PSYCHOSOCIAL CARE PSYCHOSOCIAL CARE AFTER A BIOTERROR AFTER A BIOTERROR ATTACK ATTACK Marlene Rankin, Ph D, RN Marlene Rankin, Ph D, RN Clinical Associate Professor, College of Nursing Clinical Associate Professor, College of Nursing Rutgers The State University of New Jersey Rutgers The State University of New Jersey College of Nursing College of Nursing Nursing Center for Bioterrorism and Infectious Nursing Center for Bioterrorism and Infectious Disease Preparedness Disease Preparedness
Transcript
PSYCHOSOCIAL CARE PSYCHOSOCIAL CARE AFTER A BIOTERROR AFTER A BIOTERROR
ATTACKATTACK
Marlene Rankin, Ph D, RNMarlene Rankin, Ph D, RNClinical Associate Professor, College of NursingClinical Associate Professor, College of Nursing
Rutgers The State University of New JerseyRutgers The State University of New JerseyCollege of NursingCollege of Nursing
Nursing Center for Bioterrorism and InfectiousNursing Center for Bioterrorism and InfectiousDisease Preparedness Disease Preparedness
The format and information in this moduleThe format and information in this modulefocuses on psychosocial care after a bioterror focuses on psychosocial care after a bioterror attack. This module is designed to highlightattack. This module is designed to highlightimportant information about psychologicalimportant information about psychologicalresponses and care after a bioterror attack. responses and care after a bioterror attack. This module was supported in part by This module was supported in part by USDHHS, HRSA Grant No. T01HP01407.USDHHS, HRSA Grant No. T01HP01407.
PurposePurpose Observations following conventional terrorist Observations following conventional terrorist
incidents and other trauma, including biological and incidents and other trauma, including biological and nuclear accidents, suggest that a biochemical nuclear accidents, suggest that a biochemical terrorist incident would have widespread public terrorist incident would have widespread public effects. effects.
Unlike in natural disasters or other situations Unlike in natural disasters or other situations resulting in mass casualties, nurses, health care resulting in mass casualties, nurses, health care workers and physicians would be most likely to workers and physicians would be most likely to identify the unfolding disaster associated with a identify the unfolding disaster associated with a biological attack. biological attack.
A bioterrorist attack would necessitate treatment of A bioterrorist attack would necessitate treatment of individuals and communities who experience individuals and communities who experience psychological symptoms and syndromes. psychological symptoms and syndromes.
Recognizing the influence that psychological distress Recognizing the influence that psychological distress has on recovery and physical symptoms allows has on recovery and physical symptoms allows nurses and health care workers to more effectively nurses and health care workers to more effectively treat patients.treat patients.
PurposePurpose-2-2
Initial psychosocial interventions include effective Initial psychosocial interventions include effective and accurate risk assessment, communication, and accurate risk assessment, communication, management of acute abnormal psychological management of acute abnormal psychological and somatic symptoms, and an environment that and somatic symptoms, and an environment that supports recovery and realistic client response supports recovery and realistic client response outcomes. outcomes.
Factors that influence psychological outcome Factors that influence psychological outcome include interpersonal and environmental aspects.include interpersonal and environmental aspects.
The long-term effects following a traumatic event The long-term effects following a traumatic event are influenced by an individual’s unique are influenced by an individual’s unique combination of health, developmental level, combination of health, developmental level, resources and experiences. resources and experiences.
The nurse must be cognizant of personal needs The nurse must be cognizant of personal needs and self care during this crisis time.and self care during this crisis time.
Individual EffectsIndividual Effects IndividualIndividual effects of disaster trauma include the physical and effects of disaster trauma include the physical and
psychological consequences of those injured or infected as well psychological consequences of those injured or infected as well as psychological consequences of the injured person’s loved as psychological consequences of the injured person’s loved ones. ones.
Individuals with no direct connection to the trauma, other than Individuals with no direct connection to the trauma, other than awareness, can experience psychological symptoms as well. awareness, can experience psychological symptoms as well.
In bioterrorism, where events often occur with no warning, In bioterrorism, where events often occur with no warning, individuals may experience random patterns of unpredictable individuals may experience random patterns of unpredictable and continuous fear (Braden, 2002). and continuous fear (Braden, 2002).
No one is safe and people can not within reason change their No one is safe and people can not within reason change their behavior to decrease risk. behavior to decrease risk.
The victims who are killed, injured or even directly affected are The victims who are killed, injured or even directly affected are rarely the primary target (Susser, 2002). rarely the primary target (Susser, 2002).
Victims may include adults and children, both genders, and Victims may include adults and children, both genders, and include multiple racial groups as occurred with the anthrax include multiple racial groups as occurred with the anthrax attacks. attacks.
The risk of panic is heightened when individuals believe there The risk of panic is heightened when individuals believe there is a small chance of escape or they are likely to become is a small chance of escape or they are likely to become infected (Holloway (1997).infected (Holloway (1997).
Community EffectsCommunity Effects CommunityCommunity physical resources are affected by physical resources are affected by
bioterrorism as well as the behavior and cohesive bioterrorism as well as the behavior and cohesive nature of the community. nature of the community.
A range of negative outcomes are possible A range of negative outcomes are possible including a vulnerable population’s refusal to including a vulnerable population’s refusal to accept preventative measures or treatment accept preventative measures or treatment regimes such as isolation and quarantine, social regimes such as isolation and quarantine, social disruption, and civil violence. disruption, and civil violence.
Beyond the human health toll, there is the Beyond the human health toll, there is the damage inflicted by ethnic stereotyping, damage inflicted by ethnic stereotyping, stigmatization, and finally staggering business stigmatization, and finally staggering business and economic losses (Hall, 2003). and economic losses (Hall, 2003).
There could be a disruption in the social There could be a disruption in the social infrastructure adversely affecting community, infrastructure adversely affecting community, leadership and safety. leadership and safety.
Most people pull Most people pull together and together and function after a function after a disaster, but their disaster, but their effectiveness is effectiveness is diminished. diminished.
