1	9/11 AND TSUNAMI POST-TRAMATIC STRESS SYNDROME: IMPACT, DIAGNOSIS, TREATMENT AND FUTURE CHALLENGES Jay Carrington Chunn, Ph.D. Director / Principal Investigator National Center for Health Behavioral Change Urban Medical Institute 2600 Liberty Heights Avenue Baltimore, MD 21215 410-383-5167 www.nchbc.org Modification (January 2005) of a Presentation Made for the National Medical Association Scientific Assembly Honolulu, Hawaii August, 2002
2	September 11, 2001
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10	JANUARY 2005 TSUNAMI VICTIMS
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15	9/11 and the Tsunami Both of the above traumatizing events will extract its toll from survivors with significantly high PTSD symptoms, behaviors and psychological outcomes. A recent article in the New England Journal of Medicine, suggested that the PTSD rates among men and women touched by Sept. 11 may be similar to those experienced by men and women in accidents, natural disasters or the sudden loss of loved ones. Although the two phenomenon are different the psychological impact is very similar. It has been estimated that approximately 35% of those directly exposed to the Trade Center tragedy will suffer from PTSD. Since an estimated 100,000 people directly witnessed the event, the toll could be substantial. I would estimate a much higher rate for the Tsunami which may reach as high as 70-75% of all survivors. The risk of developing PTSD increase with the observers’ proximity to the traumatic event, whether the observer lost a loved one or felt their own lives were in danger
16	PTSD 9/11 and Tsunami In November, The New York City Police Department ordered all of its 55,000 employees and officers to attend group-therapy sessions to relieve stress in the aftermath of the disaster. To help remove the stigma often associated with mental health counseling, city and state health departments in mid-January advertised on the city’s subway cars urging New Yorkers still experiencing classic PTSD symptoms to seek help. As many as 2 million New Yorkers may need some form of counseling. In the countries and areas where the Tsunami hit, it is not unreasonable to believe that as many as 70-75% will require some form of debriefing and psychological support.
17	Trauma Significant Gender Differences Men and women often develop PTSD at different rates in response to similar traumatic events In the case of physical assault, only 2% of men developed PTSD, compared to 21% of women Overall, men experience more traumatic events than women, but women’s PTSD rates are twice as high
18	How Men and Women Respond to Trauma
19	PTSD Symptom Development Risk Factors (Those among others may also serve as predictors) Female gender Age 40 to 60 Poverty or low socioeconomic status Presence of children in the home For women presence of a spouse especially if he is significantly distressed Living in a distrustful or traumatized community Secondary stress of loss of resource
20	Four Factors that Predict Severity of PTSD Intensity: People who are exposed to severe trauma have more intense symptoms that those who have witnessed less severe events Duration: People who experience repeated exposures (recurring abuse, multiple attacks) are more likely to be affected than those who have witnessed one event. Proximity: Those who are closer to the event are likely to have more significant symptoms than those further removed. History: People who have experienced previous personal trauma are at a higher risk for negative symptoms.
21	PTSD Mind/Body Reactions Similar to Prolonged and Acute Stress Blood pressure is highly sensitive to chronic stress Studies show that people who lived through traumatizing events—from World War II bombardments to the Three Mile Island nuclear accident had higher blood pressure and elevated levels of some stress-related hormones for several years after the danger passed. It’s not the just the heart and mind that react to stress. Fear and anger associated with loss trigger major changes in the way the stomach and colon function, what scientists now call the “brain-gut interaction.” Peptic ulcer is a leading cause of hospital admissions after a traumatic event.
22	PTSD Mind/Body Reactions Similar to Prolonged and Acute Stress (cont.) If people experience anger, as we often find after a disaster, there is stimulation of acid secretion and contractions in the stomach, and stimulation of the colon, which leads to ulcers and irritable bowel syndrome. Man-made disasters, like the terrorist attacks, trigger more disease than do natural disasters. However the exception to this notion may bear out given the horror and over 150,000 deaths caused by the Tsunami.
23	Rescue Workers and PTSD Technically, the PTSD diagnosis applies to rescue workers who are themselves in serious danger. Several studies have shown that up to 40% of people responsible to body handling and recovery after a disaster show signs of distress and are at risk of developing PTSD. In New York City workers have had extended exposure and the Tsunami workers have had as much or more given the horrific death rates.
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25	Children and PTSD Children of New York and the Washington, D.C. areas as well as children impacted by the Tsunami were greatly traumatized. The American Academy of Child and Adolescent Psychiatry has published Information that should help parents and teachers recognize PTSD.
