Transcript TAKE TIME TO TALK” - Virginia Commonwealth University

Mental Health in a
Time of Terror
Robert K. Schneider, MD
Assistant Professor
Departments of Psychiatry,
Internal Medicine and Family Practice
Virginia Commonwealth University
The Medical College of Virginia Campus
Outline
• Review Studies of Terror
• Disease Model
• Health Model
• What can we do?
Models of Coping
Disease Model
Trauma/Stressor + Person = Disease
Health Model:
Trauma/Stressor + Person = Health
Disease Model
PTSD: Posttraumatic Stress Disorder
Reexperiences
Hyperarousability
Avoidance
Major Depression
Depression
Anhedonia
Oklahoma City Bombing
North et. al. JAMA 1999
April 19, 1995
167 dead
684 injured
“the most severe incident of terrorism
ever experienced on American soil”
Oklahoma City Bombing
North et. al. JAMA 1999
• 45% postdisaster psychiatric disorder
34.5% PTSD
22.5% Major Depression
9.4% Alcohol Use Disorder
Oklahoma City Bombing
North et. al. JAMA 1999
• Predictors
–Any predisaster diagnosis: 66%
–Female sex: 55% vs. 34%
–94% of PTSD had early avoidance
and numbing symptoms
SCUD Missile Attacks
Israel, 1991 Gulf War
Laor et. al. Am J Psychiatry 2001
• 107 families exposed
• Half of the families displaced
• Mother’s functioning and Children’s
Symptoms
• 3 studies: 6 and 30 months and 5 years
SCUD Missile Attacks
• Over time symptoms decrease in
residentially stable children
• Mothers’ reaction correlated with
young children’s symptoms most
• Family cohesion highly correlated
with children’s well being
SCUD Missile Attacks
• Mother’s functioning:
– Ability to relate to child
– Coping skills
– Symptoms
• Children’s symptoms
– PTSD symptoms
– Avoidance
SCUD Missile Attacks
• Younger children highly correlated with
mother’s symptoms
• Displaced families had more symptoms
(longer time: more problems)
• Family functioning impacted displaced more
than residentially stable children
• Mothers coping with adaptive defenses
correlated with resolution of children’s
symptoms
PTSD in the Community
Breslau et. al. Arch Gen Psychiatry 1998
• 90%: one or more traumas
• Most prevalent trauma:
unexpected death of a loved one
Categories: traumatic events
• Personally experienced assaultive violence
– 37.7%
• Other personally experienced injury or
shocking experience
– 59.8%
• Learning about traumas to others
– 62.4%
• Sudden unexpected death of a loved one
– 60.0%
Conditional Risk
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Rape 40-60%
Combat 35%
Violent Assault 20%
Sudden death of a loved one 14%
Witnessing a traumatic event 7%
Learning about trauma to others 1-2%
Rick Factors for PTSD
Brewin et al J Consult Clinical Psych 2000
Meta analysis Civilian and Military
(Weighted averages)
–Lack of Social Support: 0.40
–Post trauma life stresses: 0.32
–Trauma Severity: 0.23
Health Model
• No predisaster disorder (OCB)
–70% remained without disorder
• Stability and High Functioning (SMA)
–No children had symptoms at five
years
Health Model – Defenses
Adaptive Coping
Anticipation
Self-assertion
Affiliation
Self-observation
Altruism
Sublimation
Humor
Suppression
Adaptive Coping
SCUD Missile Attacks
• “Mother’s capacity to control
mental images had a direct effect
on her symptoms”
Health Model – Defenses
Maladaptive Coping
Devaluation
Acting Out
Denial
Omnipotence
Dissociation
Apathy
Displacement
Complaining
What can we do?
Self
Family
Community
What can we do?
SELF
• We are in a time of stress and transition
• Use our adaptive defenses
• Avoid our maladaptive defenses
• Regulate our exposure to potentially
traumatic information:
– Television, Internet, Newspaper
• Be where you need to be
What can we do?
FAMILY
• Model adaptive behavior
• Be present and available
• Maintain Boundaries
– Clarity
– Rules
• Monitor
What can we do?
Community
• Model adaptive behavior
• Be present and available
• Maintain Boundaries
– Clarity
– Rules
• Monitor
Conclusions
• We are living in a time of stress and
transition
• Diseases to prevent include PTSD
and Major Depression
• Young children are particularly
vulnerable
• Coping is an active, conscious
process that occurs on multiple levels