Biological weapons Biological weapons are especially are especially effective at causing effective at causing fear and horrorfear and horror
Disaster Stress and Grief Disaster Stress and Grief Reactions are NormalReactions are Normal
StressStress and and griefgrief reactions reactions are normal responses to an are normal responses to an abnormal situation. abnormal situation.
Many emotional reactions Many emotional reactions of disaster survivors stem of disaster survivors stem from problems of living from problems of living brought about by the brought about by the disaster. disaster.
In a terror situation most In a terror situation most people will experience people will experience some level of psychological some level of psychological distress including an distress including an altered sense of safety, altered sense of safety, sadness, anger, fear and sadness, anger, fear and decreased concentration.decreased concentration.
Disaster Stress and Grief Disaster Stress and Grief Reactions are NormalReactions are Normal-2-2
Yet most individuals do not see Yet most individuals do not see themselves as needing mental health themselves as needing mental health services following disaster and will services following disaster and will not seek such services. not seek such services.
Most individuals will function Most individuals will function adequately, but a few will need adequately, but a few will need psychological intervention. psychological intervention.
Disaster Stress and Grief Disaster Stress and Grief Reactions are NormalReactions are Normal-3-3
Assessment considerations should include Assessment considerations should include ethnoculturalethnocultural concerns that reflect ethnic concerns that reflect ethnic heritage or cultural identity. heritage or cultural identity.
Individuals may value their ethnic Individuals may value their ethnic background but wish to avoid being background but wish to avoid being stereotyped. stereotyped.
Intrapersonal aspects must consider the Intrapersonal aspects must consider the patient’s developmental level and inner patient’s developmental level and inner resilience.resilience.
At-Risk Populations for Psychological At-Risk Populations for Psychological Sequelae Following a Bioterror AttackSequelae Following a Bioterror Attack
Those exposed to the dead and injured including Those exposed to the dead and injured including eye witnesses, emergency first responders, those eye witnesses, emergency first responders, those endangered by the event, and medical personnel endangered by the event, and medical personnel caring for victims.caring for victims.
The elderly and very young.The elderly and very young. Individuals, who because of the event are hungry, Individuals, who because of the event are hungry,
cannot drink clean water, are exposed to weather, cannot drink clean water, are exposed to weather, or become extremely fatigued.or become extremely fatigued.
Individuals who continue to be exposed to a toxic Individuals who continue to be exposed to a toxic contamination.contamination.
Individuals with a history of exposure to other Individuals with a history of exposure to other traumas or with recent or major life stressors or traumas or with recent or major life stressors or emotional strain such as poverty, homelessness, emotional strain such as poverty, homelessness, unemployment, or discrimination.unemployment, or discrimination.
Patients with chronic medical or psychiatric Patients with chronic medical or psychiatric diagnoses. diagnoses.
Assess Normal Coping Behaviors Assess Normal Coping Behaviors of Patientsof Patients
The active process of The active process of using personal, using personal, psychological, social, psychological, social, and environmental and environmental resources to manage resources to manage stress or anxiety.stress or anxiety.
Enables the patient to Enables the patient to discern problems to discern problems to recognize possible recognize possible solutions or strategies solutions or strategies such as defense such as defense mechanisms.mechanisms.
Assess Normal Coping Behaviors Assess Normal Coping Behaviors of Patientsof Patients-2-2
Factors Influencing CopingFactors Influencing Coping• Fear of pain and discomfort.Fear of pain and discomfort.• Fear of the unknown, based on experience Fear of the unknown, based on experience
and uncertainty about final outcomeand uncertainty about final outcome• Fear of complications or loss of controlFear of complications or loss of control• Fear of disruption of life pattern Fear of disruption of life pattern • The patient’s previous health care The patient’s previous health care
experiences, hospitalizations, and pre- and experiences, hospitalizations, and pre- and post-event treatment affect psychosocial post-event treatment affect psychosocial functioning functioning
Seeking informationSeeking information DenialDenial RepressionRepression Using drugs or Using drugs or
alcoholalcohol Increased smokingIncreased smoking
Physical exercisePhysical exercise Journal writingJournal writing Relaxation tapesRelaxation tapes Reading books or Reading books or
magazinesmagazines Talking the Talking the
problem outproblem out Trusting in Trusting in
religious faithreligious faith Relying on support Relying on support
from othersfrom others
Assess and Reinforce the Assess and Reinforce the Individual’s StrengthsIndividual’s Strengths
The patient’s The patient’s strengths represent an strengths represent an untapped energy untapped energy source.source.
Identifying the Identifying the patient’s strengths will patient’s strengths will give perspective.give perspective.
Determine how the Determine how the patient can use these patient can use these strengths in this strengths in this situation.situation.
Personal values and Personal values and goals differgoals differ
Mini Mental Status ExaminationMini Mental Status Examination Determine the significance and Determine the significance and
importance of the event to the patient, importance of the event to the patient, nature and degree of exposure.nature and degree of exposure.
Assess the patient’s mood, orientation, Assess the patient’s mood, orientation, affect, general appearance, and thought affect, general appearance, and thought processes.processes.
Use open-ended questions, “Tell me what Use open-ended questions, “Tell me what is going on”, “It is often difficult to know is going on”, “It is often difficult to know where to begin.” where to begin.”
Discuss temporary loss of life’s routines Discuss temporary loss of life’s routines and possible sexual restrictions.and possible sexual restrictions.
Mini Mental Status ExaminationMini Mental Status Examination-2-2
Assess sleep Assess sleep patterns for possible patterns for possible sleep disorder or sleep disorder or trauma.trauma.
Examine patient’s Examine patient’s perception of perception of possible risks or possible risks or permanent permanent limitations from limitations from bioterror agent.bioterror agent.
Evaluate according Evaluate according to individual’s to individual’s developmental level.developmental level.
The nurse must be cautious about conversations in The nurse must be cautious about conversations in the hospital because the patient may be able to hear the hospital because the patient may be able to hear what is going on but unable to clarify or interpret what is going on but unable to clarify or interpret coherently.coherently.
The hospital environment may alter the patient’s The hospital environment may alter the patient’s perception.perception.
