Transcript Document

NJ Preparedness Training Consortium
Psychological Aspects of
Bioterrorism
& Disaster Response
For Nursing Professionals
The Ultimate Tool of The
Terrorist…
• Is not chemical, biological, nuclear or
radiological…….
It is psychological, Terror of Fear
Officials Must Consider the
Possibility of….
•
•
•
•
Extreme fear and panic
Blame and mistrust of authorities
Mass Sociogenic Illness
Misattribution of Normal Arousal
Understanding Terrorism
• The goal of terrorism is the creation of
extreme fear, destroying the individual
and communal sense of safety and
security.
Assisting Victims of Terrorism
• Neighbor-Helping-Neighbor Approach
The Roll of Nursing in the
Era of Bioterrorism
As one of the most trusted
professions in America, nurses are
uniquely positioned to provide
information regarding disaster
preparedness to the community.
November 14-16, 2003 CNN/USA Today/Gallup
The Roll of Nursing in the
Era of Bioterrorism
• Nurses must have a personal and
family disaster plan
How to Prepare for
National Emergencies:
What You Can Do
There are three initial steps that families can take:
1) Assemble an emergency supply kit
2) Develop a family communication plan
3) Learn more about the different types of
emergencies you could face
http://www.ready.gov
Emergency Kit Contents
• At least three days worth of water, including one gallon
per person per day for drinking and sanitation purposes
• At least a three-day supply of non-perishable food
• Prescription medications, a first aid kit and a first aid
manual
• One blanket, change of clothing and footwear per person
• Extra set of keys, a credit card, cash or traveler’s checks
• Flashlight and extra batteries/Battery-powered radio and
extra batteries
• Important documents like birth certificates
Family Communication Plan
Contact Name_______________________________
Telephone Numbers
Work______________________
Home______________________
Cell______________________
Out of Town Contact__________________________
Telephone Numbers
Work_____________________
Home______________________
Cell______________________
Neighborhood Meeting Place _________________
Meeting Place phone number___________________
Dial 9-1-1 for Emergencies
STRESS
• 43% of all adults suffer adverse health
from stress.
• 75 to 90 % of all physician office visits are
for stress-related .
• Stress is linked to the 6 leading causes of
death– heart disease, cancer, lung
ailments, accidents, cirrhosis of the liver,
and suicide.
Medical Care/Nurse
Police/Fire/EMS/Rescue Workers
• Individuals who traditionally work in
stressful environments often develop
various coping skills and strategies.
• Resilience & Recovery
- Core Identity Development/Personality
- Learned behavior & reactions
- Typical response to difficult situations
Medical Care/Nurse
Police/Fire/EMS/Rescue Workers
• Skills enable response to maintain a
level of function, especially during
difficult situations
• Approaches  can be considered
healthy or positive.
• Approaches  can have a negative or
unhealthy consequence.
Medical Care/Nurse
Police/Fire/EMS/Rescue Workers
• They can be appropriate for the
individuals involved.
• They may seem unusual or strange to
an outsider.
People can use rituals to find
comfort
-Family
-Friends
-Activity
-Religion/Spirituality
• Even the most experienced and skilled
professionals can be affected by their
work.
Acute Stress Vs. PTSD
• Difference
• Long term impact
Symptoms of a Stress Reaction
• Can last
–
–
–
–
a few days
a few weeks
a few months
and occasionally longer
• Support and understanding of
loved ones needed
Symptoms of a Stress Reaction
• Difficulty feeling love
and intimacy
• Difficulty taking interest
and pleasure in day-today activities
Symptoms of a Stress Reaction
• Professional assistance may be necessary
Types of Traumatic Events
•
•
•
•
•
•
Natural Disasters
Technological Disasters
Disasters of Human Intention
Other Interpersonal Violence
Sudden Traumatic Loss
Serious Medical Illness
What is a Traumatic Incident?
