Psychiatric Dimensions Post- -Disaster: A Disaster: A Psychiatric Dimensions Post Public Health Perspective Public Health Perspective Anthony T. Ng, MD Anthony T. Ng, MD Uniformed Services School of Medicine Uniformed Services School of Medicine George Washington University School of George Washington University School of Medicine Medicine Director Director Mannanin Healthcare, LLC Mannanin Healthcare, LLC (917) 579- (917) 579 -5797 5797 Anthony.ng@mannainhealthcare.org Anthony.ng@mannainhealthcare.org
Public’ ’s Mental Health s Mental Health Public � Protect nation Protect nation’ ’s capabilities, s capabilities, � values, infrastructure and values, infrastructure and social capital social capital � Mitigate propagation of fear, Mitigate propagation of fear, � distress, unhealthy changes in distress, unhealthy changes in behavior, psychiatric disease behavior, psychiatric disease � Must be community, Must be community, � population focus population focus � Promote community Promote community � cohesiveness cohesiveness
What is a Disaster? What is a Disaster? � Traumatic events that Traumatic events that � overwhelm a community overwhelm a community � A severe psychosocial A severe psychosocial � disruption which can disruption which can greatly exceeds the greatly exceeds the coping capacities of the coping capacities of the community community � Disaster Disaster vs vs Mass Mass � Casualties Incidents Casualties Incidents
Disaster Pyramid Disaster Pyramid Disaster Victims Disaster Victims Families/Friends/Rescue Workers Families/Friends/Rescue Workers Medical Professionals Medical Professionals Public At Large Public At Large Presentation by Reissman Reissman, 2005 , 2005 Presentation by
Potential Long Term Disaster Issues Potential Long Term Disaster Issues � Disaster itself Disaster itself � � Death and injuries Death and injuries � � Displacement/relocation Displacement/relocation � � Relationship dynamics (loss Relationship dynamics (loss � and gain) and gain) � Uniqueness and isolation Uniqueness and isolation � � Job loss Job loss � � Financial loss Financial loss � � Post disaster experiences Post disaster experiences � � Anniversaries Anniversaries �
Ripple Effects of Disasters Ripple Effects of Disasters � Population shift Population shift � � Cultural displacement Cultural displacement � � Long term unemployment Long term unemployment � � Health problems related to Health problems related to � ongoing stress and ongoing stress and psychological distress psychological distress � Poor life adjustment Poor life adjustment � � Loss of functional capacity Loss of functional capacity � � Media coverage Media coverage � � Discrimination/ Discrimination/scapegoating scapegoating �
Factors Associated With Mental Factors Associated With Mental Health Outcomes and Resilience Health Outcomes and Resilience � The Event The Event � � Community/Societal Structures Community/Societal Structures � � Idiosyncratic characteristics of the individuals Idiosyncratic characteristics of the individuals � involved, including their interpersonal/familial involved, including their interpersonal/familial relationships relationships Warheit Warheit, 1986 , 1986
Groups at Increased Risk Groups at Increased Risk � Greater traumatic exposure, Greater traumatic exposure, � Number of negative life Number of negative life � � injury, threat injury, threat events events � Women Women � � Greater loss of resources Greater loss of resources � � Middle Middle- -aged adults aged adults � � Poor social support Poor social support � � Ethnic minorities Ethnic minorities � � Prior psychological sx, Prior psychological sx, � � Children of distressed Children of distressed � substance abuse substance abuse parents parents � Worry and anxious traits Worry and anxious traits � � Mothers with young children Mothers with young children � (Norris FH et al, 2002)
