how do people respond to natural disasters?caleblack.com/psy5523_files/tornadoes.pdf · how do...
Post on 22-May-2020
4 Views
Preview:
TRANSCRIPT
1/7/18
1
Outline
• Howdopeoplerespondtonaturaldisasters?
• WhatisPTSD?
• WhattodoandwhatnottodototreatPTSDeffec>vely
How do people respond to natural disasters?
1/7/18
2
0
5
10
15
20
25
30
35
40
Witness
Accident
Threat(w
eapon)
NaturalDisaster
PhysicalAJack
Combat
Abuse/N
eglect
Molesta>on
Rape
Men
Women
Kessler et al., 1995
ExposuretoTrauma>cEventsinU.S.
NormalorUnexpected?
• Akeyissueisunderstandingthoseresponsesthatarenormalversusthosethatrequireinterven>on
• Thereareseveralbarrierstoeffec>veiden>fica>onofpeoplewhoneedinterven>onfollowingadisaster
BarrierstoEffec>veIden>fica>on
• Inadultsandchildren,lackofknowledgeabouttypicalandatypicalreac>onshampersiden>fica>on
• Foradults,public,self,orstructurals>gmasurroundingaboutmentalhealthcanleadtolyingaboutsymptoms
• Mayalsoleadtopeoplenotevenknowingthatwhattheyareexperiencingisindica>veofproblems
1/7/18
3
BarrierstoEffec>veIden>fica>on
• Astrongresponsetoadisasterortraumaisnormalandexpected
• Upto90%ofchildrenandadultsshowpsychologicalreac>onsimmediatelya_eradisaster,20-50%showreac>onsuptoayearlater
• Majorityofthesewillnotneedservicesotherthancareandsupportfromfamily,friends,andschool/work
0
10
20
30
40
50
60
70
PhysicalAJ
ack
Threat
w/weapo
n
Disaster
Accident
SexualAssua
lt
Comb
atRap
e
Men
Women
PTSD as a Func>on of Type of Trauma
Kessleretal.,1995,1999
BarriersinChildren
• Therearetwomythsaboutchildrenwhohaveexperienceddisasters:
1. Childrenareinnatelyresilientandwillquicklyrecover,evenfromextremetrauma
2. Childrenarenotdisturbedbydisastersunlesstheirparentshavestrongresponses
1/7/18
4
BarriersinChildren
• Teachersandparentsmaymisinterpretproblema>cbehaviorasjustbeingwillful
• Adultsmaynotwishtoberemindedoftheirownreac>ons,andthusignoreorminimizeachild’sreac>on
• Mostchildrenrespondappropriatelytoadisaster,whichleadssometothinkthatallthechildrenaredoingso
HowWeReact
• Threephasesofaperson’sreac>ontoadisaster:
1. Duringthedisaster2. Immediatelyfollowingthedisaster3. Long-termreac>onstothedisaster
• Certaintypesofreac>onsarenormalduringeachphase
DuringtheDisaster
• Whenconfrontedwithatrauma,weallhavethe“fightorflight”responseduetoautonomicnervoussystemac>va>on:
• Musclestense,heartpounds• Nervesareonhighalert• Intenseanxietyorfear• Shock,senseofunreality,notunderstandingwhatishappening
1/7/18
5
ImmediatelyFollowing
• Intheweeksa_eratrauma,upto90%ofpeoplemayexperience:
• Heightenedphysiologicalarousal• Diffuseanxiety• Survivorguilt• Emo>onallability
• Theseareallnormalreac>onsandshouldbemetwithunderstandingandsupport
Long-Term
• By1-2yearspost-disaster,themajorityofpeoplewillshowfewproblema>csymptoms
• A>metowatchoutfor,however,istheanniversaryofthedisaster
• Thoses>lldisplayingthefollowingdifficul>es3-4monthsa_erthedisastermayneedfurtherassessment
SymptomsofConcern
• Inchildrenbelowage6,thesemayindicateproblema>cadjustmenttothedisaster
Ø Generalizedanxietyaboutsepara>on,strangers,orsleepproblems
Ø Avoidanceofcertainsitua>onsØ Preoccupa>onwithcertainsymbols/wordsØ Limitedemo>onalexpressionorplayac>vi>esØ Lossofpreviouslyacquiredskills
1/7/18
6
SymptomsofConcern• Forolderchildren,warningsignsofproblema>cadjustmentare
