World Congress on Disaster and Emergency World Congress on Disaster and Emergency MedicineMedicine
Targeted Agenda ProgrammeTargeted Agenda ProgrammeFIRST PSYCHOLOGICAL AIDFIRST PSYCHOLOGICAL AID
Major Erik DE SOIRMajor Erik DE SOIRPsychologist-PsychotherapistPsychologist-Psychotherapist
ROYAL MILITARY ACADEMYROYAL MILITARY ACADEMYDepartement of Behavioural SciencesDepartement of Behavioural Sciences
World Congress on Disaster and Emergency World Congress on Disaster and Emergency MedicineMedicine
Targeted Agenda ProgrammeTargeted Agenda ProgrammeFIRST PSYCHOLOGICAL AIDFIRST PSYCHOLOGICAL AID
Earliest possible trauma support : from Earliest possible trauma support : from peritraumatic support and on-scene peritraumatic support and on-scene
counselling to follow-upcounselling to follow-up
What could have prevented psychological trauma What could have prevented psychological trauma in the survivors of these accidents?in the survivors of these accidents?
KEY QUESTIONSKEY QUESTIONS
Which predictors of PTSD can be Which predictors of PTSD can be influenced on the scene of the accident?influenced on the scene of the accident?
Which kind of peritraumatic support can Which kind of peritraumatic support can rescue workers provide in order to reduce rescue workers provide in order to reduce
long term trauma sequelae?long term trauma sequelae?
THEORETICAL THEORETICAL BACKGROUND on BACKGROUND on
peritraumatic dissociationperitraumatic dissociation
Peritraumatic dissociation, Peritraumatic dissociation, acute emotions and PTSDacute emotions and PTSD
In recent years, much attention has been paid to In recent years, much attention has been paid to the predictive role of psychological phenomena the predictive role of psychological phenomena occur during or directly after various traumatic occur during or directly after various traumatic incidents. incidents.
Immediate reactions experienced at the time of the Immediate reactions experienced at the time of the trauma, such as dissociation, extreme anxiety, trauma, such as dissociation, extreme anxiety, panic, and negative emotions, may be important panic, and negative emotions, may be important predictors of subsequent PTSD symptoms. predictors of subsequent PTSD symptoms.
(Bernat, Ronfeldt, Calhoun, & Arias, 1998)(Bernat, Ronfeldt, Calhoun, & Arias, 1998)
Peritraumatic dissociation, Peritraumatic dissociation, acute emotions and PTSDacute emotions and PTSD
One of the most important predictors appears to be One of the most important predictors appears to be peritraumatic dissociation. peritraumatic dissociation.
According to Marmar, Weiss, and Metzler (1998), According to Marmar, Weiss, and Metzler (1998), peritraumatic dissociation is the occurence of peritraumatic dissociation is the occurence of dissociative symptoms during or shortly after dissociative symptoms during or shortly after exposure to extreme events involving acute exposure to extreme events involving acute alterations in cognitive and perceptual alterations in cognitive and perceptual functioning at the time of a traumatic event.functioning at the time of a traumatic event.
Traumatized patients frequently report alterations Traumatized patients frequently report alterations in the experience of time, place, and person, in the experience of time, place, and person, which lead to a sense of unreality as the event is which lead to a sense of unreality as the event is occuring (Marmar et al., 1998). occuring (Marmar et al., 1998).
Peritraumatic dissociation, Peritraumatic dissociation, acute emotions and PTSDacute emotions and PTSD
Nijenhuis, Van Engen, Kusters, and Van der Hart Nijenhuis, Van Engen, Kusters, and Van der Hart (2001)(2001) suggested that peritraumatic dissociation suggested that peritraumatic dissociation – involving both psychoform and somatoform – involving both psychoform and somatoform dissociation – is a manifestation of acute dissociation – is a manifestation of acute integrative failure, which sets the stage for the integrative failure, which sets the stage for the failure to synthesize and personify the traumatic failure to synthesize and personify the traumatic experience in the long run. experience in the long run.
Psychoform phenomena of dissociation refer to Psychoform phenomena of dissociation refer to dissociative amnesia and identity fragmentation dissociative amnesia and identity fragmentation and may involve depersonalization and and may involve depersonalization and derealization.derealization.