Underlying Assumptions Underlying Assumptions � The majority of survivors and family members will The majority of survivors and family members will � successfully “ “recover recover” ” without MH assistance without MH assistance successfully � “ “Recovery Recovery” ” involves reclaiming and reconstructing involves reclaiming and reconstructing � one’ ’s life s life - - finding a finding a “ “new normal, new normal,” ” which occurs which occurs one gradually over years gradually over years � A significant minority will experience PTSD, A significant minority will experience PTSD, � depression, anxiety and distress and may benefit from depression, anxiety and distress and may benefit from MH intervention MH intervention � Most people experiencing disaster trauma do not develop long term psychiatric pathology
Common Diagnoses in Common Diagnoses in Disasters Disasters � Acute stress disorder � Panic disorder � Adjustment disorder with depressed, anxious or mixed features � Exacerbation of Personality disorders � Psychotic illness, including Brief Psychotic Disorder � Substance use (exacerbations) � Psychiatric Disorder due to medical conditions � Exacerbation of pre-existing PTSD
LIFETIME PREVALENCE OF PSYCHIATRIC DISORDERS: NATIONAL COMORBIDITY STUDY S UBSTANCE U SE Adapted from Kessler et al. 1994, 1995 D ISORDERS 25 20 M OOD D ISORDERS % of population 15 10 A NXIETY D ISORDERS 5 0 GAD Panic Alcohol Drug Major Bipolar PTSD use use depression disorder disorder disorder disorder
Risk of PTSD Following Specific Risk of PTSD Following Specific Traumas in The U.S. Population Traumas in The U.S. Population 60 54% 49% 50 Percentage 40 32% 30 15% 20 10 4% 0 Kidnapping, Rape Beating Shooting or Natural torture, stabbing disaster captivity Breslau et al, Arch Gen Psychiatry, Breslau et al, Arch Gen Psychiatry, 55:626 55:626– –32, 1998 32, 1998
Incidence of PTSD Incidence of PTSD � 28% had PTSD one month after cafeteria 28% had PTSD one month after cafeteria � shooting with 18% having another psych dx dx shooting with 18% having another psych � 24% had PTSD one year later and 12% with 24% had PTSD one year later and 12% with � another psych dx dx another psych North CS et al. 1997 � ½ ½ of PTSD cases over 3 years were in remission of PTSD cases over 3 years were in remission � North CS et al. 2002
DSM-IV CRITERIA FOR PTSD DSM-IV CRITERIA FOR PTSD A. Exposure to traumatic event - threat to life or limb - with victim response of fear, helplessness, or horror B. > 1 new Group B symptom (Re-experiencing) : • Intrusive memories • Nightmares • Flashbacks • Upset by reminders • Physiologic reactivity to reminders C. > 3 new Group C symptoms (Avoidance/Numbing) : • Avoids thoughts/feelings B, C, & D symptoms • Avoids reminders • Event amnesia must be new after the • Loss of interest • event to qualify; Detachment/estrangement • Restricted range of affect existing symptoms such • Sense of foreshortened future as sleep problems in D. > 2 new Group D symptoms (Hyperarousal) : • Insomnia the population are not • Irritability/anger • counted & will yield Difficulty concentrating • Hypervigilance inflated estimates of • Exaggerated startle PTSD rates E. Duration > one month F. Clinically significant distress / impaired functioning Note: Delayed onset > 6 months; Chronic > 3 months
S YMPTOM G ROUPS S YMPTOM G PTSD PTSD ROUPS Oklahoma City Bombing (N=182) Oklahoma City Bombing (N=182) Group B Group B 79% Intrusive re- Intrusive re -experience experience Group C Group C 36% Avoidance/numbing Avoidance/numbing 94% 94% Group D Group D 82% Hyperarousal Hyperarousal Groups B, C, and Groups B, C, and D D 34% PTSD PTSD 0 10 20 30 40 50 60 70 80 90 100 % of subjects meeting criteria North et al 1999 North et al 1999
How Do You Diagnose PTSD? Not with a questionnaire, but the old fashioned Not with a questionnaire, but the old fashioned way… …by taking a history to determine if by taking a history to determine if DSM DSM- - way IV- -TR TR diagnostic criteria are met IV diagnostic criteria are met NEED TO MEET ALL 6 NEED TO MEET ALL 6 CRITERIA: CRITERIA: A, B, C, D, E, AND AND F A, B, C, D, E, F
Disasters and Psychopathology Disasters and Psychopathology But…… …….. .. � But �
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