Ø Repe>>ousplayreenac>ngapartofthedisasterØ Preoccupa>onwithdangerorexpressedconcernsaboutsafety
Ø SleepdisturbancesandirritabilityØ AngeroutburstsoraggressivenessØ ExcessiveworryaboutfamilyorfriendsØ Schoolavoidance,par>cularlyinvolvingsoma>ccomplaintsØ Behaviorscharacteris>cofyoungerchildrenØ Changesinpersonality,withdrawal,andlossofinterestinac>vi>es
SymptomsofConcern
• Inadults,watchoutforthefollowing:
Ø IncreaseinsubstanceuseØ AvoidanceofsupportnetworksØ Droppingoutofac>vi>esØ TroubleaccomplishingtasksatworkØ Increaseinconflictwithspouse/family
• Oneormoreofthesemaybeindica>veofamaladap>veresponsetothedisaster–ofbeingavic>mratherthanasurvivor
Vic>mstoSurvivors
• Vic>msarethosewhofeeltheyhavenocontrolovertheircurrentsitua>on
• Survivorsarethosewhohaveregainedasenseofcontrolandareabletomeetthedemandsofwhateverdifficultyconfrontsthem
• Vic>msarepassiveanddependentonothers,survivorsareac>veandinvolved
1/7/18
7
What is PTSD?
TraumaandStressRelatedDisorders• Aninappropriatelysevereresponsetoatraumaacrossalongperiodof>me,resul>nginfunc>onalimpairment,canappearinmanyways
• Reac>veAJachmentDisorder• DisinhibitedSocialEngagementDisorder• PosJrauma>cStressDisorder• AcuteStressDisorder• AdjustmentDisorders
Major changes from DSM-IV to -5
• Pos0rauma2cStressDisorder• Morespecificabouthoweventwasexperienced• Subjec>vereac>oneliminated• Fourmajorsymptomclustersratherthanthree• Developmentallysensi>veforkidsages6oryounger
• Reac2veA0achmentDisordernowdividedintotwodis>nctdiagnoses• Emo>onallywithdrawn/inhibited(RAD)• Indiscriminatelysocial/disinhibited(DisinhibitedSocialEngagementDisorder)
1/7/18
8
Common Features across TSRDs
• IntrusiveMemories
• Avoidance
• Nega>vechangesinthinkingandmood
• Changesinemo>onalreac>ons
PTSDintheDSM-5CriterionA:ExposureThepersonwasexposedto:death,threateneddeath,actualorthreatenedseriousinjury,oractualorthreatenedsexualviolence,asfollows:
1. Directexposure2. Witnessing,inperson3. Indirectly,bylearningthatacloserela>veorclosefriend
wasexposedtotrauma.Iftheeventinvolvedactualorthreateneddeath,itmusthavebeenviolentoraccidental.
4. Repeatedorextremeindirectexposuretoaversivedetailsoftheevent(s),usuallyinthecourseofprofessionaldu>es(e.g.,firstresponders,collec>ngbodyparts;professionalsrepeatedlyexposedtodetailsofchildabuse)• Thisdoesnotincludeindirectnon-professionalexposurethroughelectronicmedia,television,moviesorpictures
PTSDintheDSM-5CriterionB:Intrusionsymptoms(atleast1)
• Spontaneousorcuedrecurrent,involuntary,andintrusivedistressingmemoriesoftheevent(s).
• Recurrentdistressingdreamsinwhichthecontentand/oraffectofthedreamisrelatedtotheevent(s).
• Dissocia>vereac>ons(e.g.,flashbacks)inwhichtheindividualfeelsoractsasiftheevent(s)wererecurring
• Intenseorprolongedpsychologicaldistressatexposuretointernalorexternalcuesthatsymbolizeorresembleanaspectoftheevent(s)
• Markedphysiologicalreac>onstoremindersoftheevent(s)
1/7/18
9
PTSDintheDSM-5
CriterionC:Persistentavoidanceofs>muliassociatedwiththetrauma(atleast1)
• Avoidsinternalreminders(thoughts,feelings,orphysicalsensa>ons)thatarouserecollec>onsofthetrauma>cevent(s)• Avoidsexternalreminders(people,places,conversa>ons,ac>vi>es,objects,situa>ons)thatarouserecollec>onsofthetrauma>cevent(s).