• A situation that is extraordinary and may
overwhelm coping mechanisms
Traumatic Stress reactions can be
broken down into 4 categories:
•
•
•
•
Emotional
Cognitive
Behavioral
Physical
Emotional
•
•
•
•
•
•
Feelings of shock
Anxiety
Guilt
Grief
Severe panic
Fear
•
•
•
•
•
Intense anger
Irritability
Agitation
Resentment
Shame
Cognitive
• Blaming someone
• Confusion
• Heightened or
lowered awareness
• Indecisiveness
•
•
•
•
•
Self-blame
Poor concentration
Memory problems
Nightmares
Intrusive images
Behavioral
• Change in activity
• Change in speech
patterns
• Withdrawal
• Emotional
outbursts
• Change in sexual
functioning
• Erratic movement
• Antisocial acts
• Suspiciousness/
paranoia
Physical
•
•
•
•
•
Fatigue
Nausea
Muscle cramps
Chest pain
Difficulty breathing
• Elevated blood
pressure
• Rapid heartbeat
• Thirst
• Headaches
TRAUMATIC STRESS
• Years ago, PTSD was
commonly called
“combat fatigue”
“soldiers heart” or “shell
shock.”
• Many people believed
that only soldiers or
other people who had
been in a war could get
PTSD.
Traumatic Stress
• Trauma is considered an event outside
the normal range of experience.
Learning from Our Past Experience
• The mental fallout from the Oklahoma City
bombings in 1995 didn’t peak until 12 to 18
months after the event.
Beyond the range of normal experience
The New York State Office of Alcoholism
and Substance Abuse Services
• reports that demand for alcohol and
drug treatment in New York City
increased immediately after the World
Trade Center attacks.
Phases of Disasters (Zunin/Myers)
•
•
•
•
•
PREDISASTER
HEROIC
HONEYMOON
DISILLUSIONMENT
RECONSTRUCTION
Trigger Events & Anniversary Reactions
1 to 3 Days TIME FRAME 1 to 3 Years
Who is at greatest risk
for severe stress
symptoms?
Groups Potentially Vulnerable to
Terror-Related Issues
Demartino 2001
•
•
•
•
•
Rescue workers
Medical Personnel
Leaders
“Hero”
Persons deemed
responsible
• Media
representatives
•
•
•
•
•
Elderly
Children
Single parents
Injured
Bereaved
Who is at greatest risk for severe
stress symptoms?
• Workers who directly experience or
witness any of the following during or
after the disaster are at greatest risk for
severe stress symptoms and lasting
readjustment problems
Who is at greatest risk for severe
stress symptoms?
• Life threatening danger or
physical harm (especially
to children)
Who is at greatest risk for severe
stress symptoms?
• Exposure to gruesome
death, bodily injuries, and
seriously injured persons.
Who is at greatest risk for severe
stress symptoms?
• Extreme environmental or
human violence or
destruction
Who is at greatest risk for severe
stress symptoms?
• Loss of home, valued
possessions, neighborhood,
or community
Who is at greatest risk for severe
stress symptoms?
Workers who experience:
• Loss of communication with or
support from close relations
Who is at greatest risk for severe
stress symptoms?
• Workers who experience:
–
–
–
–
Extreme fatigue
Weather exposure
Hunger
Sleep deprivation
Who is at greatest risk for severe
stress symptoms?
• Workers who experience:
– Intense emotional demands (such as
searching for possibly dying survivors
or interacting with bereaved family
members)
Who is at greatest risk for severe
stress symptoms?
• Extended exposure to
danger, loss,
emotional/physical strain
Who is at greatest risk for severe
stress symptoms?
