Psychiatric Disorders Related To Trauma And Disaster

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We are only in the infancy of understanding why some people exposed to traumatic events develop post-traumatic psychopathology and some people do not (for a meta-analysis of predictors of PTSD, see 26). Post-traumatic psychiatric disorders are most often seen in those directly exposed to the threat to life and the horror of a traumatic event. The greater the ''dose'' of traumatic stressors, the more likely an individual or group is to develop high rates of psychiatric morbidity. Certain groups, however, are at increased risk for psychiatric sequelae. Those at greatest risk are the primary victims, those who have significant attachments with the primary victims, first responders, and support providers [27]. Adults, children, and the elderly in particular who were in physical danger and who directly witnessed the events are at risk. Those who were psychologically vulnerable before exposure to a traumatic event may also be buffeted by the fears and realities of, for example, job losses, untenably longer commutes or eroded interpersonal and community support systems overtaxed now by increased demands. Persons who are injured are at higher risk, reflecting both their high level of exposure to life threat and the added persistent reminders and additional stress burden accompanying an injury. The Epidemiologic Catchment Area study of Vietnam veterans [28] documented a higher rate of PTSD in wounded than in non-wounded veterans. Similar findings were noted in the Veterans Affairs study [29,30].

Pre-existing psychiatric illness or symptoms are not necessary for psychiatric morbidity after a traumatic event, nor are they sufficient to account for it [31-34]. Nearly 40% of survivors of the Oklahoma City bombing with PTSD or depression had no previous history of psychiatric illness [35]. Therefore, those needing treatment will not all have the usually expected accompanying risk factors and coping strategies of other mental health populations. The less severe the disaster or traumatic event, the more important pre-disaster variables such as neuroticism or a history of psychiatric disorder appear to be [32,36-39]. The more severe the stressor, the less pre-existing psychiatric disorders predict outcome.

Overall, children and adolescents are at increased risk for psychiatric sequelae following trauma. Psychiatric disorders including PTSD, depression, and separation anxiety disorder [40] as well as the onset of a wide range of symptoms and behaviors [41,42] have been identified in children exposed to trauma. The re-experiencing symptoms common in ASD and PTSD may be evident in children through repetitive play with trauma themes, nightmares, and ''trauma-specific reenactment'' [43]. Children may also develop avoidant behavior to specific reminders of the tragedy (e.g., avoiding areas of the playground where someone has been killed) and the wish to stay home rather than be separated from family and loved ones. Other reactions commonly seen in children include fear of recurrence, worries about the safety of others, and guilt. Of special concern are increased risk-taking behaviors sometimes seen in adolescents following trauma [44]. The reactions of significant adults (e.g., parents and teachers) can greatly affect children's responses to trauma [45].

Media exposure is a part of nearly all community disaster events. Media exposure can be both reassuring and threatening. Limiting such exposure can minimize the disturbing effects especially in children [46]. Educating spouses and significant others of those distressed can assist in treatment as well as in identifying the worsening or persistence of symptoms.

Acute Stress Disorder and Post-Traumatic Stress Disorder

Exposure to a traumatic event, the essential element for development of ASD or PTSD, is a relatively common experience. Approximately 50-70% of the US population are exposed to a traumatic event sometime during their lifetime; however, only approximately 5-12% develop PTSD. In a nationally representative study of 5,877 people aged 15-45 in the US, the National Comorbidity Study (NCS) [47] found lifetime prevalence of exposure to trauma to be 60.7% in men and 51.2% in women. In a nationally representative sample of women in the US, the National Women's Study (NWS) [48] found that 69.0% of women were exposed to a traumatic event at some time in their lives. NCS found rates of PTSD to be 7.8%, while the NWS found rates of PTSD to be 12.3%. In an epidemiological study of people belonging to an urban health maintenance organization in the US, Breslau et al. [49] found the lifetime prevalence of PTSD to be 9.2% for adults. These studies used the DSM-III and DSM-III-R [50] Criterion A requiring only that the event be outside the range of human experience. In DSM-IV, this was replaced with Criterion A2, which requires that the response to the stressor be one of intense fear, helplessness, or horror.