PTSDintheDSM-5CriterionD:Nega>vealtera>onsincogni>onsandmoodthatareassociatedwiththetrauma>cevent(3ormore)• Inabilitytorememberanimportantaspectofthetrauma>cevent(s)
• Persistentandexaggeratednega>veexpecta>onsaboutone’sself,others,orthe
• Persistentdistortedblameofselforothersaboutthecauseorconsequencesofthetrauma>cevent(s)
• Pervasivenega>veemo>onalstate• Markedlydiminishedinterestorpar>cipa>oninsignificantac>vi>es
• Feelingofdetachmentorestrangementfromothers• Persistentinabilitytoexperienceposi>veemo>ons
PTSDintheDSM-5
CriterionE.Altera>onsinarousalandreac>vitythatareassociatedwiththetrauma>cevent(3ormore)• Irritableoraggressivebehavior• Recklessorself-destruc>vebehavior• Hypervigilance• Exaggeratedstartleresponse• Problemswithconcentra>on• Sleepdisturbance
1/7/18
10
PTSDintheDSM-5
F. Persistenceofsymptoms(inCriteriaB,C,DandE)formorethanonemonth
G. Thesymptomscauseclinicallysignificantdistressorimpairmentinsocial,occupa>onal,orotherimportantareasoffunc>oning
H. Notduetomedica>on,substanceorillness
DSM-5PTSD,PreschoolSubtype
• Rela>vetobroaderdiagnosisforthoseover6years,severalchanges
• CriterionsAandB–nochange
• CriterionsCandD–onlyneed1symptomfromeitherone• Ccluster–nochange• Dcluster–4insteadof7symptoms
• Doesnotincludeamnesia,foreshortenedfuture,persistentblameofselforothers
• CriterionE–only2symptomsneeded• Preschooldoesnotincludesymptomof“recklessbehavior”
PreschoolPTSDintheDSM-5CriterionA:ExposureThepersonwasexposedto:death,threateneddeath,actualorthreatenedseriousinjury,oractualorthreatenedsexualviolence,asfollows:
1. Directexposure2. Witnessing,inperson3. Indirectly,bylearningthatacloserela>veorclosefriend
wasexposedtotrauma.Iftheeventinvolvedactualorthreateneddeath,itmusthavebeenviolentoraccidental.
4. Repeatedorextremeindirectexposuretoaversivedetailsoftheevent(s),usuallyinthecourseofprofessionaldu>es(e.g.,firstresponders,collec>ngbodyparts;professionalsrepeatedlyexposedtodetailsofchildabuse)• Thisdoesnotincludeindirectnon-professionalexposurethroughelectronicmedia,television,moviesorpictures
1/7/18
11
PreschoolPTSDintheDSM-5CriterionB:Intrusionsymptoms(atleast1)
• Spontaneousorcuedrecurrent,involuntary,andintrusivedistressingmemoriesoftheevent(s).
• Recurrentdistressingdreamsinwhichthecontentand/oraffectofthedreamisrelatedtotheevent(s).
• Dissocia>vereac>ons(e.g.,flashbacks)inwhichtheindividualfeelsoractsasiftheevent(s)wererecurring
• Intenseorprolongedpsychologicaldistressatexposuretointernalorexternalcuesthatsymbolizeorresembleanaspectoftheevent(s)
• Markedphysiologicalreac>onstoremindersoftheevent(s)
PreschoolPTSDintheDSM-5
CriterionC:Persistentavoidanceofs>muliassociatedwiththetraumaorchangesincogni>onsandmood(atleast1)
• Avoidsinternalreminders(thoughts,feelings,orphysicalsensa>ons)thatarouserecollec>onsofthetrauma>cevent(s)• Avoidsexternalreminders(people,places,conversa>ons,ac>vi>es,objects,situa>ons)thatarouserecollec>onsofthetrauma>cevent(s).