A patient who has been medicated, receives IV A patient who has been medicated, receives IV sedation, or who is undergoing or emerging from a sedation, or who is undergoing or emerging from a biological agent may be influenced by:biological agent may be influenced by:• physical restraintphysical restraint• sensory overloadsensory overload• sensory deprivation due to edema, shock or medical sensory deprivation due to edema, shock or medical
emergencyemergency• overheard conversationoverheard conversation• generalized and specific effects of drugsgeneralized and specific effects of drugs
The patient may have The patient may have a transient a transient psychological psychological disturbance during the disturbance during the early assessment early assessment period due to:period due to:• personality structurepersonality structure• change in appearancechange in appearance• uncertainty about uncertainty about
outcome of attack or outcome of attack or prognosisprognosis
• attitudes and reactions attitudes and reactions of significant othersof significant others
Common Psychological Responses Common Psychological Responses to a Biological Attackto a Biological Attack
AnxietyAnxiety – a universal unpleasant – a universal unpleasant feeling of tension and apprehension, feeling of tension and apprehension, a normal response to stress a normal response to stress accompanied by a variety of accompanied by a variety of physical, affective, cognitive, and physical, affective, cognitive, and behavioral symptoms that have both behavioral symptoms that have both positive and negative effects and positive and negative effects and range from mild to panic (see Table 1 range from mild to panic (see Table 1 next frame).next frame).
Table 1. Table 1. DSM-IV (1994) Criteria For Panic Attack, Posttraumatic StressDSM-IV (1994) Criteria For Panic Attack, Posttraumatic Stress
Disorder and Acute Stress DisorderDisorder and Acute Stress Disorder
Panic AttackPanic Attack PTSDPTSD Acute StressAcute Stress (4 or more symptoms (4 or more symptoms (Symptoms can be (Symptoms can be (Symptoms occur (Symptoms occur present, present, sudden onsetsudden onset immediate or delayedimmediate or delayed immediately, end withinimmediately, end within peak in 10 minutespeak in 10 minutes)) for yearsfor years, stressors, stressors 4 weeks4 weeks; 3 or more symp-; 3 or more symp-
trigger at least 3 trigger at least 3 toms present for 2 days) toms present for 2 days) symptoms)symptoms)
__________________________________________________________________________________________________________________________________________________________________________ PalpitationsPalpitations Experienced an Experienced an Exposure to a traumatic Exposure to a traumatic SweatingSweating event that caused event that caused event involving threat event involving threat Trembling/ShakingTrembling/Shaking severe threat to self severe threat to self to self to self Shortness of breathShortness of breath Feeling of chokingFeeling of choking Response of intense Response of intense Response of intense Response of intense Chest discomfortChest discomfort fear, helplessness, or fear, helplessness, or fear, helplessness, or fear, helplessness, or NauseaNausea horror horror horror horror Feelings of unrealityFeelings of unreality Hypervigilance Hypervigilance Clinical distress Clinical distress Fear of losing controlFear of losing control Recurrent thoughts Detachment/Daze Recurrent thoughts Detachment/Daze Fear of dyingFear of dying or nightmares or nightmares Depersonalization Depersonalization NumbnessNumbness Flashbacks Flashbacks Recurrent dreams Recurrent dreams ChillsChills Intense distress Intense distress Flashbacks Flashbacks Hot flushesHot flushes Physiological reactivity Irritability Physiological reactivity Irritability GI upsetGI upset to symbolic cue to symbolic cue Poor concentration Poor concentration Avoidance of cues Avoidance of cues Avoidance of Avoidance of associated to trauma associated to trauma recollections of trauma recollections of trauma Symptoms of arousal Symptoms of arousal Amnesia Amnesia Sleep disorderSleep disorder Anxiety Anxiety
Common Psychological Responses Common Psychological Responses to a Biological Attackto a Biological Attack-2-2
Mild anxietyMild anxiety is reflected as verbal is reflected as verbal expression of concerns, restlessness, expression of concerns, restlessness, irritability, agitation, or crying. Often times irritability, agitation, or crying. Often times there are repeated questions and an there are repeated questions and an inability to focusinability to focus
Moderate levels of anxietyModerate levels of anxiety may include may include periods of shortness of breath, gastric periods of shortness of breath, gastric symptoms such as “butterflies” in the symptoms such as “butterflies” in the stomach”, selective inattention, facial stomach”, selective inattention, facial twitches and trembling lips, and twitches and trembling lips, and irritability.irritability.
Common Psychological Responses Common Psychological Responses to a Biological Attackto a Biological Attack-3-3
InterventionsInterventions include distraction techniques such include distraction techniques such as listening to music, reading a book, talking to as listening to music, reading a book, talking to a friend, playing a game, or counting backward a friend, playing a game, or counting backward by threes.by threes.
RationaleRationale: Distraction techniques allow people to : Distraction techniques allow people to remain in control when experiencing moderate remain in control when experiencing moderate levels of anxiety, the brain levels of anxiety, the brain
cannot hold two thoughts at cannot hold two thoughts at
PanicPanic Panic level of anxietyPanic level of anxiety is associated with is associated with
awe, dread, and terror. awe, dread, and terror. The person experiences a loss of control The person experiences a loss of control
and is unable to do things even with and is unable to do things even with direction and results in increased motor direction and results in increased motor activity, decreased ability to relate to activity, decreased ability to relate to others, distorted perceptions, and loss of others, distorted perceptions, and loss of rational thought. rational thought.
This level of anxiety is incompatible with This level of anxiety is incompatible with life; death and exhaustion will occur if it life; death and exhaustion will occur if it continues for a long period (Stuart and continues for a long period (Stuart and Laraia, 2005). Laraia, 2005).