26	Survey Children of Trauma* Tens of thousands of public-school children in New York City are experiencing chronic nightmares, fear of places, severe anxiety and other mental health problems. The Board of Education conducted a study examining the impact of September 11 on about 8,300 of school system’s 1.1 million students. A disproportionate number of the students surveyed attend school near ground zero, but the study, using random sampling techniques, also evaluated children in every other neighborhood of New York
27	Findings of the Survey The results provide strong evidence that the terrorist attack and other events took a heavy toll on children, including those not directly affected Overall 64% of students surveyed who did not attend school near ground zero , and 51% of those who did, said that they had suffered some sort of previous trauma Those who had previous trauma were more likely to have mental health problems related to the terrorist attack 75,000 school children in the 4^th-12^th grades, or 10.5% of the children in those grades suffered PTSD after 9/11 105,395 or 15% suffered from agoraphobia Hispanic students were disproportionately affected by psychological problems after the attack
28	Findings of the Survey 13.8% of Hispanic students city-wide suffered PTSD, compared with 9% of non-Hispanic blacks, 8% of non-Hispanic whites and 9% of Asians Researchers estimated that 13.8% of Hispanic student citywide suffered from PTSD, compared with 9.3% of blacks, 6.5% of whites and 3.2% of Asians This finding mirrored results of a study published in March which found that among the city’s adult population, more Hispanics suffered mental health problems after 9/11 The study also showed that girls were more likely than boys to experience psychological problems and 4^th and 5^th graders seemed to have more symptoms than older ones
29	Warning Signs of Children Suffering from PTSD Refusal to return to school and “clinging” behavior Persistent fears related to the catastrophe Sleep disturbances (nightmares, screaming during sleep, bedwetting) persisting more than several days after the event Irritability and loss of concentration Jumpiness, startling easily behavior problems not typical of the child Physical complaints with no physical cause found
30	Talking to Children Children suffering from trauma have many of the same symptoms as adults experience Children may regress into thumb sucking and other behaviors they have outgrown They often have stomach aches, headaches, appetite loss and other physical symptoms Children between that ages of 6-11 may feel guilty, as though they are somewhat responsible for the disaster They may engage in repetitious play related to the traumatic experience Adolescents may express their feelings in a rebellious risk-taking, anti-social behavior
31	Helping Children to Cope with Trauma Adults have to make children feel safe, reassuring them that they will note injured, killed or orphaned They should maintain routines and spend more time than usual with the children Children can be told that it is normal and acceptable to admit fear, guilt and even anger Adults should present a positive image for children to observe, because children often model their responses on what they see in their parents Very young children should not be exposed to reminders, such as repeated television viewing of disasters. They often think that the disasters are continuing or that they and their families are in danger Their nightmares can be explained and schoolwork should be monitored They should be assured that “babyish” feelings and behavior are normal and will go away Adolescents can be encouraged to talk about their feelings to the family and one another
32	Seven Steps: Critical Incident Stress Debriefing
33	Seven Steps: Critical Incident Stress Debriefing (cont.)
34	National Survey Data 9/11
35	Stress Reactions According to the Characteristics of the Respondents
36	Stress Reactions According to the Characteristics of the Respondents
37	Stress Reactions According to the Characteristics of the Respondents
38	Coping Behavior and Other Reaction by Adults
39	Antidepressants Prozac works by preventing the brain from reabsorbing too much of the neurotransmitter serotonin, leaving more in nerve synapses and thus helping to improve moods. Paxil is used for the treatment of social-anxiety disorder Zoloft has been approved for OCD and panic disorder
40	Conclusion In closing I strongly believe that the following events and realities will occur in America and the world.
41	Conclusion Primary and secondary prevention strategies and techniques will have to be developed—public informed in advance on how to avoid the worst trauma psychologically. Rescue personnel searching for survivors, bodies, and remains should not be allowed to work 6 to 7 days a week plus extended hours—12 hour days because of their own personal impact—many in New York, for example, have now retired on disability, experiencing severe PTSD reaction along with some alcoholism and drug abuse. NMA, AGA, APHA and International Catholic agencies and International Red Cross will need to undertake training of their membership on the public health prevention side and prepare members on the Rx side also along with lobbying on the public policy issues.
42	Conclusion Further public safety also is critical and we should be more involved with foreign policy, that is, on the anti-terrorist side that recognizes that the third world is now the first world and that people of color constitutes 2/3’s of the world population and controls approximately 75% of the world’s oil and mineral resources Therein, fellow healers lies the paradox and the reality. Prevention of terrorism is the answer. As psychiatrist, medical and health practioners we must become involved on both sides of the equation--Primary Prevention and Rx
43	Credits
44	Credits