PreschoolPTSDintheDSM-5
• Substan>allyincreasedfrequencyofnega>veemo>onalstates(e.g.,fear,guilt,sadness,shame,confusion)• Markedlydiminishedinterestedorpar>cipa>oninsignificantac>vi>es,includingconstric>onofplay• Sociallywithdrawnbehavior• Persistentreduc>oninexpressionofposi>veemo>ons
1/7/18
12
PreschoolPTSDintheDSM-5
CriterionD.Altera>onsinarousalandreac>vitythatareassociatedwiththetrauma>cevent(2ormore)• Irritableoraggressivebehavior• Hypervigilance• Exaggeratedstartleresponse• Problemswithconcentra>on• Sleepdisturbance
PreschoolPTSDintheDSM-5
E. Persistenceofsymptoms(inCriteriaB,C,DandE)formorethanonemonth
F. Thesymptomscauseclinicallysignificantdistressorimpairmentinsocial,occupa>onal,orotherimportantareasoffunc>oning
G. Notduetomedica>on,substanceorillness
PTSDSpecifiers
• Withdissocia>vesymptoms• Theindividual’ssymptomsmeetthecriteriaforPTSDandtheindividualexperiencespersistentorrecurrentsymptomsofeitherofthefollowing:
1. Depersonaliza>on• Persistentorrecurrentexperiencesoffeelingdetachedfrom,andasifonewereanoutsideobserverof,one’smentalprocessesorbody
• Feelingasthoughonewereinadream,feelingasenseofunrealityofselforbodyorof>meslowlymoving
2. Derealiza>on:Persistentorrecurrentexperiencesofunrealityofsurroundings• Theworldaroundtheindividualisexperiencedasunreal,dreamlike,distant,ordisordered
1/7/18
13
PTSDSpecifiers
• Withdelayedexpression• Ifthefulldiagnos>ccriteriaisnotmetun>latleast6monthsa_ertheevent.
PTSDPrevalence
• 61%ofmenand51%ofwomenexperienceatraumaintheirlife>me
• Morethan25%experiencemul>pletraumas
• Life>merate6.8%,currentrate3.6%
Kessler et al., (1995, 2005)
MostVulnerablePopula>ons
• Thosewhoseexperiencewasespeciallyterrifyingorextreme
• Childrenbetween5-10yearsofage,especiallyifseparatedfromparents
• Thosewithoutstrongsocialsupportnetworks
• Thosewithapriorhistoryofanytypeoftrauma>cexperience
1/7/18
14
PTSDisHigherinPopula>onswithMoreTrauma
DeJongetal.,2001
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
Algeria
Cambodia
Ethiopia
Gaza
US
Life>mePTSDinfourpost-conflictseqngsandUS
PTSDRiskFactors
• Pretrauma>cevent:• Femalegender• Somegene>cfactors• Childhoodtrauma• Previouspsychiatricproblems• Lowerlevelofeduca>on• Lowersocioeconomicstatus• Minorityrace
PTSDRiskFactors
• Pretrauma>cevent:• Femalegender• Somegene>cfactors• Childhoodtrauma• Previouspsychiatricproblems• Lowerlevelofeduca>on• Lowersocioeconomicstatus• Minorityrace
1/7/18
15
PTSDRiskFactors
• Peritrauma>cevent:• Greaterperceivedthreatordanger,andhelplessnessincreasesrisk• Unpredictabilityanduncontrollabilityoftrauma>ceventalsoincreasesrisk
• PosJrauma>cevent:• Lackofsocialsupport,lifestress,aJribu>ons
GenderDifferences
• Muchhigherratesinfemalesincivilianpopula>ons
• Equalratesseeninmilitarypopula>ons,althoughsomecontroversyoverthis
OklahomaandTornadoes
• Oklahomaaverages54tornadoesyear,morepersquaremilethananywhereelseonEarth
• ResearchhasshownveryhighlevelsofPTSDinOKchildren• 66%ofnon-exposedchildrenhadmoderateorhighlevelsofPTSSduringtornadoseason(Romero,1997)
• 41%metPTSDcriteriaoneyearlater(Evans&Oehler-S>nneJ,2006)
• 52%ofexposedchildrenhadmoderateorhigherlevelsofPTSSat18monthspost-tornado(Lack,2003)
• HigherthaninothertornadosurvivorsoutsideofOklahoma(Lacketal.,2010)
1/7/18
16
WhySuchHighRatesinOK?
