Transcript Bioterrorism: It`s all in your head - Northwest Center for Public Health

Mental Health
Aspects of
Bioterrorism
Edward A. Walker, MD
Professor and Vice Chair, Department of
Psychiatry and Behavioral Sciences
Chief, Psychiatric Services, University
of Washington Med Center
Overview
• Emotional consequences of what has happened
and what may still come
• Distinguishing normal and abnormal responses
• Psychiatric disorders that accompany trauma
exposures
• Meeting needs of special populations
• Practical strategies for managing the emotional
sequelae of trauma and anxiety in your practice
• Your cases and observations
Labor Day Weekend 2001:
the last of the “good old days”
• What were you doing that weekend?
• What was your world like?
• What were your assumptions about what was
safe?
• What do now do differently?
• What do you no longer do?
• How did this tragedy change your world?
Traumatic events
 Traumatic events are usually sudden and unexpected. Whether
single brief events or chronically repeated, they overwhelm our
ability to cope and adapt.
 Examples can include rape, mugging, assault, war, car
accidents, disasters, viewing a friend being injured, and
physical or sexual abuse.
 Children are more vulnerable than adults to traumas, because
they have fewer skills and less experience with life. Adults can
predict and avoid events that take kids by surprise.
 But adults can also be overwhelmed by situations or events
that occur suddenly and are beyond their control.
 When this happens, a number of predictable reactions occur.
These reactions to trauma are normal responses to abnormal
events, and may produce Post Traumatic Stress Disorder
Responses to traumatic events
• Each individual is unique
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degree of exposure
nature of exposure
developmental timing of exposure
personal meaning of the event
ability to understand what occurred
available resources
ability to cope
degree of distress
Coping cycle
stressor
coping
strategy
appraisal
resources
Once you’ve been sensitized:
dissecting the terror in bioterrorism
• Before the next event:
– Uncertainty: what next, to whom, when, where, how?
– Changing the way you live to minimize exposure
– 1000 small wounds
• During the next event:
– Degree of possible dramatic harm
– Direct effects to victims
– Vicarious trauma
• After the next event:
– life disruption and fear of future events
– anxiety about repetition
– overcoming denial: “I’m no longer safe”
What to look for in your clinic
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Fear
Anxiety (it’s different from fear)
Depression
Medically unexplained symptoms
Family and marital distress
Occupational disability
Substance and alcohol use
Increased demand for sedative hypnotics
Post Traumatic Stress Disorder symptoms
US News and World Report
Title: The Second Wave
Author(s): Amanda Spake; Marianne Szegedy-Maszak
Issue Date: OCTOBER 8, 2001
Words in article: 1375
Lead Paragraph: What would have been a simple diagnosis for
doctors at Boston's Massachusetts General Hospital has
suddenly become murky. Are the fatigue, respiratory distress,
and insomnia symptoms of a viral infection that has been
sending Bostonians to bed? That's what physicians would have
assumed a month ago. But now it's equally plausible that these
same symptoms are signs of the profound psychological stress
people are feeling after the recent terrorist attacks.
Relationship of terrorism to
psychiatric disorders
• Consequences of direct exposure to a severe
stressor: Post Traumatic Stress Disorder
• New learned fear behaviors: phobias
• Decompensation of any existing psychiatric
disorder, especially depression and anxiety
• Increase in medically unexplained physical
symptoms
• Increase risk for substance/Etoh use
PTSD definition
A. Exposure to a traumatic event in which both of the
following were present:
1. The individual experienced, witnessed, or was confronted
with an event of actual or threatened death or serious injury
2. The event evoked a reaction of intense fear, helplessness
or horror
B. Persistent re-experiencing of the event
Intrusive recollections
Recurrent distressing dreams
Acting or feeling as if the events were recurring
Distress on exposure to cues that resemble event
Physiological reactivity after exposure to cues
C. Persistent symptoms of avoidance and numbing
Efforts to avoid thoughts, feelings, our conversations
Efforts to avoid activities, places, or people
Inability to recall important aspects of the trauma
Diminished interest or participation in activities
Feelings of detachment or estrangement
Restricted range of affect
Sense of foreshortened future
D. Persistent symptoms of increased arousal
Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hypervigilance
Exaggerated startle
E. Duration of symptoms for more than 1 month
F. Clinically significant distress and disability
What is known about PTSD?