• Workers who experience:
–
–
–
–
Exposure to toxic contamination
Gas or fumes
Chemicals
Radioactivity
Risk Factors:Summary
• Life threatening danger/physical harm
• Exposure to gruesome death and bodily injury
• Extreme environmental/human violence or
destruction
• Loss of home, possessions, community
• Loss of communication with, or support from,
close relations
The psychological problems that may result
from disaster experiences include:
• Physical reactions:
–
–
–
–
–
–
Tension
Fatigue
Edginess
Difficulty sleeping
Bodily aches or pain
Startling easily
Learning from Our Past Experience
• One year after the bombing, 3 times as
many residents of Oklahoma City reported
increased drinking as those in a control
community (Indianapolis).
• Elevated rates of substance abuse,
depression and suicide.
The psychological problems include interpersonal
reactions in relationships at school, work, in
friendships, interpersonal relationship, or as a
parent:
–
–
–
–
–
Distrust
Irritability
Conflict
Withdrawal
Isolation
– Feeling rejected or
abandoned
– Being distant
– Judgemental
– Over-controlling
What severe stress symptoms can
result from disasters?
• Most disaster rescue workers only
experience mild, normal stress reactions,
and disaster experiences may even
promote personal growth and strengthen
relationships.
Development of PTSD
• 1 out of every three rescue workers
experience some or all of the following
severe stress symptoms,  Post
Traumatic Stress Disorder (PTSD).
Severe stress symptoms
• Disassociation (feeling completely unreal
or outside yourself, like in a dream;
having “blank” periods of time you
cannot remember)
Severe stress symptoms
• Intrusive re-experiencing
– Terrifying memories
– Nightmares
– Flashbacks
Severe stress symptoms
• Extreme attempts to avoid disturbing
memories (such as through substance
use)
Severe stress symptoms
• Extreme emotional numbing (completely
unable to feel emotion, as if empty)
Hyper-arousal
•
•
•
•
Panic attacks
Rage
Extreme irritability
Intense agitation
Severe anxiety
• Paralyzing worry
• Extreme helplessness
• Compulsions or obsessions
Severe depression
• Complete loss of
–
–
–
–
Hope
Self-worth
Motivation
Purpose in life
TERRORISM
How is Terrorism Different?
• Terrorism wins only if you respond to it in the
way the terrorist wants you to…
• You can control the fate of the terrorist act in
terms of your response to it. Psychologically
speaking, the impact is up to you and not to
the terrorist.
Adopted from DeMartino 11/15/01and his interpretation of Franklin 1975
Psychodynamics of Chemical, Biological,
Nuclear, or Radiological Disasters(CBNR)
Referred to as “silent disasters”.
Dimension of “future orientation”: delayed
medical illnesses and the risk of birth defects
and other forms of genetic transmission.
Psychodynamics of CBNR
Disasters
• Disrobing in public.
• Wash-downs in chemical solutions (smells,
tastes, tactile experience, etc).
• Periods of isolation and observation
• The sight of responders in protective suits.
• General confusion or lack of information
shared with victims.
Terror Producing Aspects of
CBNR Events
•
•
•
•
•
Potential for high number of casualties
Limited availability of treatments
Uncertainty about effectiveness of treatments
Contagion
Dispersion of biological casualties
Silent Disasters…
Odorless, Invisible, Quiet
Long-Term Response to
CBNR Disasters
Long-term reactions include:
• Apathy.
• Resignation.
• Decrease tolerance to additional stressors.
• Irritability, hostility, aggression.
These reactions are more common than classic
PTSD-type responses. (Vyner, 1987)
Behavioral and Cognitive
Reactions to CBNR Disasters
Following toxic exposures to CBNR agents,
victims often report:
• Feeling trapped in their own bodies.
• Social isolation, being avoided by others.
• Obsessive thinking about the event.
• Damaged and helplessness.
Reactions to CBNR Terrorism
•
•
•
•
•
Unusual physical complaints
Overwhelming fear and anxiety.
Greater anger and mistrust.
Higher ratio of psychiatric:medical casualties.
High levels of healthcare-seeking behavior.
Panic, Hysteria and
Sociogenic Illness
Panic is a group phenomena characterized by
an intense, contagious fear.