PanicPanic-2-2
Specific clinical cues include: Specific clinical cues include: • shortness of breath, choking smothering shortness of breath, choking smothering
sensationsensation• hypotension, dizziness, chest pain or pressure, hypotension, dizziness, chest pain or pressure,
palpitationspalpitations• nauseanausea• hot flasheshot flashes• agitation, poor motor coordination, body agitation, poor motor coordination, body
tremblingtrembling• facial expression of terrorfacial expression of terror• fear of losing control, fear of dyingfear of losing control, fear of dying• completely disrupted perceptual fieldcompletely disrupted perceptual field
Interventions for Panic AttacksInterventions for Panic Attacks Use a calm approach, stay with the patient and Use a calm approach, stay with the patient and
give directions using simple, short sentences.give directions using simple, short sentences. Keep the patient focused on the present.Keep the patient focused on the present. Suggest deep breathing and tensing and relaxing Suggest deep breathing and tensing and relaxing
muscles of hands and feet. muscles of hands and feet. RationaleRationale: Staying : Staying with a patient promotes safety and reduces fear, with a patient promotes safety and reduces fear, deep breathing helps patients feel connected to deep breathing helps patients feel connected to the environment and reduces the physical the environment and reduces the physical excitement phase (Fontaine, Kneisl, & Trigoboff, excitement phase (Fontaine, Kneisl, & Trigoboff, 2004). 2004).
Depressive EpisodeDepressive Episode The patient reports a depressed mood or the loss of The patient reports a depressed mood or the loss of
interest or pleasure in nearly all activities. interest or pleasure in nearly all activities. In children and adolescents the mood may be In children and adolescents the mood may be
irritable rather than sad. irritable rather than sad. Appetite is usually reduced but in some cases Appetite is usually reduced but in some cases
individuals crave sweets or carbohydrates. individuals crave sweets or carbohydrates. Decreased energy, tiredness, and fatigue are Decreased energy, tiredness, and fatigue are
common with even the smallest tasks requiring a common with even the smallest tasks requiring a substantial effort.substantial effort.
There is a sense of worthlessness or guilt that may There is a sense of worthlessness or guilt that may include negativity or unworthiness. include negativity or unworthiness.
Many patients report impaired ability to think, Many patients report impaired ability to think, concentrate, and make decisions. concentrate, and make decisions.
Children may reflect poor academic performance Children may reflect poor academic performance and have recurrent thoughts of dying young (DSM-and have recurrent thoughts of dying young (DSM-IV, 1994). IV, 1994).
Patients do not have hallucinations or delusions! Patients do not have hallucinations or delusions!
Depressive EpisodeDepressive Episode-2-2
Symptoms include:Symptoms include:• SadnessSadness• DemoralizationDemoralization• Isolation/withdrawalIsolation/withdrawal• Impaired concentrationImpaired concentration• Sleep and appetite Sleep and appetite
disturbancesdisturbances
Somatization DisorderSomatization Disorder
The patient has reported physical The patient has reported physical symptoms with no clinical findings to symptoms with no clinical findings to support subjective complaints. support subjective complaints.
The DSM-IV (1994) includes the following The DSM-IV (1994) includes the following criteria:criteria:• A history of many physical complaints that A history of many physical complaints that
begins to interfere with social, occupational begins to interfere with social, occupational and other important areas of functioning. and other important areas of functioning.
This disorder may occur in patients This disorder may occur in patients undergoing serious life stressors, and undergoing serious life stressors, and whose coping patterns and defense whose coping patterns and defense mechanisms are failing. mechanisms are failing.
Somatization DisorderSomatization Disorder-2-2
Symptoms may include:Symptoms may include:• Fatigue Fatigue • WeaknessWeakness• MalaiseMalaise• GI complaintsGI complaints• Headache Headache • Impaired balanceImpaired balance• Skin rashesSkin rashes
Post Traumatic Stress Disorder Post Traumatic Stress Disorder (PTSD)(PTSD)
The patient has experienced a traumatic The patient has experienced a traumatic event (bioterrorism) that threatens serious event (bioterrorism) that threatens serious injury, death or is a threat to one’s own injury, death or is a threat to one’s own physical integrity. physical integrity.
The patient reacts with horror, extreme The patient reacts with horror, extreme fright, or helplessness and repeatedly re-fright, or helplessness and repeatedly re-experiences the event or avoids anything experiences the event or avoids anything that evokes memories of it. that evokes memories of it.
These patients tend to be easily startled, These patients tend to be easily startled, anxious, and tense and the full symptom anxious, and tense and the full symptom picture must be present for more than one picture must be present for more than one month. month.
PTSDPTSD-2-2
Most patients complain of insomnia Most patients complain of insomnia and they struggle with concentration. and they struggle with concentration.
Major depression is common in Major depression is common in delayed reactions. delayed reactions.
Many patients will use alcohol or Many patients will use alcohol or sleeping medications.sleeping medications.
Children will have scary nightmare Children will have scary nightmare and think they will die young. and think they will die young.
PTSDPTSD-3-3
The DSM-IV (1994) lists the following cluster of The DSM-IV (1994) lists the following cluster of symptoms:symptoms:
• Re-experiencingRe-experiencing• Efforts to avoid Efforts to avoid
thoughts, feelings thoughts, feelings associated with the associated with the traumatrauma
• Shock Shock • FearFear• PanicPanic• Numbing Numbing • Inability to recall an Inability to recall an
important aspect of the important aspect of the traumatrauma
• Hyperarousal or Hyperarousal or hypervigilance hypervigilance
• Anger Anger • Difficulty concentratingDifficulty concentrating• Irritability Irritability • DetachmentDetachment• Estrangement from Estrangement from
Most patients suffer some form of PTSD Most patients suffer some form of PTSD initially and in the majority of cases it will initially and in the majority of cases it will diminish over two months. diminish over two months.
However, referral to a mental health clinic However, referral to a mental health clinic is appropriate for patients who have is appropriate for patients who have symptoms of PTSD after three months for symptoms of PTSD after three months for treatment and usually includes cognitive treatment and usually includes cognitive and behavioral therapies. and behavioral therapies.
Medication such as fluoxetine (Prozac) has Medication such as fluoxetine (Prozac) has been effective in controlled clinical trials. been effective in controlled clinical trials.
Treatment for PTSDTreatment for PTSD-2-2
After the World Trade Center 9/11 attack, After the World Trade Center 9/11 attack, the estimated prevalence of PTSD in the estimated prevalence of PTSD in Manhattan was 20% (Hall et al. 2003). Manhattan was 20% (Hall et al. 2003).
