Disaster Strikes: Just-In-Time Training
For First Responders, Mental Health Professionals and Primary Care Providers
Peter Yellowlees, MD
Kathleen Ayers, PsyD
Donald Hilty, MD
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Author Disclosure
These materials are based on a continuing education program which was developed in a different format with a grant from the California Department of Mental Health Services to the University of California Davis Health System. These materials contain some similar content, but have been updated.
All authors have refrained from making recommendations regarding products or services. They have limited content to pathophysiology, diagnosis and research findings, and support these materials with the best available evidence from medical literature.
Internet
Resources
A compilation of the websites mentioned throughout these materials is listed below.
Office of Emergency Services
California Emergency Plan
www.res.ca.gov/Operational/OESHome.nsf/PDF/California%20Emergency%20Plan/$file/CEP.pdf
SEMS Training
www.oes.ca.gov/Operational/OESHome.nsf/All?SearchView&Query=sems
American Red Cross
Lutheran Social Services Disaster Response
National Organization for Victims Assistance
Catholic Charities USA Disaster Response
www.catholiccharitiesusa.org/response/index.cfm?
Salvation Army
Centers for Disease Control and Prevention
www.phppo.cdc.gov/phtn/webcast/stress-05
SAMHSA—National Mental Health Information Center—Disaster Publications
www.mentalhealth.samhsa.gov/cmhs/emergencyServices/fpubs.asp
Institute of Medicine
www.iom.edu/report.asp?id=11573
The National Center for PTSD
Uniformed Services University of the Health Sciences
www.usuhs.mil/psy/disasterresources.html
US Department of Justice
Disaster Mortuary Operational Response Team
National Disaster Medical System
National Transportation Safety Board
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Just-In-Time Training (JIT-T)
Just-In-Time Training (JIT-T) is considered to be “as needed” as opposed to traditional training, in which a group of individuals meet and go through training materials and methods which they anticipate using once they return to their jobs. If this training is not used, however, it is forgotten and the individuals typically need to be retrained. JIT-T also refers to just enough training at the right time, and in the right context. It is similar to on-the-job training. JIT-T also does not neglect general training, but offers some general training, which can be used as background information.
JIT-T was used during Hurricane Katrina; Centers for Public Health Preparedness (CPHP) provided this training to responders and to volunteers throughout the region affected by the hurricane. CPHP provided training via the internet, by CD-ROM, and in person. CPHP also offered “toolkits” with easy to reference materials, and a website that contained specific information on many topics. Materials were also available in Spanish.
Despite the training and availability, many people still believe that more training should be available. Individuals who have participated in different disasters indicate that not only are more materials needed, but that methods not requiring electricity be utilized in case of power outages during a disaster.
This material is provided as another method to convey JIT-T. Selected pages or the entire book may be downloaded, depending on the individual and on the training needed. It could be accessed from anyplace with internet capabilities, even while traveling to a disaster site.
Preparedness for all types of disasters needs to be rapid and current. It requires materials that are easily and quickly accessible. It should not have large amounts of extraneous materials. Behavioral health and mental health issues must be addressed as part of preparedness.
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Chapter Overviews
Chapter One—Mental Health Response System and Federal Funding Overview
Overview of the mental health response system and federal funding; includes information about the National Response Plan and National Incident Management System; disaster classification and key response agencies; immediate and regular services programs; Federal Emergency Management CCP Services.
Chapter Two—Basic Clinical Principles
Basic clinical principles of disaster mental health based on best practices; phases of disaster response; intervention strategies; psychological responses to disaster; psychotherapy versus disaster mental health; relating to victims; ethics for professionals; emerging responders; Department of Mental Health team deployment; assessment considerations; initial and delayed responses to trauma; when to refer someone for professional services.
Chapter Three—Weapons of Mass Destruction
Effects of intentional disasters with weapons of mass destruction, which are unconventional agents or conventional agents used in an unconventional way; the biopsychosocial view; problems specific to chemical, biological, radiologic, nuclear and explosive weapons; physical and psychological damage to survivors and family members, community; short and long-term implications of bioterrorist attacks; beginning treatment.
Chapter Four—Anxiety and Related Topics
Acute stress disorder; anxiety-related disorders; how individuals may present to a primary care physician; screening for Posttraumatic Stress Disorder; group and individual responses to a disaster; unique features of biological and chemical agents which can produce psychiatric symptoms; pharmacologic treatments for Posttraumatic Stress Disorder; when to refer out for psychotherapy.
Chapter Five—Medically Unexplained Physical Symptoms, Coping Skills, and Long-term Psychosocial Implications
Coping skills; types of coping; effect of coping styles on PTSD development and course; teaching coping skills; medically unexplained physical symptoms (MUPS); treatment of MUPS, triage, short and long-term treatment including medications, referring out for psychotherapy; long-term psychosocial implications of a terrorist-caused disaster; chronic PTSD; disaster characteristics that may affect PTSD; long-term physical problems.
Chapter Six—Delivering Bad News: Families, Victims and Agencies
Delivering bad news and providing death notifications; debriefing for medical professionals; debriefing for first responders and for volunteers; mass casualties; setting up family resources and family assistance centers for short and long term services to survivors and families of victims of a mass casualty.
Chapter Seven—Risk Management, Isolation and Quarantine Issues
Risk management and risk communications; topics and challenges unique to bioterrorism; enlisting the general public as a capable partner; thinking beyond the hospital for mass casualty care; issues around isolation and quarantine; evacuation; sheltering-in-place; how the public views government readiness plans.
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Chapter One—Mental Health Response System and Federal Funding Overview
Objectives:
Readers will:
Acquire a general understanding of disaster response systems and the way mental health services are provided within those systems
Learn to distinguish disasters from other types of emergencies and describe the characteristics of natural and human caused disasters
Become familiar with funding that may be available for disaster mental health services and the programmatic features of the FEMA Crisis Counseling Program
Overview
Each disaster has unique features.
There is an established hierarchical system for disaster response involving local, state, federal, and volunteer agencies.
Severity of the disaster dictates the level of response.
Federal resources are available for the most severe disasters.
Many states are multi-hazard states and are susceptible to many types of natural disasters affecting widespread geographic areas. Many states also have many public targets vulnerable to terrorism (human caused disasters). California, for example, has received a major Presidential Major Disaster Declaration over 20 times since 1985.
What is a disaster? The term is typically defined as a large-scale catastrophe regardless of the cause. It is of sufficient severity and magnitude to warrant federal assistance to support state, local, and relief organization response efforts. Assistance is required to alleviate damage, loss, hardship, and suffering (FEMA, Pub. 229 (4), November 1995, p.1).
