T 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

RC = Regional Behavioral Health

Coordinators

DMHAS = Dept of Mental Health &

Addiction Svs

RC RCRC RC RC

Gov = Governor

OEM = Office of Emergency Mgmt

DPH = Dept of Public Health

CTRP = Ctr. for Trauma Response/Recovery & Preparedness

DCF = Dept of Children & Families

Taken in Part from aTaken in Part from aCenter for Trauma Response, Recovery Center for Trauma Response, Recovery and Preparedness (CTRP) Presentationand 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 Siemianowski, MSW

CT Department of Children and Families Thomas Gilman, MSW

Documents

Psychological and Behavioral Responses to Disasters Steve Bunney, MD Department of Psychiatry Yale School of Medicine