Panicked individuals think only of their
own needs or survival.
Panic, Hysteria and
Sociogenic Illness
Panic is related to the perception that there is a
limited opportunity for escape, a high-risk of
being injured or killed, or that help will only be
available to the very first people who seek it.
.
Hysteria and Sociogenic
Illness
Epidemic Hysteria or Mass Sociogenic
(Psychogenic) illness refer to the social
phenomena of two or more people experiencing
a cluster of symptoms for which there is no
apparent medical cause.
The Psychological Reaction
to the Tokyo Sarin Attack
6 Months after the attack:
• 32% reported overwhelming fear.
• 28% with insomnia.
• 16% with depression.
• 10% fear us using the subway again.
Short Term Response
The Psychological Reaction
to the Tokyo Sarin Attack
• 72% habitually used sleeping pills.
• 57% complained of nightmares and
flashbacks.
• 77% used alcohol to calm their nerves.
Long Term Response
In 1999 survey of 1,247 respondents, more than ½
stated that they still suffered mental and physical
effects.
Psychological First Aid
• Long established principle of “buddy-care” in
U.S. military.
• Growing body of empirical evidence
demonstrating relationship between
physiological arousal and PTSD development
following crises.
• Recommended by the National Academy of
Sciences-Institute of Medicine and National
Center for PTSD.
Working Definition
“Psychological first aid (PFA) refers to a ser of
skills identified to limited the distress and
negative behaviors that can increase fear and
arousal.”
(National Academy of Science, 2003)
Psychological First Aid is…
• Psychological first aid (PFA) is as natural,
necessary and accessible as medical first aid.
• Psychological first aid means nothing more
complicated than assisting people with
emotional distress resulting from an accident,
injury or sudden shocking event.
PFA Can…
• Reduce physiological arousal.
• Mobilize support for those who are most
distressed.
• Facilitate reunion with loved ones and keep
families together.
• Provide education about available resources
and coping strategies.
• Incorporate effect risk communication
techniques.
Where to use PFA
•
•
•
•
On the Frontline of a disaster.
Points of Dispensing (POD’s).
ER’s and medical emergencies.
First Response activities.
PFA for Fear-based Reactions
Typical traumatic stress reactions are
characterized by:
•Arousal.
•Avoidance.
•Re-experiencing.
Early-phase (threat-present) reactions are
characterized by:
•Fear
•
•
•
•
•
Key Elements of Early
Intervention
Preparation.
Provision for Basic Needs.
Psychological First Aid.
Needs Assessment.
Monitoring of the Rescue and Recovery
Environment.
Continued
•
•
•
•
•
Outreach and Information Dissemination.
Technical Assistance, Consultation and Training.
Fostering Resilience/Recovery.
Triage.
Treatment.
Recommendations for
Early-intervention
• Reduce high arousal.
• Increase social support.
• Enhance coping with event and reactions
 Decrease fear of symptoms.
 Increase understanding of traumatic stress reactions
and grief.
Continued
• Prevent maladaptive coping.
Avoidance, rumination, substance abuse,
isolation.
• Prevent “loss of resources”
• Later (3 weeks – year):
Reframe negative cognitions.
Increase therapeutic exposure.
Facilitate emotional processing.
Psychological First Aid
• Early assistance provided b those first
on-scene.
• Initial assessment of emotional impact
of event
• Stabilization of immediate emotional
wounds
• Prevention of further exposure of
emotional injury
Psychological First Aid
• Maintenance of emotional status until
professional mental health care is
available
• Facilitate transition to trained mental
health professional when necessary
• Promote quicker and better emotional
recovery
Psychological First Aid is not
•
•
•
•
Debriefing
Counseling
Psychotherapy
Mental health treatment.
The PFA Skill Set
•
•
•
•
Supportive Communication.
Assisted Coping.
Verbal De-escalation.
Screening and referral to higher level of care.