• Re-exposuretoenvironmentalcues
• Exposuretotrauma-relatedmedia
• Modelingoftrauma-responsebyadults
UniquelyOklahoman
• Luckily,thedistressseemstobehighlyspecific,withnoevidenceofgeneralizeddistressorfunc>onalimpairmentsformostchildrenexposedtotornadoeswhohavePTSS(Lack,2003;Lack,2006)
• Sucharesponsemaybemore“phobic”thanPTSDformanyOklahomans,giventhesefactors
ImpactofPTSD
• Elevatedriskofmood,otheranxiety,andsubstanceabusedisorders
• Greaterfunc>onalimpairment
• Reducedqualityoflife
• Elevatedriskofpoorphysicalhealth
1/7/18
17
What to do and what not to do to treat PTSD
EBT for PTSD
• Thereisahugeandverystrongevidencebasefortheuseofcogni>ve-behavioraltherapiestotreatPTSD• Prolongedexposuretherapy• Cogni>veprocessingtherapy• Trauma-focusedCBT
• But,therearemanyproponentsofpseudoscien>fic,non-EBTtreatmentsaswell
CBT for PTSD
• ThevariousformsofCBTaremuchmoreeffec>vethanmedica>onsinreducingPTSDsymptoms
• Medica>on,however,ismorereadilyavailableandcanusefulfortrea>ngcomorbidproblemsorloweringsymptomsenoughtobeabletoengageindoingCBT
1/7/18
18
Meta-Analysis of PTSD Treatments
Van Etten & Taylor, 1998
Pharmacology for PTSD
• SSRIsarethemostwellstudiedandmosto_enprescribed
• Theyoutperformplacebossignificantly,inbothcivilianandmilitarypopula>ons
• Venlafaxine(Effexor)slightlyoutperformsSSRIsinbothpopula>ons
CBT for PTSD
• Prolongedexposure(PE),cogni>veprocessingtherapy(CPT),andtrauma-focusedCBT(TF-CBT)areconsistentlyshowntobeeffec>vetreatmentsforPTSD
• Generalcomponentssharedare• Psycho-educa>on• Anxietymanagement• Exposure• Cogni>verestructuring
1/7/18
19
Prolonged Exposure (PE) 1. Psycho-education: Patient learns about trauma
and PTSD
2. Breathing skills: Learns to manage anxiety
3. In vivo exposure: Confronts feared stimuli in real life
4. Imaginal exposure: Involves mental exposure to trauma by repeated telling of memories
Cogni>ve Processing Therapy (CPT)
1. Educa>onaboutPTSD,thoughtsandemo>ons
2. Processingtrauma(withorwithoutaccount)
3. Challengingthoughts
4. Cogni>verestructuring
TF-CBT
• Developedspecificallyforchildrenandadolescents
1. Psychoeduca>on2. Relaxa>onandstressmanagement3. Affectexpressionandmodula>on4. Cogni>vecoping5. Traumanarra>on6. Cogni>veprocessing7. BehaviorManagementTraining8. Parent-childsessions
1/7/18
20
PEorCPTforAdults?
• Not a lot is known about treatment matching
• Most important is to use evidence-based therapy • Dropout rates are similar • Therapist comfort • Patient preference
Pseudoscien>ficPTSDTherapies
• Cri>calincidentstressmanagement(CISM)
• Eyemovementdesensi>za>onandretraining(EMDR)
• Emo>onalfreedomtechnique(EFT)andthoughtfieldtherapy(TFT)
Conclusions
• Experiencingtraumaisverycommon,butmostpeoplewillcomethroughwithoutmentalhealthproblems
• Beonthelookoutforwarningsignsthatcanpredictlong-termdifficul>esadjus>ng
• KnowhowPTSDpresentsdifferentlyinchildrenandadults
• Useeffec>ve,evidence-basedtreatmentstohelpthosestruggling
top related