Unfortunately, PTSD is rarely a patient’s Unfortunately, PTSD is rarely a patient’s only psychiatric diagnosis and it is only psychiatric diagnosis and it is sometimes difficult to distinguish sometimes difficult to distinguish overlapping independent symptoms from overlapping independent symptoms from effects of the trauma. effects of the trauma.
Nearly half of all people with PTSD also Nearly half of all people with PTSD also suffer from major depression and more suffer from major depression and more than a third from phobias and alcoholism. than a third from phobias and alcoholism.
PTSD is a highly prevalent and impairing PTSD is a highly prevalent and impairing condition (Moore & Jefferson, 2004).condition (Moore & Jefferson, 2004).
Psychological Responses to Bioterror Psychological Responses to Bioterror Trauma in Children and AdolescentsTrauma in Children and Adolescents
Pre-school agePre-school age • depressed or irritable depressed or irritable
mood, mood, • temper tantrums, temper tantrums, • clinginess, clinginess, • increased dependency, increased dependency, • changes in appetite, changes in appetite, • sleep disturbances and sleep disturbances and
somatic complaints.somatic complaints.• After any disaster, After any disaster,
children are most afraid children are most afraid that the event will that the event will happen again or they happen again or they will be separated from will be separated from their family and left their family and left alone.alone.
Psychological Responses to Bioterror Psychological Responses to Bioterror Trauma in Children and AdolescentsTrauma in Children and Adolescents-2-2
School Age ChildrenSchool Age Children • separation anxiety, separation anxiety, • avoidance, avoidance, • regressive symptoms, regressive symptoms, • fear of the dark, fear of the dark, • decrease in school decrease in school
performance, performance, • re-enactment through re-enactment through
traumatic play, traumatic play, • withdrawal from friends, withdrawal from friends, • depression, depression, • aggressive behavior at aggressive behavior at
home or school, andhome or school, and• hyperactivity that was not hyperactivity that was not
present earlier. present earlier.
Psychological Responses to Bioterror Psychological Responses to Bioterror Trauma in Children and AdolescentsTrauma in Children and Adolescents-3-3
AdolescentsAdolescents • increased risk taking behavior, increased risk taking behavior, • drug or alcohol abuse, drug or alcohol abuse, • decline in previous decline in previous responsible behavior,responsible behavior,• social withdrawal, social withdrawal, • apathy, apathy, • depression, depression, • rebellion at home or at school, andrebellion at home or at school, and• increased sexual acting out. increased sexual acting out.
Helping Children Cope After A Helping Children Cope After A Traumatic EventTraumatic Event
Younger children under the age of 5 will Younger children under the age of 5 will understand the disaster in more general understand the disaster in more general terms. terms.
Eight to eleven year olds will be more Eight to eleven year olds will be more concrete in their understanding and ask concrete in their understanding and ask for more details. for more details.
Teenagers will understand all the Teenagers will understand all the implications and feel increasingly unsafe.implications and feel increasingly unsafe.
The child may feel responsible in some The child may feel responsible in some way- do not allow them to feel way- do not allow them to feel accountable for events that they have accountable for events that they have nono control over. control over.
Helping Children Cope After A Helping Children Cope After A Traumatic EventTraumatic Event-2-2
Talk with them openly at their developmental Talk with them openly at their developmental level, focus on the future and what they can do level, focus on the future and what they can do going forward. going forward.
Looking toward the future will empower the child Looking toward the future will empower the child and give a sense of control. and give a sense of control.
Focusing on the past will increase feelings of Focusing on the past will increase feelings of helplessness and anxiety.helplessness and anxiety.
Ask what they think has happened and about Ask what they think has happened and about their fearstheir fears
Emphasize the normal routine, going to school, Emphasize the normal routine, going to school, sports, and activities.sports, and activities.
Limit media re-exposure.Limit media re-exposure. Allow expression in private ways; storytelling, art, Allow expression in private ways; storytelling, art,
General Crisis Intervention PrinciplesGeneral Crisis Intervention Principles
Establish a trusting nurse/patient Establish a trusting nurse/patient relationship during the outreach stage.relationship during the outreach stage.
Focus on communication between the Focus on communication between the nurse and the patient/victim.nurse and the patient/victim.
Demonstrate a positive, nonjudgmental Demonstrate a positive, nonjudgmental attitude.attitude.
Focus on the patient’s verbal messages, Focus on the patient’s verbal messages, gestures, facial expressions, along with gestures, facial expressions, along with listening to the patient.listening to the patient.
General Crisis Intervention PrinciplesGeneral Crisis Intervention Principles-2-2
Discuss tests and procedures with the patient and Discuss tests and procedures with the patient and significant others. significant others.
Provide an opportunity for questions and answers Provide an opportunity for questions and answers if possible and if patient is coherent. if possible and if patient is coherent.
Never assume they cannot hear or understand!Never assume they cannot hear or understand! Allow the patient to verbalize any concerns or Allow the patient to verbalize any concerns or
fears. fears. Providing consistent emotional support and Providing consistent emotional support and
information in a nonthreatening manner information in a nonthreatening manner increases emotional safety.increases emotional safety.
Place importance on understanding the personal Place importance on understanding the personal meaning of the patient’s words, behaviors, and meaning of the patient’s words, behaviors, and feelings. feelings.
Priority Nursing InterventionsPriority Nursing Interventions The The first priorityfirst priority is to assess the lethality of the is to assess the lethality of the
bioterror event and to provide for the safety bioterror event and to provide for the safety needs of the victim. needs of the victim.
Normal patterns of response and coping Normal patterns of response and coping mechanisms are inadequate, and extra resources mechanisms are inadequate, and extra resources from within the patient, family, and health care from within the patient, family, and health care team are necessary (Aguilera, 1998).team are necessary (Aguilera, 1998).• Knowing and understanding the nature of the Knowing and understanding the nature of the
threat/attack.threat/attack.• Assessing the patient’s perception of the threat.Assessing the patient’s perception of the threat.• Identifying and reinforcing positive coping behaviors.Identifying and reinforcing positive coping behaviors.• Providing assistance for significant others.Providing assistance for significant others.• Coordinating care.Coordinating care.• Serving as a patient advocate.Serving as a patient advocate.• Mobilizing community resources as appropriate.Mobilizing community resources as appropriate.• Psychopharmacology (anti-anxiety agents) as ordered.Psychopharmacology (anti-anxiety agents) as ordered.