PTSD has been widely studied following both natural and human-made disasters (for review, see 51). PTSD is not uncommon following many traumatic events, from terrorism to motor vehicle accidents to industrial explosions. In its acute form, PTSD may be more like the common cold, experienced at some time in one's life by nearly all. If it persists, it can be debilitating and require psychotherapeutic and/or pharmacological intervention.

Curiously absent from DSM-III and DSM-III-R was a diagnostic category for acute responses to trauma and disaster events. With the diagnosis of ASD, DSM-IV [52] acknowledged a broader spectrum of responses to traumatic events. Because ASD is a relatively new diagnosis, empirical investigations are just beginning to examine its course and outcome [53,54]. However, recent studies of war suggest that acute combat-related stress reactions (which could now be thought of as representing an ASD) predict an adverse outcome [32] and are associated with increased rates of somatic complaints [55-57]. Numerous investigations also document that acute symptoms of intrusion, avoidance, and dissociation [58], part of the symptom complex of ASD, predict the development of later psychiatric disorders, particularly PTSD [59-64]. Early symptoms usually respond to education, obtaining enough rest and maintaining biological rhythms (e.g. sleep at the same time, eat at the same time) [65].

The Traumatic Stressor Criterion: Criterion A

Recognizing that traumatic stressors are all too often a part of everyday life, DSM-IV [52] deleted the DSM-III-R [50] requirement that the stressor be ''outside the range of usual human experience''. An essential feature for ASD and PTSD in the DSM-IV is development of ''intense fear, helplessness, or horror'' after exposure to a traumatic event that does not need to be outside the normal range of human experience (Criterion A) [43] (see Tables 2.1 and 2.2). Exposure can involve direct experience or witnessing or learning about a traumatic event that caused ''actual or threatened death'', ''serious injury'', or ''threat to the physical integrity'' of oneself or others. Both natural (e.g., tornadoes, earthquakes) and human-made traumatic events (e.g., accidents, rape, assault, war, terrorism) can evoke these symptoms. Some of these traumatic events occur only once while others involve chronic or repeated exposure.

In general, human-made traumatic events (as opposed to natural disasters) have been shown to cause more frequent and more persistent psychiatric symptoms and distress (for review see 66). However, this distinction is increasingly difficult to make. The etiology and consequences of natural disasters often are affected by human beings. For example, the damage and loss of life caused by an earthquake can be magnified by poor construction practices and high-density occupancy. Similarly, humans may cause or contribute to natural disasters through poor land-management practices that increase the probability of floods. Interpersonal violence between individuals (assault) or groups (war, terrorism) is perhaps the most disturbing traumatic experience. Technological disasters may bring specific psychiatric concerns about normal life events - for example, fear of flying after a plane crash or claustrophobia after a mine accident. Each of these requires evaluation and intervention to treat the specific phobia and limit generalization to other areas of life (e.g., ''I cannot cook any more because the boiling water reminds me of the explosion'').

Table 2.1

DSM-IV-TR diagnostic criteria for acute stress disorder (308.3)

A. The person has been exposed to a traumatic event in which both of the following were present:

1. the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

2. the person's response involved intense fear, helplessness, or horror

B. Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:

1. a subjective sense of numbing, detachment, or absence of emotional responsiveness

2. a reduction in awareness of his or her surroundings (e.g., ''being in a daze'')

3. derealization

4. depersonalization

5. dissociative amnesia (i.e., inability to recall an important aspect of the trauma)

C. The traumatic event is persistently re-experienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.

D. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people).

E. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.

G. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.

H. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition, is not better accounted for by Brief Psychotic Disorder, and is not merely an exacerbation of a preexisting Axis I or Axis II disorder.