Peritraumatic dissociation, Peritraumatic dissociation, acute emotions and PTSDacute emotions and PTSD
Somatoform dissociation designates dissociative Somatoform dissociation designates dissociative symptoms that phenomenologically involve the body. symptoms that phenomenologically involve the body. The adjective “somatoform” indicates that the The adjective “somatoform” indicates that the physical symptoms suggest, but cannot be explained physical symptoms suggest, but cannot be explained bu a physical condition or by the direct effect of a bu a physical condition or by the direct effect of a substance (substance (Nijenhuis & Van der Hart, 1999Nijenhuis & Van der Hart, 1999). ).
Somatoform dissociative phenomena include the Somatoform dissociative phenomena include the inability to move and speak, anesthesia of various inability to move and speak, anesthesia of various perceptual modalities, such as lack of pain perception perceptual modalities, such as lack of pain perception (analgesia), tunnel vision, and bodily numbing (tactile (analgesia), tunnel vision, and bodily numbing (tactile and kinesthetic anesthesia; Nijenhuis, et al., 2001).and kinesthetic anesthesia; Nijenhuis, et al., 2001).
Ozer et al. (2003)Ozer et al. (2003) performed a meta-analysis on performed a meta-analysis on predictors of PTSD and related symptoms following predictors of PTSD and related symptoms following different forms of trauma.different forms of trauma.
Peritraumatic dissociation, Peritraumatic dissociation, acute emotions and PTSDacute emotions and PTSD
Peritraumatic dissociation was found to be the Peritraumatic dissociation was found to be the strongest predictor for PTSDstrongest predictor for PTSD as compared to as compared to prior traumaprior trauma, , prior psychological adjustmentprior psychological adjustment, , family history of psychopathologyfamily history of psychopathology, , perceived perceived life threat during traumalife threat during trauma, posttrauma social , posttrauma social support, and peritraumatic emotional support, and peritraumatic emotional responses.responses.
Measures of peritraumatic dissociation have Measures of peritraumatic dissociation have been found to predict PTSD and been found to predict PTSD and posttraumatic stress symptoms beyond the posttraumatic stress symptoms beyond the level of stress exposure, general dissociative level of stress exposure, general dissociative tendencies, locus of control, and social tendencies, locus of control, and social support (support (Marmar et al., 1999; Shalev, Peri, Marmar et al., 1999; Shalev, Peri, Canetti, & Schreiber, 1996Canetti, & Schreiber, 1996).).
Peritraumatic dissociation, Peritraumatic dissociation, acute emotions and PTSDacute emotions and PTSD
Peritraumatic dissociation was also predictive in Peritraumatic dissociation was also predictive in various groups of victims of trauma: Vietnam various groups of victims of trauma: Vietnam combat veterans (combat veterans (Kaufman et al., 2002Kaufman et al., 2002; ; Tichenor Tichenor et al., 1996et al., 1996), ), motor vehicle accident victimsmotor vehicle accident victims ((Delahanty, Roger, Raimonde, & Spoonster, 2003Delahanty, Roger, Raimonde, & Spoonster, 2003; ; Ursano et al., 1999Ursano et al., 1999), victims of natural disasters ), victims of natural disasters ((Koopman, Classen, & Spiegel, 1994Koopman, Classen, & Spiegel, 1994), emergency ), emergency service personnel (service personnel (Marmar et al., 1999Marmar et al., 1999), and ), and survivors of crime and assault (survivors of crime and assault (Freedman, Freedman, Brandes, Peri, & Shalev, 1999Brandes, Peri, & Shalev, 1999; ; Shalev et al., Shalev et al., 19961996) )
Peritraumatic dissociation, Peritraumatic dissociation, acute emotions and PTSDacute emotions and PTSD
Nevertheless, in the general trauma field the Nevertheless, in the general trauma field the predictive role of peritraumatic dissociation has predictive role of peritraumatic dissociation has not been confirmed in several other studies. not been confirmed in several other studies.
Marschall and Schell (2002)Marschall and Schell (2002) examined the link examined the link between peritraumatic dissociation and between peritraumatic dissociation and symptoms of PTSD in a sample of survivors of symptoms of PTSD in a sample of survivors of community violence. Although peritraumatic community violence. Although peritraumatic dissociation at baseline correlated with dissociation at baseline correlated with subsequent PTSD symptom severity, it was not an subsequent PTSD symptom severity, it was not an independent predictor of chronic PTSD symptoms.independent predictor of chronic PTSD symptoms.