Provide the patient with specific Provide the patient with specific instructions, such as:instructions, such as:• written literature and educational materialswritten literature and educational materials• teaching activitiesteaching activities• verbal reassurance, expression of concernverbal reassurance, expression of concern• emergency phone number and pager emergency phone number and pager
instructionsinstructions Provide your full attention when you are Provide your full attention when you are
Reassure patient that Reassure patient that the nurse is present the nurse is present and available:and available:• do what you say you do what you say you
will dowill do• answer patient’s answer patient’s
questions clearly and questions clearly and preciselyprecisely
• help patient verbalize help patient verbalize feelingsfeelings
• touch patient when touch patient when he/she needs comforthe/she needs comfort
Many losses may be associated with Many losses may be associated with a bioterror attack such as a bioterror attack such as bereavement following the death of bereavement following the death of loved ones, finances, occupational loved ones, finances, occupational changes and social withdrawal.changes and social withdrawal.
Patients may be depressed, with Patients may be depressed, with suicidal thoughts present. suicidal thoughts present.
Many experience “survivor guilt” Many experience “survivor guilt” ( Stuart& Laraia, 2005). ( Stuart& Laraia, 2005).
Nursing Interventions for Nursing Interventions for DepressionDepression
Assess for suicidal thoughts and plans. A high Assess for suicidal thoughts and plans. A high percentage of patients who are depressed commit percentage of patients who are depressed commit suicide, the first priority of care is prevention and suicide, the first priority of care is prevention and patient safety. patient safety. • Has the patient made any verbal suicide threats? Has the patient made any verbal suicide threats? • Has the patient communicated nonverbally by giving away Has the patient communicated nonverbally by giving away
prized possessions or revised a will?prized possessions or revised a will? Referral for psychopharmacological evaluation. Referral for psychopharmacological evaluation. Evidence supports that selective serotonin reuptake Evidence supports that selective serotonin reuptake
inhibitors (SSRIs) are effective for the treatment of inhibitors (SSRIs) are effective for the treatment of depression.depression.
Patient’s thoughts are slowed down, give extra time Patient’s thoughts are slowed down, give extra time to process questions and respond to messages.to process questions and respond to messages.
Use reality testing to help patients identify irrational Use reality testing to help patients identify irrational beliefs and thoughts. beliefs and thoughts.
Nursing Interventions for Nursing Interventions for DepressionDepression-2-2
Set limits on amount of time patient spends Set limits on amount of time patient spends discussing bioterror event and trauma.discussing bioterror event and trauma.
Rumination may intensify guilt and feelings Rumination may intensify guilt and feelings of helplessness.of helplessness.
Encourage some form of physical exercise Encourage some form of physical exercise such as walking. such as walking.
The literature gives evidence that even The literature gives evidence that even walking for 20 minutes three times per walking for 20 minutes three times per week improves depressive symptoms.week improves depressive symptoms.
Facilitate patients use of coping strategies Facilitate patients use of coping strategies that improve functioning; prayer, journal that improve functioning; prayer, journal writing, meditation, yoga, and relaxation writing, meditation, yoga, and relaxation techniques.techniques.
Clinical Application: Clinical Application: Altered Body ImageAltered Body Image
When the bioterror attack involves an When the bioterror attack involves an agent such as smallpox or disfiguring agent such as smallpox or disfiguring germs, many patients may have a germs, many patients may have a diagnosis of disfigured or altered body diagnosis of disfigured or altered body image. image.
There will be a severe psychological There will be a severe psychological disconnect between the individual’s disconnect between the individual’s perception of how his or her body was and perception of how his or her body was and the modified “new” body or disfigurement the modified “new” body or disfigurement (Stuart& Laraia, 2005).(Stuart& Laraia, 2005).
Nursing Interventions for Altered Nursing Interventions for Altered Body ImageBody Image
Recognize the stages of grief and encourage Recognize the stages of grief and encourage patients to utilize appropriate coping mechanisms patients to utilize appropriate coping mechanisms to work through reintegration of body image to work through reintegration of body image changes. changes.
Discuss with patient perceptions of changed Discuss with patient perceptions of changed appearance. The patient will feel depersonalized appearance. The patient will feel depersonalized and have a feeling of unreality and alienation and have a feeling of unreality and alienation from the self.from the self.
Provide incremental exposure to social Provide incremental exposure to social environments and support the patient in his/her environments and support the patient in his/her rehearsal of useful coping strategies.rehearsal of useful coping strategies.
Focus on the patient as a whole. Focus on the patient as a whole. Emphasize the acknowledgment and utilization of Emphasize the acknowledgment and utilization of
what remains, rather than focusing on what was what remains, rather than focusing on what was lost. lost.
Nursing Interventions for Altered Nursing Interventions for Altered Body ImageBody Image-2-2
Assist patient in coping with temporary Assist patient in coping with temporary changes such as bruising and edema.changes such as bruising and edema.
Provide patient opportunities for privacy to Provide patient opportunities for privacy to reflect on what has happened and what reflect on what has happened and what the body changes mean, and to the body changes mean, and to experiment with approaches to deal with experiment with approaches to deal with body image alterations.body image alterations.
Although body image contains elements of Although body image contains elements of reality and the ideal, the nurse should reality and the ideal, the nurse should emphasize reality.emphasize reality.
Nursing Interventions for Altered Nursing Interventions for Altered Body ImageBody Image-3-3
Sensory input is vital to body image Sensory input is vital to body image reintegration, especially when body reintegration, especially when body boundaries need to be reestablished boundaries need to be reestablished (e.g., loss of limb). (e.g., loss of limb).
Provide sensory stimulation to Provide sensory stimulation to damaged areas to renew and reinforce damaged areas to renew and reinforce previous responses and mobilize previous responses and mobilize forgotten sensations and functions.forgotten sensations and functions.