Fear vs. Exercise-induced
Arousal
Fear-induced arousal:
• SNS-driven.
• Elevates heart rate, BP, respiration, etc.
• Results in vasoconstriction.
• Is linked to the development of PTSD.
Grossman, D. 2004
Exercise-induced arousal:
•Non-SNS driven.
•Elevates heart rate, BP, respiration,
etc.
•Results in vasodilatation.
•Helps trigger PNS/Relaxation
•Is not linked to PTSD.
Grossman, D. 2004
The Heart Rate-Traumatic
Memory Connection
“Psychological
arousal during
traumatic events may trigger the
neurobiological processes that lead
to posttraumatic stress disorder
(PTSD).”
Shalev, et al, 1998
“
The Psychophysiology of Fear
Normal resting heart rate= 60-80 bpm
115-145 bpm
•Hypervigilance begins.
•Fine motor skills deteriorates.
•Problem solving diminished
•Numbing opioid response begins.
•Vasoconstriction begins.
•Depersonalization begins.
Grossman, D., 2004
The Psychophysiology of Fear
Normal resting heart rate= 60-80 bpm
Above 145 bpm
•Breathing becomes fast and shallow
•Sweat production reduces heat.
•Conscious thought diminishes further
•Auto-response mode begins.
•Vasoconstriction advances.
Grossman, D., 2004
The Psychophysiology of Fear
Normal resting heart rate= 60-80 bpm
Above 175 bpm
•Breathing is fast and shallow
•Shut down complex motor skills
•Higher cognitive functions shut down
•Advanced vasoconstriction
•Irrational fighting or feeling: freezing
•“Autopilot” behavior
•Submissive behaviors
Grossman, D., 2004
The Formation of traumatic
Memories
Both the hippocampus and cortex have
disproportionate number of glutamate
receptors.
Supportive Communication
•Verbal & Non-verbal Communication Skills.
•Active Listening & Responding.
•Providing Supportive Feedback.
•Knowing When to Refer
and more
Assisted Coping
•Autogenic Breathing Exercises.
•Guided Relaxation techniques.
•Managing Fear.
•Reducing Emotional and Physiological
Reactivity.
and more
Autogenic Techniques
Autogenic techniques include:
•Breathing exercises
•Progressive muscle relaxation
•Guided imagery
•others
Screening and Referral
•Physical
•
•
•
•
Chest pain
Respiratory trouble
Loss of consciousness
Cardiac arrhythmias/palpitations
•Affective
•
•
•
•
Suicidal ideation
Homicidal ideation
Catatonia
mania
Screening and Referral
•Cognitive
•
•
•
•
Pervasive disorientation
Blackouts
Psychotic symptoms
amnesia
•Behavioral
• Self-injurious acts
• Total lack of self-care
• Dangerousness to self, others, property
Complication Variables in
Delivering Mental health
Service Delivery
Travel may be greatly restricted during the initial impact
and decontamination stages of recovery delaying
psychological support.
Exposed individuals may be isolated for observation
and treatment thus preventing contact with family,
friends or counselors.
Complication Variables in
Delivering Mental health
Service Delivery
In the instance of extreme illness or death of an
exposed person, families may not e able to “say good
bay”, see or touch their loved ones.
Rituals, such as funerals and special treatment of the
body may be disrupted causing further emotional
distress for loved ones.
Mental Health Service
Delivery Methods
•Outreach when life-safety issues are fully
addressed.
•Anticipate home-based counseling needs.
•Community consultation and training.
Service Delivery Methods
•Individual, group and public education
•Online, web-base resources
•Hot lines and tele-counseling
•Bi-lingual and bi-cultural staff
On Site
Trauma Response
Stabilizing Individual
• Assess the survivors for injury and shock.
• Get uninjured people involved in helping.
• Provide support by:
– Listening
– Empathizing
• Help survivors connect with natural
support systems
Avoid Saying…
•
•
•
•
•
•
“I understand.”