Peritraumatic dissociation, Peritraumatic dissociation, acute emotions and PTSDacute emotions and PTSD
In a study on motor vehicle accident victims (In a study on motor vehicle accident victims (Holeva Holeva & Tarrier, 2001& Tarrier, 2001) peritraumatic dissociation was ) peritraumatic dissociation was not found to be predictive of PTSD. not found to be predictive of PTSD.
According to According to Gershuny, Cloitre, and Otto (2003),Gershuny, Cloitre, and Otto (2003), little attention has been paid to possible little attention has been paid to possible mediating relationships between peritraumatic mediating relationships between peritraumatic emotions and peritraumatic dissociation. These emotions and peritraumatic dissociation. These authors found in their study that the effect of authors found in their study that the effect of peritraumatic dissociation was eliminated when peritraumatic dissociation was eliminated when controlling for peritraumatic emotions such as controlling for peritraumatic emotions such as fear and loss of control. fear and loss of control.
These studies indicate that the predictive role of These studies indicate that the predictive role of peritraumatic dissociation is still indistinct.peritraumatic dissociation is still indistinct.
Peritraumatic emotions and Peritraumatic emotions and peritraumatic dissociationperitraumatic dissociation
The occurence of negative emotional responses The occurence of negative emotional responses during or directly after the traumatic event has during or directly after the traumatic event has also been found to be predictive of PTSD and also been found to be predictive of PTSD and posttraumatic stress symptoms. posttraumatic stress symptoms.
Brewin et al. (2000)Brewin et al. (2000) reported that intense levels of reported that intense levels of fear, helplessness, and horro strongly predicted fear, helplessness, and horro strongly predicted PTSD six months post-trauma. PTSD six months post-trauma.
In their meta-analysis In their meta-analysis Ozer et al. (2003)Ozer et al. (2003) found that found that peritraumatic emotional responses were the peritraumatic emotional responses were the second strongest predictor of posttraumatic second strongest predictor of posttraumatic stress symptoms or current PTSD, after stress symptoms or current PTSD, after peritraumatic dissociation.peritraumatic dissociation.
Peritraumatic emotions and Peritraumatic emotions and peritraumatic dissociationperitraumatic dissociation
Vehement emotional reactions during or shortly Vehement emotional reactions during or shortly after the trauma such as after the trauma such as intense fear, intense fear, helplessness, loss of control, and horrorhelplessness, loss of control, and horror were were found to be related to PTSD and posttraumatic found to be related to PTSD and posttraumatic stress symptoms in various groups of victims of stress symptoms in various groups of victims of potentially traumatizing experiences such as potentially traumatizing experiences such as serious accidents and natural disasters (Bernat et serious accidents and natural disasters (Bernat et al., 1998), violent crime (Brewin et al., 2000), al., 1998), violent crime (Brewin et al., 2000), motor vehicle accidents (Ehlers, Mayou, & Bryant, motor vehicle accidents (Ehlers, Mayou, & Bryant, 1998), and terrorist attacks (Simeon, Greenberg, 1998), and terrorist attacks (Simeon, Greenberg, Knutelska, Schmeidler, & Hollander, 2003).Knutelska, Schmeidler, & Hollander, 2003).
Peritraumatic emotions and Peritraumatic emotions and peritraumatic dissociationperitraumatic dissociation
Studies have suggested that dissociation is a Studies have suggested that dissociation is a response to response to overwhelming emotionaloverwhelming emotional and and physiological arousalphysiological arousal (Bernat et al., 1998; Van der (Bernat et al., 1998; Van der Kolk & Van der Hart, 1989).Kolk & Van der Hart, 1989).
Peritraumatic dissociationPeritraumatic dissociation has been found to be has been found to be related to related to greater perceived threatgreater perceived threat and and greater greater externality in locus of controlexternality in locus of control (Marmar, Weiss, (Marmar, Weiss, Metzler, & Delucchi, 1996),Metzler, & Delucchi, 1996), loss of control, loss of control, helplessnesshelplessness, and , and angeranger (Simeon et al., 2003),(Simeon et al., 2003), and and hyperarousalhyperarousal and and anxietyanxiety (Sterlini & Bryant, (Sterlini & Bryant, 2002).2002).