Facilitate body image reintegration by Facilitate body image reintegration by encouraging the patient to look at and encouraging the patient to look at and touch the site, face, limb while touch the site, face, limb while exploring questions and feelings about exploring questions and feelings about appearance and/or function. appearance and/or function.
Stress Management and Self Care Stress Management and Self Care of Nursesof Nurses
Nurses need to be aware of their own Nurses need to be aware of their own stress responses, especially if they are stress responses, especially if they are providing direct care to victims. providing direct care to victims.
Psychological preparation can reduce Psychological preparation can reduce psychological risk in first responders. psychological risk in first responders.
The more exposure to trauma the more The more exposure to trauma the more the nurse is at risk. the nurse is at risk.
It is cumulative! It is cumulative! Experience is not necessarily protective, Experience is not necessarily protective,
intense feelings occur while confronting intense feelings occur while confronting beliefs about personal safety, trust and beliefs about personal safety, trust and control. control.
Stress Management and Self Care Stress Management and Self Care of Nursesof Nurses-2-2
Many nurses feel burdened by responsibility Many nurses feel burdened by responsibility and expectations. and expectations.
Fears and frustrations may be transferred Fears and frustrations may be transferred to patients, thus compounding their to patients, thus compounding their problems.problems.
The nature of the emergency creates The nature of the emergency creates fracturing across organizations and may fracturing across organizations and may lead to miscommunication, disengagement, lead to miscommunication, disengagement, escape or refusal to work. escape or refusal to work.
Loyalties between taking care of one’s own Loyalties between taking care of one’s own family and one’s professional patients will family and one’s professional patients will be a challenge that needs to be addressed. be a challenge that needs to be addressed.
Common Stress Responses of Common Stress Responses of NursesNurses
High degree of High degree of burnoutburnout related to related to increased work load increased work load and organizational and organizational stressstress
Feelings of rage, guilt, Feelings of rage, guilt, helplessness, fear, helplessness, fear, shame, and a fearful shame, and a fearful or evil world view. or evil world view.
Emotions such as Emotions such as anxiety, sadness, anxiety, sadness, anger or feel anger or feel overwhelmed. overwhelmed.
Practical Suggestions to Decrease Practical Suggestions to Decrease StressStress
Practice relaxation techniques, deep Practice relaxation techniques, deep breathing, yoga, journal writing, breathing, yoga, journal writing, spirituality breaks, and guided imagery to spirituality breaks, and guided imagery to clarify feelings and reduce anxietyclarify feelings and reduce anxiety
Attend exercise sessions, short walks in Attend exercise sessions, short walks in the hall the hall
Regular scheduled breaks from tending to Regular scheduled breaks from tending to patients. patients.
Establish a break area for nurses and Establish a break area for nurses and health care providers to talk and receive health care providers to talk and receive support from colleagues. support from colleagues.
Practical Suggestions to Decrease Practical Suggestions to Decrease StressStress-2-2
Encourage frequent contact with loved Encourage frequent contact with loved ones through telephone interactions or e-ones through telephone interactions or e-mails mails
Progressive relaxation exercises reduce Progressive relaxation exercises reduce internal anxiety and promote blood flow to internal anxiety and promote blood flow to body organs body organs
Complements serve as powerful Complements serve as powerful motivators. motivators.
Hold department or hospital meetings to Hold department or hospital meetings to keep people informed of plans and events. keep people informed of plans and events.
Summary of Psychological Summary of Psychological Principles After A Bioterror AttackPrinciples After A Bioterror Attack
The most useful attitude for the nurse to possess is The most useful attitude for the nurse to possess is to view the patient as a person coping, perhaps in a to view the patient as a person coping, perhaps in a most inadequate way, with a situation that is most inadequate way, with a situation that is overwhelming and frightening.overwhelming and frightening.
Patients are sensitive to the nurse’s feelings and Patients are sensitive to the nurse’s feelings and attitudes as evidenced by touch, handling of the attitudes as evidenced by touch, handling of the patient’s body, willingness to talk and listen, and in patient’s body, willingness to talk and listen, and in discussion of the changes that have occurred in the discussion of the changes that have occurred in the body and through trauma the patient has suffered body and through trauma the patient has suffered through.through.
Patients who perceive their nurses as concerned and Patients who perceive their nurses as concerned and caring are better prepared to deal with the stress the caring are better prepared to deal with the stress the recovery phase. recovery phase.
Summary of Psychological Summary of Psychological Principles After A Bioterror AttackPrinciples After A Bioterror Attack-2-2
They report fewer vague complaints, They report fewer vague complaints, feelings of disappointment, expressions of feelings of disappointment, expressions of anger and hostility, and are more satisfied anger and hostility, and are more satisfied with their outcomes.with their outcomes.
Encourage sufficient rest and sleep, Encourage sufficient rest and sleep, normalizing eat-sleep-work cycles, limiting normalizing eat-sleep-work cycles, limiting exposure to media reports and exposure to media reports and traumatizing images and sounds are all traumatizing images and sounds are all measures that facilitate coping and measures that facilitate coping and recovery.recovery.
Survivors experience profound grief, Survivors experience profound grief, anguish, anger, guilt and sadness. anguish, anger, guilt and sadness.
Summary of Psychological Summary of Psychological Principles After A Bioterror AttackPrinciples After A Bioterror Attack-3-3
Talking through one’s emotions is an Talking through one’s emotions is an important part of the recovery process for important part of the recovery process for both patients and providers. both patients and providers.
Refer patients with abnormal stress Refer patients with abnormal stress responses to psychiatric treatment team.responses to psychiatric treatment team.
Anxiety responses are most likely Anxiety responses are most likely following a BT attack, but depressive following a BT attack, but depressive symptoms, PTSD and substance abuse symptoms, PTSD and substance abuse may also occur. may also occur.
Encourage re-entry into social roles when Encourage re-entry into social roles when possible and appropriate. possible and appropriate.
ReferencesReferences Aguilera, D.M.. (1998). Aguilera, D.M.. (1998). Crisis intervention: Theory and Crisis intervention: Theory and
methodologymethodology (8th edition). St. Louis, MO: C.V. Mosby (8th edition). St. Louis, MO: C.V. Mosby Company.Company.
