Expert Commentary

* Psychiatric Disaster Response: Staging and PTSD

Craig Katz, MD

Associate Clinical Professor of Psychiatry and Medical Education
Mount Sinai School of Medicine
New York, NY

 

The psychotherapeutic response to the aftermath of a life-threatening disaster must be taken within a defined timeframe. There are two windows for a psychotherapeutic approach, the acute and the long-term. In the acute phase, (days to weeks after the event), first priorities are determining how to actually get to the patients and then managing their immediate distress responses. Likewise, the earliest focus will be on symptoms rather than diagnosis. In the long-term phase (months to years after the event) the approach changes to a more traditional pattern of medical service delivery. The focus then is on defined psychiatric syndromes like PTSD, major depression, substance abuse and suicidality.
Post-traumatic stress disorder is only one of a number of post-traumatic sequelae, but is perhaps the best known, (one of the first groups in which this was studied was among the survivors of the 1937 Hindenburg disaster). It is best defined as a “fight or flight response” that does not go away. In broad terms it can be characterized as thinking and remembering so intensely that it affects present reality. PTSD can be characterized by three clusters of symptoms: 1) intrusive symptoms such as nightmares and flashbacks; 2) avoidance symptoms such as numbing or detachment from life, accompanied by a loss of intense or loving feelings; essentially an avoidance of reminders of the traumatic event; 3) hyperarousal symptoms, where a person is always on ”guard duty” and hyper-reactive to otherwise innocuous environmental stimuli. This symptom cluster can also include severely disturbed sleep.
Identifying PTSD in a post-disaster setting can sometimes be difficult, so one of the best broad stroke identifiers of the disorder is the question: “how much do you find that the (disaster) event lingers for you, emotionally, in your daily life?” If the patient endorses this, the clinician can begin refining questions and inquiries into the depth of the problem. Another useful approach is inquiries about sleep, which is often very disturbed in these patients and is also symptomatic of major depression. When the patient endorses sleep problems the clinician might enquire: “When you are up at night, what is on your mind?”
When PTSD is identified, the patient with a prior psychiatric history is somewhat more easily approached. However, in patients without such history techniques for getting the patient to embrace the need for help include discussing the limitations this disorder has imposed in their day-to-day functionality and noting that if the symptoms are not gotten under control now they can become chronic and disabling.
In terms of the Tohoku event, another serious concern is fear of radiation exposure, subsequent congenital malformations and social stigma. In reference to the Chernobyl incident of 20 years ago it is known that the clean-up workers suffer from an array of psychiatric symptoms ranging from psychosomatic neurasthenia to severe depression, anxiety and suicidality. To remediate this, a long-term approach is clearly needed, particularly in communities where the radiation-exposed patient is thought to be “contagious”. In such cases, open public awareness campaigns stressing the facts of radiation exposure are critically important, - especially due to the “invisible” characteristics of the contagion and the associated psychological impact.

 

References

  1. Agustini, EN et al (2011) The prevalence of long-term post-traumatic stress symptoms among adolescents after the tsunami in Aceh. J Psychiatr Ment Health Nurs Aug;18(6):543-9.
  2. Ghosh Ippen C. (2011) Traumatic and stressful events in early childhood: can treatment help those at highest risk? Child Abuse Negl. Jul;35(7):504-13.
  3. Pandya A, and Katz CL. (2010) Services provided by volunteer psychiatrists after 9/11 at the New York City family assistance center: September 12-November 20, 2001. J Psychiatr Pract. May;16(3):193-9.

 

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