Natural disasters are an act of nature happening instantaneously or over time. Natural disasters occur about every two weeks (on average) in the United States. Approximately 17 million North Americans are exposed to trauma from a disaster each year (Meichenbaum, 1995). Examples include winter storms and flooding, earthquakes, firestorms, hurricanes and tornadoes. Acts of nature are more readily comprehended by the human imagination and psyche than are human-caused disasters.
Human-caused disasters may be accidental or intentional. Intentional disasters (terrorism) are commonly referred to as Weapons of Mass Destruction (WMD) or CBRNE events: Chemical, Biological, Radiological, Nuclear, and Explosive. Examples of human-caused disasters include the Oklahoma City bombing, the World Trade Center and Pentagon bombings (aircraft used as bombs), and transit system attacks in London, Madrid, and Tokyo. Human-caused disasters occur less frequently than natural disasters, and they “terrorize” and heighten vulnerability in the general population.
A hierarchical system exists for managing disaster responses. Each state will have an emergency management system. The federal system is the National Incident Management System (NIMS). NIMS must be followed by all levels of government and all response organizations. NIMS will be discussed in more detail later.
In some states, disaster classifications are grouped in three levels. Level I is a minor to moderate incident prompting a local government response. Local resources are adequate, and mental health response may not be required. This could be local flooding or a small, quickly contained wildfire. In Level II disasters, a moderate to severe incident occurs, which prompts a regional response. A “Local Emergency” is proclaimed by county government. The disaster may require mutual aid from other counties, and a mental health response is likely. Examples include more widespread flooding, rapidly spreading wildfires affecting several communities, or an earthquake damaging numerous structures. A Level III incident requires prompting of both a state and federal response. The local and state resources are overwhelmed; a “State of Emergency” is proclaimed by the governor. A request is made for a “Presidential Major Disaster Declaration.” Mental health response is typical; it may be of short- or long-term duration. Examples include extensive wildfires covering a large populated area, flooding and landslides, and hurricane response (such as with Hurricane Katrina).
Key federal, state and county agencies have a “lead” role for disaster mental health response. Volunteer Organizations Active in Disasters (VOADs) partner with and supplement the lead government agencies. Some examples of VOADs are: the American Red Cross, Lutheran Social Services Disaster Response, Catholic Charities USA, National Organization for Victim Assistance, and the Salvation Army. For Level I disasters, the county mental health department and local VOAD (e.g., American Red Cross) will provide services. For a Level II incident, the State Department of Mental Health and the Governor’s Office of Emergency Services provide assistance, along with mutual aid from adjoining counties. Additional VOADs also provide assistance. At a Level III incident, the Federal Emergency Management Agency (FEMA) and long-term recovery VOADs provide help.
Local (county) and regional (state) services vary from location to location. Federal disaster mental health funding has uniform requirements. A Presidential Major Disaster Declaration must first be declared, along with a demonstrated need for disaster mental health services. Funds are made available through the FEMA Crisis Counseling Program (FEMA CCP). Various County Mental Health Departments implement FEMA CCP services through contracts with community-based organizations.
FEMA CCP grant funding is available through two sequential grant programs based on severity and duration of need. The Immediate Services Program (ISP) is one of the two programs, which provides funds for the first 60 days after the disaster; funding is often extended after this period. The Regular Services Program (RSP) follows ISP funding and provides services up to an additional nine months. Together, these grants generally extend services through the first year anniversary of the event. These programs are discussed in more detail below.
The Immediate Services Program (ISP), provided in the first 60 days after a disaster, has a goal of assessing the needs of, and stabilizing the victims of a disaster. The program initiates immediate services and utilizes community-based needs assessment. Agencies typically provide outreach; crisis counseling; diffusing/debriefing; screening; individual assessment; referrals; and public education.
The Regular Services Program (RSP) provides aid up to an additional nine months after the disaster. The goal is to help disaster survivors return to pre-disaster levels of functioning. Agencies provide continued outreach; counseling and support groups; assessment and referral to long-term recovery services; continuing public education and training; and facilitation of community capacity building.
The FEMA CCP core services provided after a disaster are outreach; crisis counseling; screening and assessment; information and referral; public education; and stress management interventions. Services are provided to anyone who lives or works in the declared disaster area, first response personnel, and disaster workers. Interventions are psycho-educational in focus. Mental health diagnoses or labels are avoided; services are tailored to target populations and community-based needs. Assessment focuses on strengths, adaptation and coping skills. Reactions to stress are validated and experiences are normalized. Services are typically offered at care and shelter sites; neighborhoods, homes, businesses, and other gathering places; in town hall meetings and public forums; at medical triage centers; in government offices and private businesses; and in schools and social activity centers.
FEMA CCP services have several benefits. There is a reduced stigma of seeking help on the part of survivors, with a recovery focus versus a mental health or counseling focus. Services are provided at no cost to disaster survivors or communities. These services are neighborhood and community based. Providers avoid diagnosis and other limitations of formalized psychotherapy. Individuals may become involved with these organizations by volunteering for the local County Mental Health Department disaster response team or by volunteering for a well-established VOAD. Examples of disasters in which FEMA CCP services were provided include the 2003 California Wildfires and World Trade Center and Pentagon bombings. In California, three counties implemented services, with $1.2 million provided under ISP and $3.8 million under the RSP. Services were provided for 14 months. For the World Trade Center and Pentagon bombings, six states in the vicinity of the attacks received funding. $166.5 million was allocated via FEMA CCP.
Other federal plans include The National Response Plan and National Incident Management System. The National Response Plan establishes a comprehensive, all-hazards plan integrating multiple response sectors. This includes Homeland Security and emergency management; law enforcement and fire departments on various levels; public works departments; public health departments; emergency medical service providers; and the private sector.
The National Incident Management System (NIMS) provides “a consistent nationwide approach for federal, state, tribal, and local governments to work effectively and efficiently together to prepare for, prevent, respond to, and recover from domestic incidents, regardless of cause, size, or complexity (Homeland Security Presidential Directive 5).” NIMS has three components—the Command and Management System, the Preparedness System, and Resource Management.
The Command and Management System is made up of the Incident Command System, Multiagency Coordination System and the Public Information System. Preparedness is made up of Planning, Training and Exercises, Standards and Certification, Mutual Aid, and Information and Publications. Resource Management identifies and types resources; certifies and credentials personnel; inventories, acquires, mobilizes, tracks and recovers resources.
