Mental Health Aspects of Bioterrorism

1. 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

2. 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

3. 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?

4. 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

5. Responses to traumatic events • Each individual is unique • 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

6. Coping cycle stressor coping strategy appraisal resources

7. 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”

8. What to look for in your clinic • 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

9. 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.

10. 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

11. PTSD definition A. Exposure to a traumatic event in which both of the following were present: • The individual experienced, witnessed, or was confronted with an event of actual or threatened death or serious injury • 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

12. 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

13. 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

14. PTSD Scores in 1225 Women HMO Members 71% 23% 7% 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)

15. Functional Disability and PTSD 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.

16. 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 Physician coded ICD-9 diagnoses

17. LOW MODERATE HIGH N=843 N=270 N=83 Primary Care 337 + 396 (237) 432 + 494 (319) 510 + 485 (405) Specialty Care 267 + 584 (0) 261 + 512 (0) 355 + 615 (108) Emergency Care 18 + 134 (0) 31 + 161 (0) 110 + 445 (0) Pharmacy 160 + 406 (66) 240 + 393 (112) 331 + 578 (128) Mental Health 35 + 190 (0) 150 + 394 (0) 162 + 502 (0) Total Outpatient 1352 + 3236 (609) 1590 + 2112 (829) 2603 + 4939 (1283) Inpatient 294 ± 2032 (0) 189 ± 1130 (0) 457 ± 1750 (0) Total Costs 1646 ± 5156 (609) 1779 ± 3008 (829) 3060 ± 6381 (1283) Unadjusted Health Care costs for 1225 Female Group Health Members with PTSD symptoms

18. Meeting special needs

19. Who is affected? • You • Your family • Your fellow providers • Your health delivery system • Direct victims • Vulnerable patients • Children

20. You • 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?

21. Your family • 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?

22. 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?

23. READ ME FIRST! Dear colleague- Before 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

24. 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?

25. 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?

26. Vulnerable patients • Previous exposures to trauma • 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

27. Children • After any disaster children are most afraid that: • 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 • 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

28. 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

29. Practical management strategies

30. 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)

31. Model Predisposing Factors Precipitating Factors Perpetuating Factors

32. Case Example

33. Predisposing Factors

34. Precipitating Factors

35. Perpetuating Factors

36. Predisposing Factors • 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

37. Precipitating Factors • medical disease • psychiatric disorder • social, fiscal or occupational stress • changes in social support • re-experienced trauma • dietary factors

38. Perpetuating Factors • disability-induced vicious cycles • decreased self confidence • decreased activation, wellness • chronic somatization • social isolation • primary gain (intrapsychic) • secondary gain (interpersonal) • tertiary gain (interpersonal)

39. The Plan: Work Backwards • get control of perpetuating factors • tertiary prevention • limit precipitating factors • secondary prevention • decrease power of predisposing factors • primary prevention

40. Controlling Perpetuating Factors • decrease functional disability • symptom reduction a better endpoint than cure • increase positive activities, social contacts • medications • decrease chronic somatization • deal with illness beliefs (figure-ground issue) • regular medical visits • “your job is to fix me” • doctor patient collaboration

41. Controlling Perpetuating Factors (cont’d) • deal with reinforcers (gain) • emotional, financial • stop re-creations of trauma • consultation referral • deal with interpersonal problems • use of opiates • recurrent medical procedures/surgeries

42. Limiting Precipitating Factors • treat comorbid medical/psychiatric diseases • stress management • change what can change, accept what can’t • appraisal, resources, coping (activation) • increase social support • decrease exposures to trauma • focus on wellness (exercise, diet) • decrease chronic social stress

43. Decreasing Power of Predisposing Factors • 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

44. Behavioral support • Media abstinence • CNN: “All anthrax, all the time” • “Breaking news! This just in….” • 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

45. Pharmacological Support • Proper diagnosis • 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

46. 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