Bleiberg,KL, & Markowitz, JC. (2005) A pilot study for Bleiberg,KL, & Markowitz, JC. (2005) A pilot study for interpersonal psychotherapy for posttraumatic stress interpersonal psychotherapy for posttraumatic stress disorder. disorder. Am JAm J Psychiatry,Psychiatry, 162: 181-183. 162: 181-183.
Diagnostic and Statistical Manual of Mental DisordersDiagnostic and Statistical Manual of Mental Disorders. (4th . (4th ed.). (1994). American Psychiatric Association, Washington, ed.). (1994). American Psychiatric Association, Washington, D.C.D.C.
Fontaine, KL, Kneisl, CR, Trigoboff, E. (2004) Fontaine, KL, Kneisl, CR, Trigoboff, E. (2004) Clinical Clinical companion for psychiatric mental health nursingcompanion for psychiatric mental health nursing. Upper . Upper Saddle River: Prentice Hall.Saddle River: Prentice Hall.
Galea, S., Ahern J., Resnick, H, Kilpatrick, D., Bucuvalas, M., Galea, S., Ahern J., Resnick, H, Kilpatrick, D., Bucuvalas, M., Gold, J., Vlahov, D. (2002) Psychological sequelae of the Gold, J., Vlahov, D. (2002) Psychological sequelae of the September 11 terrorist attacks in New York City. September 11 terrorist attacks in New York City. New Eng J New Eng J MedMed. 346:982-987.. 346:982-987.
ReferencesReferences-2-2
Garrett, L. (2002) Garrett, L. (2002) Betrayal of trust: The collapse of Betrayal of trust: The collapse of global public healthglobal public health. New York: Hyperion.. New York: Hyperion.
Hall, MJ, Norwood, AE, Ursano, RJ, Fullerton, CS. Hall, MJ, Norwood, AE, Ursano, RJ, Fullerton, CS. (2003) The psychological impacts of bioterrorism. (2003) The psychological impacts of bioterrorism. Biosecurity and bioterrorism: Biosecurity and bioterrorism: Biodefense strategy, Biodefense strategy, practice and sciencepractice and science 1(2); 139-144. 1(2); 139-144.
Holloway, HC, Norwood, AE, Fullerton, CS. Engel, CC, Holloway, HC, Norwood, AE, Fullerton, CS. Engel, CC, Ursano, RJ. (1997) The threat of biological weapons: Ursano, RJ. (1997) The threat of biological weapons: Prophylaxis and mitigation of psychological and Prophylaxis and mitigation of psychological and social consequencessocial consequences. J Am Med Assoc. J Am Med Assoc, 278 (5) : 425-, 278 (5) : 425-427.427.
Moore, DP, & Jefferson, James, W. (2004Moore, DP, & Jefferson, James, W. (2004) Handbook ) Handbook of Medical Psychiatryof Medical Psychiatry (2nd Ed.) Philadelphia: (2nd Ed.) Philadelphia: Elsevier/MosbyElsevier/Mosby
Norwood, AE, Holloway, HC, Ursano, RJ. (2001) Norwood, AE, Holloway, HC, Ursano, RJ. (2001) Psychological effects of biological warfare. Psychological effects of biological warfare. Military Military MedMed. Dec 166 (12 Suppl) 27-8.. Dec 166 (12 Suppl) 27-8.
ReferencesReferences-3-3
Ruzek, JI, Young, BH, Cordova, MJ, Flynn, BW.(2004) Ruzek, JI, Young, BH, Cordova, MJ, Flynn, BW.(2004) Integration of disaster mental health services with Integration of disaster mental health services with emergency medicine. emergency medicine. Prehospital Disaster MedicinePrehospital Disaster Medicine, , 19:(1) 46-53.19:(1) 46-53.
Schlenger, WE, Caddell, JM, Ebert, L, Jordan, BK, Schlenger, WE, Caddell, JM, Ebert, L, Jordan, BK, Rourke, KM, Wilson, D., Thalji, L., Dennis, JM, Rourke, KM, Wilson, D., Thalji, L., Dennis, JM, Fairbanks, JA, Kulka, RA. (2002) Psychological Fairbanks, JA, Kulka, RA. (2002) Psychological reactions to terrorist attacks: Findings from the reactions to terrorist attacks: Findings from the national study of Americans’ reactions to September national study of Americans’ reactions to September 11. 11. J AmJ Am Med AssocMed Assoc. 288:581-588.. 288:581-588.
Stuart, GW & Laraia, MT. (2005) Stuart, GW & Laraia, MT. (2005) Principles and Principles and practice of psychiatric nursingpractice of psychiatric nursing. 8th ed. St Louis, Mo: . 8th ed. St Louis, Mo: Elsevier Mosby. Elsevier Mosby.
Susser, ES, Herman, DB, et al. Combating the terror Susser, ES, Herman, DB, et al. Combating the terror of terrorism. (2002) of terrorism. (2002) Scientific AmericanScientific American, 287: 72-77, 287: 72-77
Web ResourcesWeb Resources American Academy of Experts in Traumatic StressAmerican Academy of Experts in Traumatic Stress www.aaets.orgwww.aaets.org American Association of SuicidologyAmerican Association of Suicidology www.suicidology.orgwww.suicidology.org Center for Disease Control and PreventionCenter for Disease Control and Prevention www.bt.cdc.gov/emcontact/index.aspwww.bt.cdc.gov/emcontact/index.asp Disaster ReliefDisaster Relief www.diasterrelief.orgwww.diasterrelief.org FBI TerrorFBI Terror www.fbi.gov.terrorism/terrorism/htmwww.fbi.gov.terrorism/terrorism/htm Mail securityMail security www.usps.comwww.usps.com National Institutes of Mental HealthNational Institutes of Mental Health www.nimh.nih.govwww.nimh.nih.gov Substance Abuse and Mental Health AdministrationSubstance Abuse and Mental Health Administration www.samhsa.govwww.samhsa.gov Federal Emergency Management AgencyFederal Emergency Management Agency www.fema.govwww.fema.gov