California as an Example
The California Emergency Plan and Standardized Emergency Management System (SEMS) are available statewide. The California Emergency Plan establishes general policies to guide statewide emergency management activities; assigns specific responsibilities to state agencies; and provides guidance on interagency coordination. SEMS was created after the 1991 Oakland Hills Firestorm. More than 2800 homes/dwellings were lost. Fire departments from multiple jurisdictions established independent incident command systems with different response priorities, and had equipment with incompatible fittings, which rendered much equipment useless with Oakland/Berkeley hydrants and pumps. In response to this, SEMS was created to address three key areas: prescribed structure for coordination among all responding agencies; control information flow and resource allocation; and allow for more rapid mobilization, deployment and tracking of personnel, equipment and other assets. The principal components of SEMS are the Incident Command System, Multi/inter-agency coordination, mutual aid, and the concept of a county “Operational Area.” Beyond the field and local levels, SEMS has an Emergency Operations Center (EOC) for operational areas after a disaster. Beyond that, the Regional Emergency Operations Center (REOC) is activated for a regional response. Finally, a State Operations Center (SOC) exists for the state level.
Organizationally, SEMS includes individuals for Public Information, Liaison, and Safety. Other organizational aspects are Operations (with Disaster Mental Health Services under this division), Planning/Intelligence, Logistics, and Finance/Administration.
With a Presidential Major Disaster Declaration, conditions must meet the provisions of the Robert T. Stafford Disaster Relief and Emergency Assistance Act (PL93-288, as amended by PL-100707). This would occur after a Level III disaster with massive destruction. Criteria for a Presidential Major Disaster Declaration are “Any natural catastrophe (including any hurricane, tornado, storm high water, wind-driven water, tidal wave, tsunami, earthquake, volcanic eruption, landslide, mudslide, snowstorm, or drought) or regardless of cause, any fire, flood or explosion in any part of the United States, which in the determination of the President causes sufficient severity and magnitude to warrant major disaster assistance under this act…” (Robert T. Stafford Disaster Assistance and Emergency Relief Act [PL93-288 as amended]). For a Presidential Declaration to be made, the disaster response and recovery needs exceed local and state resources. Damage assessments of financial impact, infrastructure damage, personal loss factors, human impact, and rebuilding needs exceed certain thresholds. Also, there are defined geographic areas of impact usually declared by county boundaries.
Voluntary Organizations Active in Disasters (VOADs) may be locally or nationally based. Nationally based VOADs are always in need of volunteers for disaster relief work. Local chapters generally serve as a point of entry. VOADs may specialize in specific services; provision of disaster mental health services varies. Examples of VOADs include American Red Cross, Lutheran Social Services Disaster Response, National Organization for Victims, Catholic Charities USA Disaster Response, and the Salvation Army.
Each state has a different emergency management system, as do the states’ counties and some cities (especially larger cities). Check for local and state government information under city, county and state websites.
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Chapter Two—Basic Clinical Principles
Objectives: The reader will
Understand basic disaster mental (DMH) principles and the methods, strategies, and best practices for delivering DMH services
Recognize typical reactions to disasters and their time scope
Understand differences between disaster mental health services and other clinical interventions
Understand assessment processes following a disaster
There are some important key concepts unique to disaster mental health:
No one who sees a disaster is untouched by it
A wide range of normal stress and grief reactions follow a disaster
Reactions may disorient victims at a very basic level
Most people pull together and function well during and immediately after a disaster
Coping and adjustment problems tend to manifest later
Many emotional reactions stem from practical problems caused by the disaster
DMH services must be tailored to the people and communities they serve
Natural social support systems are crucial to recovery
Disaster trauma may be both individual and collective
Each of these key concepts will be discussed further.
It is important to keep in mind that the nature of DMH is more “practical” rather than “psychological.” Disaster mental health is not psychotherapy. To compare, DMH is community-based, focuses on strengths and coping skills, seeks to restore pre-disaster levels of functioning, accepts content at face value, and takes an approach which validates and supports. Psychotherapy, however, is primarily office-based, focuses on diagnosis and treatment, attempts to change an individual’s personality and functioning, interprets thoughts and behaviors, and has an approach which questions and examines.
There are disruptions to daily living, sometimes devastation to public infrastructure (depending on the nature of the disaster), personal loss, economic devastation, loss of equilibrium to individuals, communities, and geographic regions, and a ripple effect of multiple losses may occur.
Both community and individual responses to a major disaster tend to progress according to phases. These phases are shaped by the interaction of psychological processes and external events. Historically, emphasis has been on the division of disasters into the phases of: warning, threat, impact, inventory, rescue, remedy, and recovery. A more recent description of the post-disaster period is based upon the emotional states of those involved. There is much overlap between the phases. A “pre-disaster” period of time may exist, when there is a warning (as in a pandemic moving from region to region, or notification of a hurricane moving onshore) or threat. The impact occurs and the devastation or damage is done. It is also important to keep in mind the kind of disaster which has occurred. Most natural disasters have a clearly defined end point, which serves as a marker for the beginning of the recovery period. Some disasters are “silent” disasters (such as nuclear accidents, toxic spills) with little or no visible damage. There is no observable “low point” from which recovery can begin. If the impact period is prolonged, this impedes the recovery process. Survivors of such a disaster are more vulnerable to chronic stress and anxiety.
The Heroic phase is next, which may last one to three days. During this phase, people take inventory of what has been lost and what has been saved. Emotions are strong and direct, and people respond to demands for heroic action. Altruism is prominent; people expend major energy in helping others to survive and recover. Family groups, neighbors, and emergency teams of various sorts are key supports.
The Remedy or Honeymoon phase is next; this period generally extends from one week to three to six months after the disaster. People have a strong sense of having shared and survived a dangerous, catastrophic experience. There is an influx of official and governmental persons promising help. Victims begin cleanup and rebuilding, anticipating considerable help. Pre-existing and ad hoc community groups are especially important.
In the Inventory phase, survivors begin to recognize the limits of available disaster assistance. Physical exhaustion sets in due to enormous multiple demands, financial pressures, and the stress of relocation or living in a damaged home. Unrealistic optimism gives way to discouragement and fatigue.
About two months to two years after the disaster, the Disillusionment phase begins, as people come to terms with their grief and losses. People experience strong feelings of disappointment, anger, resentment, and bitterness. People also begin to see that, despite promises, help may be insufficient, may be slow in coming forth, or may not come at all (Hurricane Katrina as a recent example). The reality of losses and limits of the available assistance become apparent. Disaster assistance agencies and volunteer groups often pull out; survivors feel abandoned and resentful. The sense of a “shared community” is lost as victims concentrate on rebuilding their individual lives or move to other, unaffected communities. Trigger events (such as another hurricane warning) and anniversary reactions occur over time.
After about one to three years, the Reconstruction phase begins. Victims realize and accept that they will need to solve the problems of rebuilding their own homes, businesses, and lives largely by themselves. This phase lasts for several years following the disaster, as new buildings and development appear. Victims’ belief in their community and in their own capabilities return. If rebuilding is delayed, emotional problems which appear may be more serious and intense. Community groups with long-term investments become key factors. Stressors abound—there are family discord, financial losses, bureaucratic hassles, time constraints, home reconstruction, relocation, and lack of recreation or leisure time. Health problems and exacerbations of pre-existing conditions emerge due to ongoing, unrelenting stress and fatigue.