• Prevalence rate of about 8 percent of general
population (Kessler et al, NCS, 1995)
• Significantly higher in selected populations were risk
of trauma is much higher
• Associated with increased numbers of medically
unexplained symptoms and functional impairment.
• High comorbidity with other psychiatric disorders
such as alcohol and substance abuse, affective
disorders and other anxiety disorders
• little is known about the magnitude of health care
costs and utilization that are specifically attributable
to PTSD in medical settings
PTSD Scores in 1225 Women HMO Members
80
71%
60
40
23%
Percent
20
7%
0
LOW
MODERATE
HIGH
PTSD score
Walker EA, Katon W, Russo J, Ciechanowski P, Newman E, Wagner AW: Health Care Costs Associated
with Post Traumatic Stress Disorder Symptoms in Women, Archives of General Psychiatry (in press)
Functional Disability and PTSD
100
90
80
PHYSICAL
70
ROLE
EMOTIONAL
60
SOCIAL
50
PAIN FREE
Mean
40
MENTAL HEALTH
30
VITALITY
20
HEALTH PERCEPTION
LOW
MODERATE
HIGH
PTSD score
Walker EA, Russo J, Katon, Newman, E: Adult health status of women HMO members with PTSD symptoms,
Submitted, American Journal of Psychiatry
Walker EA, Gelfand A, Katon W, Koss M, Von Korff M, Bernstein D, Russo J: Adult health status
of women HMO members with histories of childhood abuse and neglect. Am J Med 1999;107:332-9.
Physician coded ICD-9 diagnoses
LOW
(n = 843)
MODERATE
(n = 270)
HIGH
(n = 83)
F(2,1145)
Total mean
number of ICD-9
Diagnoses
1.5 + 1.6
2.0 + 1.8
2.4 + 2.1
13.54
p < .001
Number of minor
infectious
diseasesb
0.6 + 0.9
0.8 + 1.1
1.0 + 1.2
3.67
p = .026
Number of pain
disordersc
0.2 + 0.5
0.3 + 0.7
0.5 + 0.8
10.28
p < .001
Number of
mental health
diagnosesd
0.2 + 0.5
0.3 + 0.6
0.4 + 0.6
15.41
p < .001
Number of other
diseasese
0.3 + 0.6
0.4 + 0.7
0.4 + 0.7
1.44
p = .24
Unadjusted Health Care costs for 1225 Female
Group Health Members with PTSD symptoms
Primary Care
Specialty Care
Emergency Care
Pharmacy
Mental Health
Total Outpatient
Inpatient
Total Costs
LOW
MODERATE
HIGH
N=843
N=270
N=83
337 + 396
(237)
267 + 584
(0)
18 + 134
(0)
160 + 406
(66)
35 + 190
(0)
1352 + 3236
(609)
294 ± 2032
(0)
432 + 494
(319)
261 + 512
(0)
31 + 161
(0)
240 + 393
(112)
150 + 394
(0)
1590 + 2112
(829)
189 ± 1130
(0)
510 + 485
(405)
355 + 615
(108)
110 + 445
(0)
331 + 578
(128)
162 + 502
(0)
2603 + 4939
(1283)
457 ± 1750
(0)
1646 ± 5156
(609)
1779 ± 3008
(829)
3060 ± 6381
(1283)
Meeting special needs
Who is affected?
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You
Your family
Your fellow providers
Your health delivery system
Direct victims
Vulnerable patients
Children
You
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Physician heal thyself
How do you feel?
Are you distracted, worried about anything?
Have you had a traumatic experience before?
Do you know your limits?
Can you ask for help from colleagues?
Do you feel you have to be strong and a
leader at all costs?
Your family
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What do you think you family is feeling?
Are you worried about them?
What would you do if they became infected?
Do you feel you can protect them while you
work?
• Does anyone have a previous experience to
a traumatic event?
• Are you worried about your children?
Your fellow providers and staff
• Do you feel you have good team support?
• Have you figured out how to work as a team without
fatiguing?
• Are you worried about any of them in particular?
• Have any of them had a previous traumatic
experience?
• Do you know their vulnerabilities?
• Do you have a way of signaling distress to each
other?
• Are you front line staff fearful or distracted?
READ ME FIRST!
Dear colleagueBefore you rush off to start doing anything else, please take a few moments to orient yourself with this note. It will help
with everything else you do in the next few hours. You’re facing a situation where you and everyone around you will be stressed.