“Don’t feel bad.”
“You’re strong/You’ll get through this.”
“Don’t cry.”
“It’s God’s will.”
“It could be worse” or “At least you still
have…”
Emergency Mental Health and
Traumatic Stress
• Most people who are coping with the
aftermath of a disaster have normal
reactions as they struggle with the
disruption and loss caused by the disaster.
“Traditional”
Mental Health Practice
• Is often office based.
• Focuses on diagnosis and
treatment of a mental illness.
• Attempts to impact the baseline
of personality and functioning.
• Examines content.
• Encourages insight into past life
experiences and their influence
on current problems.
• Has a psycho-therapeutic focus.
Crisis Counseling
• Is primarily home and community
based.
• Focuses on assessment of
strengths, adaptation of existing
coping skills and development of
new ones.
• Seeks to restore people to predisaster levels of functioning.
• Accepts content at face value.
• Validates the appropriateness of
reactions to the event and its
aftermath and normalizes the
experience.
• Has a psycho-educational focus.
COMMON CRISIS COUNSELING SERVICES
•
•
•
•
•
•
•
•
Information
Education
Outreach
Counseling
Supportive listening
Referrals
Training
Collaboration with other programs
Disaster Stress Interventions
• Individual stress
management
training
• Social support and
creating a
supportive
organization
Disaster Stress Interventions
Social support is
one of the most
important and
powerful stress
reducers.
Managing Stress During Disaster
• On scene briefings for
incoming responders
• Develop a “buddy” system
• Watch out for each other
Managing Stress During Disaster
•
•
•
•
Take care of yourself physically
Take frequent rest breaks
Drink plenty of fluids
Eat healthy foods
Managing Stress During Disaster
• Take breaks away from the work area
• Give yourself permission to feel rotten
Fatigue as a Health Hazard
The Health Effects of Working Long Hours
• Stress
– Causes a lack on concentration, memory loss and
errors in judgment
• Depression
– May be caused by extended periods of stress
– Can be caused when workers experience high
demands and low levels of control over their work
• Burnout (Work Exhaustion)
– When workers undergo extended periods of high
demanding & high stress situations coupled with
long hours & work overload
Helping Children Feel Better
• Carry out daily routines and outings
(when possible)
Helping Children Feel Better
• Encourage children
to talk and ask
questions
Helping Children Feel Better
• Reassure children
they are safe
Helping Children Feel Better
• Screen TV
KISS = Keep It Simple Silly
• Remember you are dealing with a very
stressful situation and its aftermath
– TALK – especially to others who relate to
your situation
– DON’T make major decision’s alone
– LIMIT – Expectations on self and others
HALT
Avoid Being
•
•
•
•
Hungry
Angry
Lonely
Tired
REMEMBER
• Take care of yourself.
• Take care of family.
Available Resources
Nursing Peer Assistance
24 Hour Hotline 1-800-662-0108
Referral, information, education and fees:
www.njnsa.org/ramp.htm
(609) 883-5335 ext. 34
Confidential email: [email protected]
Disaster Nursing and Emergency
Preparedness for Chemical,
Biological, Radiological Terrorism
and Other Hazards
By Tener Goodwin Veenema,
PhD, MPH, MS, CPNP, Editor
Recipient of 2 “AJN Book of the Year Awards”
Acknowledgements
•
•
•
•
•
•
•
•
•
•
•
National Centers for Posttraumatic Stress Disorders Dept of Veterans Affairs
American Psychological Association
American Psychiatric Association
American Health Association
The American Academy of Experts in Traumatic Stress
FEMA
CDC
NIDA, NIH, NIAAA
Jamie F. Becker of the Laborers’ Health and Safety Fund of North America
Steven M. Crimando MA, BCETS, Extreme Behavioral Risk Management
Deborah J. DeWolfe PHD, MSPH Training Manual for Mental Health and Human
Service Workers in Major Disaster. SAMHSA Publication