Disaster mental health recognizes the hierarchy of needs. Survival is the first need that survivors have. They want to ensure that their loved ones have survived. The next need is for safety and security; survivors want to ensure that they and their loved ones are safe from another incident or aftermath (such as aftershocks or rising floodwaters). Then the needs for food, clothing and shelter take precedent. Survivors look for help in getting these. Finally, health and well-being are considered by the survivors, as they deal with possible health issues and deal with losses. DMH services are provided in all these steps in the hierarchy, and in a variety of non-traditional settings. DMH may occur in temporary shelters, disaster recovery assistance centers, extrication sites, food distribution centers, medical triage areas, and even while survivors are waiting in line for services.
In the early phase after a disaster, survivors experience a mix of emotions and feelings, such as energy, optimism, altruism, hope, relief (“I survived”), shock, and denial. In later phases, “reality sets in;” survivors may experience multiple grief reactions, a sense of loss, fatigue, frustration, cynicism, and diminished cognitive functioning may occur. Initial and delayed responses to trauma can be emotional, cognitive, physical, or spiritual. With initial responses, survivors may experience these emotional responses: emotional numbing, depression, anxiety, guilt, fear, clinginess and dependency. Behavioral responses are withdrawal, hypervigilance, fatigue, and increased substance abuse. Physical responses are shock, reduced sleep and appetite, and worsening health. Spiritual responses are resolve/despair, altruism/isolation, and questioning/affirming. For delayed responses to trauma, emotional signs are: distancing through denial, intellectualization, compartmentalization, blaming, or use of humor. Cognitive responses are slowed thought, disorientation, hallucinations, flashbacks to the trauma, and decreased performance at school or work. Physical responses are chronic low energy, stress-related problems, and frequent injuries. Spiritual responses are changes in relationships, promiscuity, social withdrawal, fatalism and cynicism.
It is difficult to predict what psychological responses people will have to disasters. Personal assets and vulnerabilities mitigate and/or exacerbate disaster stress. A disaster affects survivors both psychologically and socially. Pre-existing community structures for social support and resources for recovery will vary. However, engagement with survivors and the overall community is key to promoting recovery. Program planners, administrators, and providers must appreciate the “macro” view of all these interacting factors.
There are some key intervention strategies for DMH providers. Crises should be addressed in manageable doses. Talking with a person in crisis doesn’t always mean talking about the crisis. It’s important to avoid psychological or psychiatric jargon and the concept of pathology. Offer assistance with everyday tasks. Be a hopeful presence, but don’t offer false assurances. Provide human contact and basic information to assist in problem-solving. Build rapport with survivors through supportive listening. Perform rapid assessment and triage. Build trust through multiple brief contacts. Focus on survivors’ strengths, existing resources, and natural support systems. When relating to survivors, recognize that this person’s life may have changed immeasurably and “returning to normal” may not be possible or desirable. Feelings may be intense, and it may be difficult for victims to “get down to business” or “be practical.” An outsider’s view of the situation may be less emotion-laden, but isn’t necessarily more “objective” or “reasonable.” Offer information and encouragement to victims and survivors; avoid advice or directives. Opportunities to review or process feelings come naturally; pushing victims to move too quickly may be harmful. Finally, recognize and accept your own tolerance for others’ pain; being aloof, condescending, or telling your own story is rarely helpful.
DMH providers must also keep in mind that disasters present clinicians with opportunities for “secondary gain.” Personal limitations and motivations should be examined and recognized. Avoid questionable or unethical practices: referring victims to your own clinical practice; telling a victim that he or she needs a specific treatment or technique that only you can provide; and using your knowledge of or relationships with victims for personal or professional gain.
Teams of DMH providers are a core feature of the incident command system. DMH teams have members with varying levels of disaster and/or mental health experience. Leadership roles are based on experience and skills, and may differ from ordinary roles. No one responds alone or outside the organized system. Team deployment relies on four concepts: continuity, confidentiality, consultation, and communication. Team members work in shifts for days to weeks at a time; good handoffs and the ability to collaborate are very important (continuity). Sharing information on victims contacted or in need of contact is expected and an important part of responding appropriately (confidentiality). Opportunities for frequent consultation exist and should be maximized (consultation). No responder works alone; all must keep up to date with information, and help keep other team members informed (communication).
Assessment of survivors is generally an informal process of noticing needs and responding appropriately. Start with practical information and supportive interventions or refer as appropriate. When unsure of the proper response, support, consult, and return. Provide support to the victim (support); review the situation with team members (consult); frequent brief contact builds a relationship and provides more accurate understanding of needs (return). Differentiate four general groups:
Those in need of practical information only.
Those who may benefit from a return visit for further contact, support, and monitoring.
Those who need immediate crisis counseling (supportive listening, debriefing, comfort).
Those who require referrals for severe reactions or chronic mental health conditions.
Evaluate the following: alertness and awareness; actions; speech; and emotions.
Alertness and awareness
You can probably handle the situation if the person:
Is aware of who they are, where they are, and what has happened
Is only slightly confused or dazed, or shows slight difficulty in thinking clearly or concentrating on a subject
Consider referral to a mental health agency if the person:
Is unable to give own name or names of people with whom he or she is living
Cannot give the correct date or state where they are or tell what they do
Cannot recall events of the past 24 hours
Complains of memory gaps
Actions
You can probably handle the situation if the individual:
Wrings hands or sits motionless for several minutes
Is restless, mildly agitated, and excited
Has sleep difficulty
Has rapid or halting speech
Consider referral if the individual:
Is depressed and shows agitation, restlessness, and paces
Is apathetic, immobile, unable to arouse self to movement
Is incontinent
Mutilates self
Uses alcohol or drugs excessively
Is unable to care for self (doesn’t eat, drink, bathe, or change clothes, endangers self)
Repeats ritualistic acts
Speech
You can handle the situation if the person:
Has appropriate feelings of depression, despair, and/or discouragement
Has doubts of ability to recover
Is overly concerned with small things, neglecting more pressing problems
Denies problems or states that they can take care of everything themselves
Blames their problems on others, is vague in their planning, and bitter in their feeling of anger that they are a victim
Consider referral if the person:
Hallucinates—hears voices, sees visions, or has unverified bodily sensations
States that their body feels unreal and fears they are losing their mind
Is excessively preoccupied with one idea or thought
Has the delusion that someone or something is out to get them and their family
Is afraid they will kill self or another
Is unable to make simple decisions or carry out everyday functions
Shows extreme pressure of speech—talk overflows
Emotions
You can probably handle the situation if the individual:
Is crying, weeping, with continuous retelling of disaster
Has blunted emotions, little reaction to what is going on around them right now
Shows high spirits, laughs excessively
Is easily irritated and angered on trifles
Consider referral to mental health agency if the individual:
Is excessively flat, unable to be aroused, completely withdrawn
Is excessively emotional and shows inappropriate emotional reactions
Briefly, also be on the lookout for “emerging responders.” These are professionals or paraprofessionals who feel they have valuable skills to offer victims and self-deploy to disaster sites. However, they may lack proper screening, training, organization or accountability. Participating in legitimate DMH organizations (County Mental Health, Red Cross, etc.) ensures accountability and protects victims from exploitation. Any emerging responder on site should be taken to the person in charge of volunteers.