You’ll be trying to meet the needs of patients, colleagues, and family at a time when you’re worried about your loved ones. It’s likely
that these needs will be unpredictable, somewhat intense and competing with each other.
First, stop and take a deep breath. You got this packet because we know we can count on you to do a great job. We,
your co-workers and colleagues, have confidence that you can contribute a great deal to resolving this crisis, no matter what your job
is. Nothing you will do today is insignificant or unimportant.
Before you turn to any patient care or guidance of staff, think about yourself first. What are you going to need to get
through the next few hours? You won’t be able to help us all if you don’t relax a bit and take care of yourself first. You’ll need to pace
yourself – take some breaks from time to time so you don’t burn out right away. After you’ve done some initial triage of your area,
contact your loved ones and make sure they’re ok. Let them know you’ll be with them as soon as you can, and stay in touch with
them throughout the crisis. If you can’t reach them right away you can ask Staff Support Services to help you make contact.
Watch those around you. They may not be as skilled at meeting their own needs as you are. Instead of doing
everything yourself, delegate some tasks and observe how others are doing. Do you see anybody pushing too hard or nearing
burnout? Is there anyone appears distracted by a family emergency who might benefit from Staff Support Services? Ask how each of
your colleagues is doing from time to time. If anyone looks stressed out, take that person aside and suggest a break. Don’t forget to
ask yourself the same question from time to time.
This is going to be challenging for all of us, but we’re going to get through this as a family the way we always do. The
UWMC is committed to keeping you informed and up to date about what’s happening and how it affects you, you loved ones and your
work. Thanks for your dedication and commitment to our patients, our staff and our mission.
Okay, you’re set. Put this note in your pocket and take it out from time to time today. We’ll see you on the front lines.
Take care of yourself!
Your friends and colleagues
Your health delivery system
• Do you have confidence that your health care
system will support your work?
• Is it ready for this emergency?
• Do you fear things might be hopeless?
• Is the leadership of your system ready?
• Will the system let you work effectively?
• Are you confident you’ll have what you need?
Direct victims of trauma
• Can you deal with hysteria and panic?
• Are you confident in your ability to reassure
and calm?
• Can you effectively help them deal with
uncertainty?
Vulnerable patients
• Previous exposures to trauma
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Rape
Military service
Accident trauma
Murder, civil violence
Violent crime exposures
Domestic violence
• Early childhood abuse or neglect
– Poor caretaking, limited trust
– Difficult to establish and maintain therapeutic alliances
Children
• After any disaster children are most afraid that:
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the event will happen again.
someone will be injured or killed.
they will be separated from the family
they will be left alone.
• Helping them cope
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Assume that they know that a disaster has occurred
Talk with them calmly and openly at their level
Ask what they think has happened and about their fears
Limit media re-exposure
Share your own fears and reassure
Allow expression in private ways (e.g., drawing, journals, legos)
Emphasize normal routine
Continue to monitor over time – stay involved in their recovery
Children
• Symptoms of distress in children
– Depressed or irritable mood
– Sleep disturbances, including increased sleeping, difficulty
falling asleep, nightmares, or night-time wakening
– Changes in appetite, either increased or decreased
– Social withdrawal
– Obsessional play – drawing or talking about the events –
that interferes with normal activities
– Hyperactivity that wasn’t present earlier
– Decreased school performance
– Increased dependence and clinginess, sometimes
regression
Practical management strategies
Model
• Predisposing factors
– biopsychosocial patient characteristics which set
the stage (the fire trap)
• Precipitating factors
– establish the illness process (the match)
• Perpetuating factors
– maintain the illness process (additional fuel)
Model
Predisposing
Factors
Precipitating
Factors
Perpetuating
Factors
Case Example
Mary is a 42 year-old woman who visits you on
August 20, 2001 to establish care at your practice.
Currently, she is in no distress, and would like her
yearly gynecological examination. The visit is pleasant
and unremarkable.
Predisposing Factors
During the review of systems she reports a
previous history of persistent diarrhea and joint pain,
currently inactive. Her family medical history is
remarkable for a history of alcoholism in her father and
mother which sometimes led to occasional emotional and
physical abuse. You get the sense that her self-esteem
is on the low side, and you realize that you had some
difficulty establishing a warm doctor-patient relationship.
She leaves the visit with no planned follow-up.