Perhaps the best predictors of both the probability and the frequency of post-disaster psychiatric illness are the severity of the traumatic stressor and the degree of exposure. Shore et al. [21,22] found that psychiatric outcome was related to the intensity of disaster exposure following the Mount St. Helens volcanic eruption. They documented higher rates of postdisaster psychiatric illnesses, including PTSD, generalized anxiety disorder, and depression, in those who lived closer to the volcano. Additional evidence for the association of psychiatric illness and severity of the traumatic stressor is seen in the study of war trauma. Higher rates of PTSD, depression and alcohol abuse were significantly related to greater exposure

Table 2.2 DSM-IV-TR diagnostic criteria for post-traumatic stress disorder (309.81)

A. The person has been exposed to a traumatic event in which both of the following were present:

1. the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

2. the person's response involved intense fear, helplessness, or horror. Note: In children, this may be expressed instead by disorganized or agitated behavior

B. The traumatic event is persistently re-experienced in one (or more) of the following ways:

1. recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed

2. recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content

3. acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur

4. intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

5. physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:

1. efforts to avoid thoughts, feelings, or conversations associated with the trauma

2. efforts to avoid activities, places, or people that arouse recollections of the trauma

3. inability to recall an important aspect of the trauma

4. markedly diminished interest or participation in significant activities

5. feeling of detachment or estrangement from others

6. restricted range of affect (e.g., unable to have loving feelings)

7. sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span)

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:

1. difficulty falling or staying asleep

2. irritability or outbursts of anger

3. difficulty concentrating

4. hypervigilance

5. exaggerated startle response

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Specify if:

Acute: if duration of symptoms is less than 3 months. Chronic: if duration of symptoms is 3 months or more.

Specify if:

With Delayed Onset: if onset of symptoms is at least 6 months after the stressor.

to combat in Vietnam [29]. In an interesting investigation of PTSD in monozygotic twins discordant for service in Vietnam, Goldberg et al. [31] found that PTSD was nine times as common in the twins who had been exposed to a high level of combat in Vietnam as it was in those who had not served in Southeast Asia.

Psychiatric morbidity is more likely to be engendered by some dimensions of traumatic events than others. The highest risk of psychiatric morbidity is associated with high perceived threat to life, low controllability, lack of predictability, high loss, injury, possibility that the disaster will recur, and exposure to the grotesque [35,52,67-71]. For example, terrorism often can be distinguished from other natural and human-made disasters by the characteristic extensive fear, loss of confidence in institutions, unpredictability and pervasive experience of loss of safety [72]. In a longitudinal national study of reactions to the September 11,2001 disaster, 64.6% of people outside of New York City reported fears of future terrorism at 2 months and 37.5% at 6 months [73]. In addition, 59.5% reported fear of harm to family at 2 months and 40.6% at 6 months. Terrorism is one of the most powerful and pervasive generators of psychiatric illness, distress and disrupted community and social functioning [35,74].

Vulnerability to psychiatric distress is increased by knowledge that one has been exposed to toxins (e.g., chemicals or radiation) [75,76]. In this case, information itself is the primary stressor. Toxic exposures often have the added stress of being clouded in uncertainty as to whether or not exposure has taken place and what the long-term health consequences may be. Living with the uncertainty can be exceedingly stressful. Typically uncertainty accompanies bioterrorism and is the focus of much concern in the medical community preparing for responses to terrorist attacks using biological, chemical, or nuclear agents [73,77-79].

Symptoms of ASD and PTSD

The diagnostic criteria for ASD closely resemble those of PTSD (see Table 2.3), with the primary difference being time course and the inclusion of dissociative symptoms required for a diagnosis of ASD. The diagnosis of PTSD applies if the symptoms persist longer than 1 month or if the onset of symptoms begins later than 1 month after the traumatic event. Importantly, the severity of symptoms for both ASD and PTSD must be sufficient to cause ''clinically significant distress'' or impaired functioning (Criterion F) [43]. Symptoms of ASD and PTSD are categorized into three clusters: persistent re-experiencing of the stressor (Criterion B for PTSD and Criterion C for ASD), persistent avoidance of reminders of the event and numbing of general responsiveness (Criterion C for PTSD and Criteria B and D for ASD), and persistent symptoms

Table 2.3 Comparison of acute stress disorder (ASD) and post-traumatic stress disorder (PTSD)

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