Many of these principles are part of Psychological First Aid, which is a research-based approach to help individuals of all ages in the immediate aftermath of disasters and terrorism. The approach is beyond the scope of this ebook; a manual is available through the National Center for PTSD.
References:
Myers, Diane; Wee, David F., Disaster mental health services: A primer for practitioners.
Brunner-Routledge psychosocial stress series. New York, NY, US: Brunner-Routledge (2005).
American Red Cross—Disaster Services
http://redcross.org/services/disaster/0,1082,0_500_,00.html
CDC—Surviving Field Stress for First Responders
http://www.phppo.cdc.gov/phtn/webcast/stress-05/
SAMHSA—National Mental Health Information Center—Disaster Publications
http://www.mentalhealth.samhsa.gov/cmhs/emergencyServices/fpubs.asp
Institute of Medicine
Preparing for the Psychological Consequences of Terrorism: A Public Health Strategy.
http://www.iom.edu/report.asp?id=11573
National Center for PTSD
http://www.ncptsd.va.gov
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Chapter Three—Weapons of Mass Destruction
Objectives:
Learn nomenclature for human-caused disasters that may result in mass casualties.
Understand the psychological impact of human-caused mass casualty disorders
Understand the appropriate disaster mental health response following a human-caused mass casualty event
Human-caused disasters may be accidental or intentional. Intentional disasters have significant added psychological impact. A qualitatively different disaster mental health response is required if the incident involves the use of lethal substances, infectious disease or contagion. 9/11 and its effects will be used first as an example. On September 11, 2001, four passenger planes were hijacked. They were all used as bombs and three crashed into significant national targets—the World Trade Center buildings and the Pentagon. One crashed in a field. All federal buildings in Washington, D.C. were evacuated. There were massive rates of morbidity and mortality—3030 killed in all attacks, and 2730 injured in all attacks. It was the worst terrorist attack on U.S. soil. Between September 13 and 17, according to the Pew Research Center for People & the Press survey, 71% reported feeling depressed. 49% of those polled had difficulty concentrating; 33% had trouble sleeping. The attacks created a monumental societal shift in the concept of mass casualty disasters and disaster preparedness. In another example, in Bhopal, India, in 1984, an accident occurred at a chemical processing plant, when poisonous gas was leaked. 8,000 people were killed immediately; more than 15,000 eventually died. 100,000 people have experienced chronic and debilitating injuries. More than 500,000 people were affected either directly or indirectly. More than 20 years of research after this accident demonstrate continuing significant impact on long-term, intergenerational transmission of health problems and life-threatening abnormalities. In Tokyo, Japan, in 1995, individuals from a cult released Sarin nerve gas in the subway system. Twelve people died; ten of those deaths occurred within 48 hours of exposure. Approximately 5,500 people sought medical care; 1,048 were eventually hospitalized. Five times more people sought care than were actually exposed to the Sarin gas.
What these three events have in common is that both were human-caused disasters. Human-caused disasters may be either accidental or intentional (terrorism). They may have large-scale effects, with numerous deaths and/or injuries, excessive numbers of people requiring medical attention, continuing illness, and extended psychological implications. Intentionally caused events (terrorist acts) include use of substances or agents commonly referred to as Weapons of Mass Destruction (WMD). These are designed to kill hundreds to thousands of people; they may be novel, shocking, or unprecedented. They may involve the use of unconventional agents, explosives, or substances. Such acts affect the psychological well being of the population as a whole.
We have seen numerous examples showing that terrorists are capable of using WMD. Primary concerns include growing stockpiles of weapons worldwide, with access to weapons by extremist groups. Such groups use increasingly sophisticated delivery methods. Terrorist attacks are becoming common events rather than unthinkable aberrations.
WMD agents are classified into the following categories:
Chemical (gases, liquids, or solids with toxic effects)
Biological (pathogens, plague, contagious diseases)
Radiological (“dirty” bombs, reactor accidents)
Nuclear (nuclear explosives)
Explosive (conventional bombs, improvised devices)
The impact of these agents derives from two sources: the action of the agent on the brain and body, and the implications of the terrorist act on the human psyche. Specific WMD agents will be discussed below; this section will discuss WMD characteristics as a group.
Special Characteristics of WMD
WMD target symbolic landmarks, vital infrastructure, and public places. The actions may have greater psychological impact (creating terror) than physical impact (killing or injuring). WMD may also be used in a purely psychological way (such as a hoax). They may affect multiple sites or large geographic regions. They can lead to involuntary medical isolation, mass quarantine, or other restrictions on freedom.
There are also societal effects of WMD. There is a potential for a high number of mass casualties. Treatments or their availability may be limited (such as antidotes). There may be uncertainty about the effectiveness of medical treatments, and hospitals and medical systems may be overwhelmed. Contagion may occur, along with perceptions (and misconceptions) about transmission of the infectious agent. Life-saving efforts may be impossible due to contagion factors. Possible forced closure of large geographic areas for containment or quarantine may occur. Some geographic areas may be rendered uninhabitable. Mass panic or other adverse public behaviors may occur (breaking of quarantine, vigilantism). There may be an unprecedented military response or presence. There will be sensationalized and pervasive media coverage.
Psychological effects of WMD will also be present. People will be concerned about their true level of exposure. “Worried well” may often present with somatic symptoms that mimic actual physiological responses, such as stomachaches, headaches, nausea/vomiting, skin rash, sweating, blurred vision, and non-attributable aches and pains. It is possible that there may be a delayed onset of psychological impact as more is known about the attack. Continuing fear, worry, and anxiety will occur in the general population. The potential exists for long-term generational effects.
Additional sources of trauma could occur, depending on the nature of the WMD. Some types of CBRNE emergency activities may further traumatize the public, such as disrobing in public for decontamination, hazardous materials wash-down in chemical solutions (smells, tastes, tactile experience, etc.), violations of common privacy, periods of isolation and observation, the sight of first responders in protective suits, and general confusion or lack of information, especially in the early stages of the emergency. Additionally, there is a spiraling risk to the psychological impact. In a mass casualty event, approximately 4-20 friends and family are affected for every physical victim. There are the primary victims, then their next of kin as secondary victims. Emergency response personnel would be tertiary victims, with the general public as quaternary victims. This last category could be far larger, as some past research indicates that even people who would have been at the disaster site, but were not, also suffer a psychological impact (such thoughts as that could have been me, I could have been one of the victims, etc.).