Precipitating Factors
On September 25 she presents in acute distress, stating
that she is anxious and upset. She and her husband had a
major fight last night. He has been abstinent from alcohol for 5
years now, but came home drunk every night for the past week
after finding out that he is being activated by the National
Guard. He has become increasingly emotionally abusive. Last
night he struck her. She is now very upset and presents with
signs and symptoms of diarrhea and joint pain. As you work up
her physical complaints, you also begin to make her aware of
your belief that her physical problems may be related to her
marital distress. You find her somewhat defensive and angry
and she fails to appear for several appointments.
Perpetuating Factors
Over the next month, on her own, she sees several
specialists who label her physical symptoms as “colitis”
and “fibromyalgia”. The specialists confirm her belief in
the organic foundation of her symptoms. She now is
being seen on a regular basis by a gastroenterologist, a
gynecologist and a rheumatologist. By the end of the year
she has had a negative diagnostic laparoscopy,
increasing fatigue and functional disability, and is now
applying for Social Security disability assistance for her
chronic medical problems. Her marriage has failed. She
avidly follows the internet self-help groups on fibromyalgia
and chronic fatigue. You find yourself increasingly unable
to influence this vicious cycle of disability and
somatization.
Predisposing Factors
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biological diatheses (e.g. motility)
pre-existing exposure to illness or disease
previous maltreatment or exposure to trauma
low resilience, poor coping ability
low social support
chronic social stress
comorbid medical disease
low psychological mindedness
Precipitating Factors
• medical disease
• psychiatric disorder
• social, fiscal or occupational stress
• changes in social support
• re-experienced trauma
• dietary factors
Perpetuating Factors
• disability-induced vicious cycles
– decreased self confidence
– decreased activation, wellness
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chronic somatization
social isolation
primary gain (intrapsychic)
secondary gain (interpersonal)
tertiary gain (interpersonal)
The Plan: Work Backwards
• get control of perpetuating factors
– tertiary prevention
• limit precipitating factors
– secondary prevention
• decrease power of predisposing factors
– primary prevention
Controlling Perpetuating
Factors
• decrease functional disability
– symptom reduction a better endpoint than cure
– increase positive activities, social contacts
– medications
• decrease chronic somatization
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deal with illness beliefs (figure-ground issue)
regular medical visits
“your job is to fix me”
doctor patient collaboration
Controlling Perpetuating
Factors (cont’d)
• deal with reinforcers (gain)
– emotional, financial
• stop re-creations of trauma
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consultation referral
deal with interpersonal problems
use of opiates
recurrent medical procedures/surgeries
Limiting Precipitating
Factors
• treat comorbid medical/psychiatric diseases
• stress management
– change what can change, accept what can’t
– appraisal, resources, coping (activation)
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increase social support
decrease exposures to trauma
focus on wellness (exercise, diet)
decrease chronic social stress
Decreasing Power of
Predisposing Factors
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accepting biological diatheses as given
assessing previous reactions to illness
awareness of previous maltreatment
teaching new coping skills
increasing social support
treating comorbid medical disease
practical “one day at a time” plans
consultation for psychotherapy / meds
Behavioral support
• Media abstinence
– CNN: “All anthrax, all the time”
– “Breaking news! This just in….”
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Value of print journalism (e.g., Newsweek)
Facilitated discussion groups
Becoming informed vs. obsessional
Defining “safe areas”
Cognitive therapies
– exposure, problem solving and cognitive-behavioral
• Behavioral extinction as a therapeutic process
• Supporting grieving
Pharmacological Support
• Proper diagnosis
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Panic disorder, major depression, PTSD
Anxious personalities and generalized anxiety
Resuming control of substance and alcohol abuse
Observe for relapse of previously stable disorders
Limited and selective use of anxiolytics
Role for Buspar?
Antidepressants and main approach
Short term hypnotics
Keeping things in perspective
• Risk of being struck by lightning in any given year - 1 in 750,000.
• Risk of dying from an earthquake or volcano - 1 in 11 million
• Risk of having a car accident – 1 in 8
• Risk of dying from dog bite - 1 in 20 million
• Risk of dying from snakebite - 1 in 36 million
• Risk for African for contracting Ebola Virus - 1 in 14 million
• Risk of adolescent dying in car accident - 1 in 3500
• Risk of adolescent dying from suicide - 1 in 7700
• Risk of being murdered - 1 in 11,000
• Risk of being robbed - 1 in 400
• Risk of being burglarized - 1 in 50
• Risk of being wiped out by a comet or meteor impact - 1 in 20,000