Peritraumatic emotions and Peritraumatic emotions and peritraumatic dissociationperitraumatic dissociation
Bernat et al. (1998)Bernat et al. (1998) reported that the relationship reported that the relationship between acute fear and peritraumatic between acute fear and peritraumatic dissociation was mediated by dissociation was mediated by acute panic acute panic symptomssymptoms, and that peritraumatic dissociation is , and that peritraumatic dissociation is the proximal outcome of overwhelming traumatic the proximal outcome of overwhelming traumatic fear and attendant physiological responding.fear and attendant physiological responding.
Peritraumatic emotions and Peritraumatic emotions and peritraumatic dissociationperitraumatic dissociation
According to According to Gershuny et al. (2003),Gershuny et al. (2003), peritraumatic dissociation could be peritraumatic dissociation could be conceptualized as part of a panic process. conceptualized as part of a panic process. These authors suggested that These authors suggested that fears about fears about deathdeath and and loss of controlloss of control are cognitive are cognitive components of panic.components of panic.
The cognitive appraisal of the traumatic event as The cognitive appraisal of the traumatic event as unmanageable, as reflected by fears of death unmanageable, as reflected by fears of death and losing, may help elicit dissociation. and losing, may help elicit dissociation.
In addition, fears of death and losing control In addition, fears of death and losing control mediated the relationship between mediated the relationship between peritraumatic dissociation and PTSD peritraumatic dissociation and PTSD (Gershuny (Gershuny et al., 2003).et al., 2003).
EMPIRICAL VALIDATIONEMPIRICAL VALIDATIONReduction of posttraumatic sequelae by Reduction of posttraumatic sequelae by
the use of fire & rescue squirrelsthe use of fire & rescue squirrels
De Soir, E. De Soir, E. (Royal Military Academy)(Royal Military Academy)
& & Goffings, K.Goffings, K.
(University of Maastricht)(University of Maastricht)
EVIDENCE-BASED PRACTICE FROM EVIDENCE-BASED PRACTICE FROM PRACTICE-BASED EVIDENCEPRACTICE-BASED EVIDENCE
Field experiences during Field experiences during severe MVA with fire & rescue severe MVA with fire & rescue
servicesservices
B A S I C SB A S I C S ofof
Advanced Psychological SupportAdvanced Psychological Support
Teach fire, rescue and emergency Teach fire, rescue and emergency services personnel how to act on the services personnel how to act on the scene of the accident or disaster in scene of the accident or disaster in
order to reduce the impact of ‘trauma order to reduce the impact of ‘trauma predicting factors’predicting factors’
A victims never forgets the first caregiver
INTRODUCTION OF THE FIRE-SQUIRREL CONCEPT
KEY POINTSKEY POINTS
Consider the psychobiological and physiological aspects to Consider the psychobiological and physiological aspects to be the foundation for both emotional and cognitive impactbe the foundation for both emotional and cognitive impact
Grounden the victim(s) in a controlable and predictable Grounden the victim(s) in a controlable and predictable (as much as possible) reality(as much as possible) reality
Work to influence the experience of loss of control, Work to influence the experience of loss of control, vehement emotions (panic), life-threat, pain and vehement emotions (panic), life-threat, pain and orientationorientation
Calm and reassure: reduce (hyper)arousal and provide Calm and reassure: reduce (hyper)arousal and provide feedback on physical reactions and sensationsfeedback on physical reactions and sensations
Assist the victim(s) with breathing and communicationAssist the victim(s) with breathing and communication Explore the experiences and engage the victim(s) in their Explore the experiences and engage the victim(s) in their
own rescue and evacuationown rescue and evacuation VICTIMS SHOULD BECOME AN ACTIVE ACTOR IN BOTH THE VICTIMS SHOULD BECOME AN ACTIVE ACTOR IN BOTH THE
RESCUE OPERATIONS AND TRAUMA RECOVERYRESCUE OPERATIONS AND TRAUMA RECOVERY
SAFETYSAFETY
PERMISSIONPERMISSION
STRUCTURE
INFORMATIONINFORMATION
RECONNAISSANCERECONNAISSANCE
REACTIONSREACTIONS
CONTACT POINTSCONTACT POINTS
KEY TASKSKEY TASKS
Discussion of further Discussion of further analysis opportunities and analysis opportunities and
needsneeds
[email protected]@rma.ac.be