An example of use of a biochemical WMD occurred in 2001, in Washington, D.C. Letters containing anthrax were sent to congressional representatives. The letters passed through the Brentwood post office, where employees handled the envelopes, not knowing that they were contaminated. Several workers became ill; two died. Antibiotics were distributed to 2100 workers. Hazardous materials (hazmat) cleanup involved sealing more than 100 dock doors and 235 skylights. The decontamination costs were estimated at $22 million and the facility was closed for two years.
These attacks have an enormous cost beyond the financial. In the community, paranoia grows. Mass panic, fear, and hyper-reactivity may occur. Mass evacuations may have to be undertaken. There may be quarantine and medical isolation. Discrimination may occur towards both the suspected perpetrators and toward victims of an attack. Many people will experience vicarious trauma. Individuals will experience anxiety, depression, difficulty concentrating, trouble sleeping, paranoia/mistrust, hypervigilance, and obsessive/compulsive responses. More serious individual psychological effects include the development of such disorders as: Acute Stress Disorder (ASD), Post Traumatic Stress Disorder (PTSD), Major Depression, Dissociative Disorders, increased use/abuse of alcohol and other drugs, and family dysfunction (domestic violence, child abuse, divorce).
People may have vulnerability factors which make them more likely to develop such a disorder, such as preexisting or previous psychiatric disorders; previous trauma; history of substance use/abuse; intense, prolonged exposure to traumatic events; and extended overexposure to media attention to the event. At-risk populations also exist: those who were exposed to the agent; those who believe they were exposed; first responders/HazMat personnel; site clean-up workers; media; government agency personnel; and public works employees.
When assessing such individuals, the following must be kept in mind: type and duration of exposure (direct exposure, presence in a target zone, or not directly exposed); have victims received factual information about contamination, is the victim experiencing any medical symptoms indicating actual exposure, and has the victim sought medical evaluation/treatment?
General DMH responses include normalizing reactions of victims; validating and affirming emotional responses; helping people understand what they are experiencing (facts and perceptions); identifying helpful coping strategies; helping victims determine methods by which they can most quickly return to their pre-disaster level of functioning; offering practical assistance; listening to victims’ experiences, reactions and fears; understanding that the individual may be experiencing a loss of control over his or her life and future; exploring how others are responding to the individual; assessing for ongoing needs and referring to appropriate resources; and arranging and encouraging linkages for on-going support (MH, medical, clergy, peers, online, etc.). Following WMD, DMH volunteers inquire how the exposure is affecting children and family at home; provide information that the individual can take home, addressing the physical and psychological reactions to CBRNE; provide a combination of psycho-education and medical-education about the reactions to the substance in question; and contribute to public information efforts from a strength-based perspective.
An example of a radiological WMD occurred in Goiania, Brazil in a 1987 radiological accident. Scavengers got into an abandoned hospital. They broke open a tube which contained a bright blue powder that glowed in the dark. Not knowing what the blue powder was, the scavengers divided it up and took it with them to show to their family and friends. When people who were exposed to the powder began to get sick, authorities were contacted and the material was identified as radioactive (cesium-137). 250 people were exposed to the radioactive substance; when the incident became public information, 60,000 people sought medical care. 5,000 individuals with no exposure developed physical symptoms (nausea and skin rashes) which mimicked exposure to the cesium. A total of 125,000 people (12.5% of that area’s population) requested screening for radiological contamination (a 500:1 ratio of those seeking treatment to those actually exposed).
In the WMD response paradigm, traditional disaster mental health strategies may be impossible under safety precautions caused by CBRNE. Communicable disease, contagion, or contamination may not allow person-to-person contact. A pre-planned and rehearsed response integrating mental health, public health, and emergency medical services, and hospital personnel is necessary. Collaborative triage involving mental health and medical personnel is necessary. Access to medical services will have to be prioritized. Access to psychological support services will need to be expedited. Media can be helpful in delivering crisis interventions and emotional support. This would include increased use of public service announcements, “800” crisis lines, media presentations, and web-based applications.
A well-known example of nuclear exposure occurred in 1986 at the Chernobyl power plant in Ukraine. 31 were killed due to acute exposure. 25,000 “liquidators” (soldiers, firefighters, clean-up crews) have died since then due to cancer, leukemia, and cardiovascular disease. Seven million people lived in the contaminated area (3 million children). 5.5 million still live in contaminated zones. Some have returned to the restricted areas because they prefer to live there.
Examples of CBRNE
Chemical Weapons
Chemical weapons are poisonous compounds that can be mixed into food or water supplies or spread by a bomb or spray. Chemicals tend to dissipate rapidly, making large-scale attacks difficult; the most likely assault is an isolated one, such as the 1995 Sarin-gas attack in the Tokyo, Japan subway. Examples are nerve agents (Tabun, Sarin, Soman, V agents); vesicant (blistering) agents (Mustard gas, Lewisite, Phosgene Oxime); blood agents (hydrogen cyanide, cyanogens chloride, arsine); and choking agents (chlorine, phosgene, diphosgene). These agents may be weaponized via liquid, vapor, or aerosol form. Each agent enters the skin or lungs and may quickly incapacitate or kill. Antidotes exist for blood and nerve agents. Such an attack requires first responders to wear personal protective equipment (PPE) and use decontamination processes. For protective measures, have emergency supplies of food and water in case public supply is disrupted or if you are instructed to stay indoors. If you see signs of a chemical attack, such as people choking or tearing, move upwind from the area. If you must remain in place, seal vents, doors and windows.
Biological Weapons
Biological weapons are bacteria, viruses and toxins spread through spraying or contamination of food or water. These agents are difficult to grow and disperse, but such an attack could kill thousands. Bacteria, viruses, and toxins can be weaponized or released to cause widespread illness and death. The more prominently known are anthrax, tularemia, plague, and smallpox. These agents are easy to acquire, synthesize and use. Small amounts can kill hundreds of thousands of people in a metropolitan area. Concealment, transportation, and dissemination are easy. Agents are difficult to detect or protect against; they are invisible, odorless, and tasteless. Variables that can alter the effectiveness of a delivery system include particle size of the agent, stability of the agent under desiccating conditions, UV light exposure, wind speed, wind direction, and atmospheric stability. For protective measures, listen to the news reports and follow instructions for receiving care, vaccines and antibiotics. A surgical mask rated N95 can help protect against contagious diseases.
Radiological/Nuclear Weapons
These agents are from the detonation of nuclear devices (suitcase atomic bomb) that disperse radioactivity over an area determined by the initial blast, and wind direction/speed. Those not killed by the initial blast that did not have shielding would die of acute radiation poisoning. Those with some form of shielding or at a sufficient distance would have a chance of survival with treatment. For example, a dirty bomb is a crude method of scattering low-level radioactive materials. It uses conventional explosives like dynamite along with radioactive material gathered from X-ray machines or food irradiation plants. Reaction times can be minutes to years; injuries may be due to the explosion itself. Acute radiation poisoning is unlikely. Symptoms include vomiting, diarrhea, skin burns, weakness, and fatigue. Local contamination depends on the size of the conventional explosive, the amount and type of radioactive material used, and weather conditions. Prompt detection of the type of radioactive material involved is important in advising the community on protective measures. Subsequent decontamination of the affected area could involve considerable time and expense. Those outside of the immediate blast zone need to put whatever form of shielding is available between themselves and the blast. Those inside the blast zone should stay indoors, dispose of clothes, wash thoroughly, and seek medical treatment.
Explosive Weapons
Explosive incendiary devices (traditional explosives or improvised devices) may be concealed or delivered by a variety of means. These WMDs instantly kill or injure people within the immediate vicinity of the bomb; structural damage or failure can lead to further casualties. Examples are traditional (TNT) and high-energy (C-5) explosives. There are also non-traditional explosives (fertilizer bombs), and fuels (propane tanks, jet fuel, gasoline). Delivery methods include car bombs, backpacks, suicide attacks, and planes. The explosive weapon characteristics vary. They can be large (as in 9/11) or small (Madrid) in scope. The attack creates widespread anxiety within the community. It typically occurs in busy public places and involves a constant media presence through the response. The attack can result in non-acute physical symptoms that last well into the future, including: sleep disturbance, fatigue, and difficulty concentrating. For protective measures, run from the blast if possible or “duck, cover and hold” if present in the vicinity of where an explosion occurs, seek medical treatment for injuries; avoid the impact zone until it is safe to enter the zone.
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Chapter Four—Anxiety Disorders After a Disaster
Disasters have major impacts on life for many individuals. Anxiety may increase visits to primary care providers for vague complaints (fatigue, insomnia). Anxiety may present at ASD, PTSD, or another anxiety disorder. There are many symptoms of anxiety and arousal, including:
Anxiety
Chest pain/tightness
Diaphoresis
Dyspnea
Faintness
Fatigue
Flushing
Hyperventilation
Light-headedness
Memory problems
Muscle tension/ache
Nausea
Pain
Pallor
Palpitations
Paresthesias
Sleep disturbances
Tachycardia
Urinary frequency
Vomiting
Post-disaster pathology can be affected by several factors: the degree of exposure to the disaster; the size and scope of the disaster; death toll and the number of other casualties; construct of the disaster; and existing pathologies, such as personality and mood disorders, and substance abuse.
Screening for ASD/PTSD is important. People can experience marked psychological and biological reactions after a disaster. A terrorist attack may exacerbate post-disaster reactions. Primary and emergency care clinics will likely see stress-related emotional and physical symptoms or worsening of existing health conditions (especially among victims without mental health care). About 30% of exposed individuals will display some disorder, experiencing flashbacks or nightmares; emotional numbing; persistent symptoms of autonomic arousal; and the desire to avoid reminders of the trauma. Normal and abnormal group and individual responses will be discussed before going to screening.
Normal survival reactions for groups include loss of confidence in government and other institutions; anger at authority figures; scapegoating; social isolation; and demoralization. Abnormal group reactions include mass panic; symptoms of anxiety and arousal, which may be misattributed to the effects of some WMD or medical illness; a mass outbreak of contagious symptoms with no identifiable cause. Adaptive, helpful prosocial behaviors are actually typical, not rare.
For individuals, immediate responses include strong emotions; signs and symptoms of autonomic arousal; and initially, improved cognitive performance (focusing is adaptive for rescuers, for example). Later as stress persists, cognitive problems may occur, and thinking may become disorganized, with a “fight or flight” response. In the short term, which lasts from one week to several months, normal individuals will begin to experience intrusive symptoms (recollection of the event, abnormal startle response, hypervigilance, insomnia, and nightmares). These survivors may have increased visits to primary care for vague symptoms such as dizziness, headache, nausea, and fatigue. Anger, irritability, apathy, grief, mourning and social withdrawal are also common. Over the long term, which may last up to a year or more after the disaster, victims may feel disappointed and resentful if hopes for aid and restoration are not met. The sense of community may weaken as individuals focus on personal needs. Most people will rebuild their lives and focus on future challenges. Some will experience post-traumatic symptoms, as well as extended grief and mourning. All who have exposure to the disasters are at potential risk: immediate victims, family members and friends, rescue workers, health care workers, and others in the local community. Other problems associated with the disaster include depression, grief, bereavement, increased substance abuse, increased domestic violence, and anxiety disorders. Patients may report fatigue, trouble sleeping, loss of appetite, or irritability rather than depression or anxiety.
Why screen for PTSD? Few clinics systematically identify trauma survivors who have related health problems. Primary care practitioners will likely see more traumatized individuals, both soon and long after a disaster or terrorist attack. Many patients will present with physical symptoms rather than mental ones, such as fatigue or trouble sleeping, not anxiety or depression. PTSD is associated with increased health complaints, use of health services, morbidity, mortality, and high levels of functional impairment. PTSD is also associated with alcohol abuse, marital problems, unemployment, and suicidal ideation. Traumatic stress brings about hormonal, neurochemical, immune functioning, and autonomic nervous system changes that can affect physical health. Life-threatening medical conditions can cause or exacerbate PTSD.
Screening instruments
If the disaster was recent and you know the patient, ask if he or she was affected in any way by the events. You may also utilize self-report screening instruments. It may also be helpful to cover general trauma, as in the Life Events Checklist (listed below). Some of these screens are available for free on the Internet. One such instrument is the Primary Care PTSD screen, which consists of four yes-or-no questions, which can be given before the appointment or asked during the appointment. The results are positive is a patient answers yes to any three questions. Ask, “In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you…”
Have had nightmares about it or thought about it when you did not want to?
Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
Were constantly on guard, watchful, or easily startled?
Felt numb or detached from others, activities or your surroundings?
Another brief, helpful test is the CAGE, for alcoholism.
C: Have you ever felt you should Cut down on your drinking?
A: Have people Annoyed you by criticizing your drinking?
G: Have you ever felt bad or Guilty about your drinking?
E: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?
Life Events Checklist
Listed below are a number of difficult or stressful things that sometimes happen to people. For each event check one or more of the boxes to the right to indicate that: (a) it happened to you personally; (b) you witnessed it happen to someone else; (c) you learned about it happening to someone close to you; (d) you’re not sure if it fits; or (e) it doesn’t apply to you.
This listing is provided as an example, and is not complete:
Natural disaster
Fire or explosion
Transportation accident
Serious accident at work, home, or during a recreational activity
Exposure to toxic substances
Physical assault with or without a weapon
Sexual assault
Patient responses
Review
the results of the screening instrument; you need not go into detail.
If someone screens positive, also screen for suicidal ideation
(anxious people also attempt suicide). If you believe the patient
needs a referral, suggest a consultation rather than treatment, such
as “I think you have this, but I’m not sure. I’d like you to
see someone who is more familiar with PTSD.”
It is important to
normalize the idea of treatment; explain that treatment involves
education, learning to cope with symptoms, and so on. Provide
handouts about PTSD. Follow up at the next session. If the patient
hasn’t followed through, ask, “What kept you from doing so?”
or “What are your thoughts about treatment?” You may wish to
include the patient’s spouse or significant other, if appropriate,
and if the patient gives permission. Ask the patient how he or she
copes with the symptoms. If there are on-going threats to the
patient, determine if reporting is legally mandated. Help the
patient with a plan to file a report in a way that increases his or
her safety, if needed.
Treatment
Treatment involves education, pharmacotherapy, and psychotherapy, which can all be provided locally. NAMI and The National Center for Post-Traumatic Stress Disorder both have informational websites:
Pharmacotherapy can involve serotonergic agents, tricyclic antidepressants, antiadrenergic agents (may be effective for autonomic hyperactivity), and benzodiazepines (used extensively, but efficacy has not been proven). Psychotherapy helps the patient to break the pattern of reexamining the traumatic event. It also provides education, teaches other ways of coping, and helps the patient improve relationships.
Unique Features of Biologic and Chemical Agents
Initially, the agents may be invisible and odorless. Initial symptoms may resemble common illness and go undetected in individual cases. Many agents may be unfamiliar to U.S. physicians and may not be promptly diagnosed. It may also take time before community public health agencies see enough cases to discern a pattern. Slowed response and treatment times are possible. Some agents may cause gross deformities. The use of protective gear may increase the sense of isolation and the incidence of psychiatric casualties and may decrease intragroup communication. People may fear contagious spread of disease; behavioral problems may result. All conditions need rapid diagnosis and prompt treatment to minimize both medical and neuropsychiatric complications. Long-term effects may include disfigurements or impairments; scarring; blindness; encephalitis with resulting brain damage; depression and other mood disorders; and PTSD, with ensuing effects on families of victims and communities.
Hospitals and communities must develop emergency and disaster plans and practice them to reduce the likelihood of chaos and behavioral problems after a disaster. Hospitals, clinics, and emergency rooms will most likely be overwhelmed with people seeking treatment. Many patients may present with physical symptoms that either reflect the direct effects of a biologic or chemical agent or the psychological response to the agent.
Effects of Selected CBRNE’s
Different chemical agents produce different syndromes/symptoms. Organophosphates (nerve agents such as Sarin, Soman, VX and Tabun) produce depression, sleep disturbance, impaired cognition, and delirium.
Atropine (used for treating symptoms of organophosphates) can produce blurred vision, urinary retention, dry mouth, tachycardia, delirium, suppression of sweating, psychosis and cognitive impairment.
Cyanide can produce anxiety, confusion, hypoventilation, and giddiness.
Blistering agents, such as mustard gas, produce blindness, burnes, and distress over disfigurement.
Phosgene inactivates charcoal; it also causes a suffocating sensation as if the lungs were filling with fluid.
Biological agents such as anthrax and brucellosis can cause meningitis, irritability, headaches, and depression.
Q Fever can cause malaise, encephalitis, hallucinations, and fatigue.
Finally, Botulinum toxin has a lengthy recovery time, which can produce depression.
*****
Chapter Five—Coping Among Survivors: Medically Unexplained Physical Symptoms, Coping Styles, and Long-term Psychosocial Implications
Medically Unexplained Physical Symptoms (MUPS)
After a disaster, some individuals will present with psychological responses. Two groups present in triage: (1) the non-distressed require no further medical treatment; (2) the emotionally distressed may need to be monitored for disruptive behavior. In triage, treat physical injuries first. After treatment, patients may be moved away from intense triage activity but near the Emergency Department (ED) to permit further treatment if necessary. Patients may require rest, education and support and should be reassured that symptoms of autonomic arousal and anxiety are normal reactions to abnormal situations.
In the short term treatment of MUPS, people should be informed about the scope of the disaster. The role of the agent should be minimized. Individuals should be separated to minimize the spread of symptoms by sight and sound. Leaders need to be calm, authoritative, supportive, and non-confrontational. Some people may require medications for agitation, insomnia, or psychosis. Antipsychotics are effective for delirium or psychosis resulting from WNDs. Benzodiazepines can be used for anxiety and insomnia. Beta blockers and alpha agonists may be helpful for decreasing autonomic arousal. For insomnia, medications that preserve sleep architecture are preferred.
For long term treatment of MUPS, a collaborative approach, focusing on behavioral outcomes, is preferred. Patients are suffering psychological distress; they need to have someone listen to their own explanations for their symptoms. Use a “less is more” approach; diagnostic tests have a low yield. Avoid quick labels, such as “PTSD;” instead, keep a “medically unexplained” diagnosis. Ask the patient to consider a mental health consult early in the process, perhaps for “stress management,” or “issues in the management of a chronic condition.” Other organizations can be helpful: the Red Cross, religious leaders, private practice mental health specialists, and community mental health centers. These resources strengthen the community’s social organization and decrease the burden of primary care facilities. These Internet resources offer printable handouts and articles free of charge:
Red Cross
CDC
Uniformed Services University of the Health Sciences
http://www.usuhs.mil/psy/disasteresources.html
Coping Styles
Coping styles are the behavioral and psychological methods that people use to master, tolerate, reduce, or minimize stressful events. There are different categories for coping styles. Problem-focused coping strategies use actions intended to alleviate stressful circumstances. Emotion-focused coping strategies involve efforts to regulate the emotional consequences of stressful or potentially stressful events. Active coping involves behavioral or psychological responses designed to change the nature of the stressor itself. Passive coping involves activities or mental states that prevent directly addressing stressful events. Passive coping can also include activities that may provide more information without leading to action. These can all be useful coping strategies, and most people use a combination of them to deal with stressful events. Coping strategies that are not useful, and may even be harmful, are dangerous coping, which involves attempting to get closer to a disaster (not to help, but simply to get nearer). Avoidant coping involves engaging in activities to get one’s mind off the disaster, instead of taking appropriate actions (such as using drugs). Both dangerous and avoidant coping may expose an individual to greater risk.
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