Psychological and Behavioral
Responses to Disasters
Steve Bunney, MD
Department of Psychiatry
Yale School of Medicine
9-11-01
•
Unique Disaster
• First disaster in history
where in the aftermath
psychological repair was
more important than
repairing bodies or
burying the dead
• Part of event was
watched live by millions
of people
Personal Experience Post 9-11

Day 1
– Call from Walter Reed
– Activation of Emergency Response Plan

Day 2
– Call from Service Union

Day 7
– Call from business CEO

Day 21
– Call from airline unions

Day 30
– Call from insurance company
PHASES of IMPACT and
RECOVERY
I. EMERGENCY/IMPACT
SHOCK – first hours/days
HEROIC – first days/weeks
II. EARLY POST-IMPACT
HONEYMOON – 1-3 Months
DISILLUSIONMENT – 3-6 months
III. RESTORATION vs. BREAKDOWN
RESTABILIZATION – 6-9 months
RECOVERY – 9-12 months
PREPAREDNESS – 12+ months
What is Psychological
Trauma?
Overwhelming, unanticipated danger that
cannot be mediated/processed in way that
leads to fight or flight
Immobilization of normal methods for
decreasing danger and anxiety
Neurophysiological dysregulation that
compromises affective, cognitive and
behavioral responses to stimuli
Psychological Shock
 Objective Exposure
 Exposure to threat of imminent/actual death
 Witnessing bodies and body parts
 Extreme exposure to fire, dust, exhaustion
 Subjective Survival Responses
 Terror: fear, helplessness, impulsivity
 Horror: disbelief, revulsion, guilt, shame, rage
 Numbing: derealization, depersonalization, fugue,
amnesia.
Stress vs Trauma
Dealing with Problems
Trying to Survive
Heart Pounding
Rapid Breathing
Muscles Tense Up
Fight or Flight
Feel Excited or Worried
Seeing/Thinking Clearly
Acting Rapidly
Feel in Control
Heart Feels Like Bursting
Gasping, Feeling Smothered
Muscles Feel Like Exploding
Just Try to Get Through It
Feel Terrified of Panicked
Confused, Mentally Shut Down
Automatic Reflexes or Freezing
Feel Helpless or Out of Control
Neurobiology of Severe Stress

Responses are complex
– Biological defenses against a threat
– Mechanisms related to learning and adaptation
– Responses to social cues
– Reactions to loss and separation
– Effects of cognitive disarray and chaotic
experience
Neurobiology of Severe Stress
(cont.)

Thalamus registers whether sensory input is
familiar or novel and a threat or not
 Threat triggers brain alarm system (amygdla) and
release of corticosteroids and norepinephrine
 Fight-flight responses (autonomic nervous system,
sympathetic branch)
 Peripheral resource conservation (autonomic
nervous system, parasympathetic branch)
Neurobiology of Severe Stress
(cont.)





Alarm: insula and amygdala coordinate body’s
mobilization in response to threat
Attention: norepinepherine release by locus ceruleus
(brain stem area) promotes focused attention
Reactivity: corticosteroids promote instinctual survival
rather than goal-directed reflection
Information Processing: Hippocampus inhibited in spatial
orientation and categorization of sensory inputs
Executive Decision Making: prefrontal cortex receives
confusing/chaotic alarm signals and is down-regulated
Neurobiology of Severe Stress
(cont.)

Delayed responses
 Cascade of neuronal and genomic events including:
Increased synthesis of cortiotropin releasing hormone
(CRH) and cortisol related receptors in areas of brain
not directly in hormonal stress response
 Increased protein synthesis in memory areas provides
mechanism for two types of long term memory
of stressful events :

Hippocampus
 Explicit - verbalizable and recallable

Amygdala
 Implicit - unconscious changes in habit and conditioned
responses (e.g. fear response when exposed to cues relevant
to traumatic event
Neurobiology of Severe Stress
(cont.)

Summary
– The early aftermath of a disaster is a critical time of
increased neuronal plasticity.
– The perceived threat triggers intense bodily reactions
that shape the mental traces of adverse events.
– Physiological and psychological factors can either
concur to cause chronic stress disorders or adaptation
and resilience.
– Early interventions may reduce the risk of chronicity
Event Factors That Influence
Psychological Responses
How directly events affect their lives:
Physical proximity to event
Emotional proximity to event (threat to
child, parent versus stranger)
Secondary effects-of primary
importance (does event cause disruption
in on-going life)
Individual Factors That Influence
Psychological Response
Genetic vulnerabilities and capacities
Prior history (i.e. consistent stress or one or
more stressful life experience/s)
History of psychiatric disorder
Familial health or psychopathology
Family and social support
Age and developmental level
Other: Female, divorced or widowed, lower
IQ, lower income, lower education level
Children
Responses and Treatment
Role of Adults
For all children, especially younger
children, experience and especially
upsetting experience is mediated by adults.
Adults emotional response often as
important as the actual event
Children’s Typical Initial Responses
Normal reactions to abnormal situations
Emotional and Somatic
 Sleep disturbance (nightmares etc.)
 Decreased or increased appetite
 Sad or anxious mood (withdrawn or more quiet)
 Irritable, fussy or argumentative
 Loss of recently achieved milestones
 Clingy or wanting to be close to parents
 Difficulty paying attention
 Daydreaming or easily distractible
Spectrum of Developmentally Determined Responses
Toddlers
Rely on Parents
Regression
Preschoolers
Highly Imaginative
Concerned About Safety
School Age
Social Difficulties
Concerned About Right/Wrong (Revenge)
Adolescents
Struggling With Independence
Conflict With Authority Figures
Minimize or Exaggerate
Increased Risk Taking
Substance Use
Older Adolescents & Young Adults
Concerns About Future
Substance Use
Implications of Neurobiological
Development for Treatment
 Hippocampus not fully functional until 4-5 years
old
 Prefrontal cortex not fully functional until around
age 10
Treatment and Intervention
In the immediate aftermath
Reunite children with important adults/
family members
Interventions for children include
interventions for caretakers. If adults can
not attend to children, outcome will be poor
Adults tend to underestimate impact on
children or alternatively displace own
feelings onto their children
Treatment and Intervention
In the immediate aftermath (cont.)
Criteria for Referral

Presence of Dissociation
Decreased motor function
Blunted affect
Absence of speech
Decreased responsiveness to external stimuli

Presence of Hyperarousal (heart rate and often
respiration increased)
 Avoidance/Withdrawal Symptoms
 Extreme Emotional Upset
 Symptoms of Acute Stress Disorder
Acute Stress Disorder
 3+ of 5 Dissociative Sx (Detached, Dazed,
Derealization, Depersonalization, Amnesia)
 Recurrent Unwanted Memories Awake/Asleep or
Biopsychological Distress Due to Reminders
 Avoidance of Internal/External Reminders
 Hyperarousal (Anxious, Irritable, Insomnia, Poor
Concentration, Hypervigilant, Reactive)
 Significant psychosocial/healthcare impairment
 Duration 2-30 days
Treatment Issues 4-6 Months After
Disaster
Criteria For Referral









Extreme emotional upset
Sleep disturbances
Somatization
Hyper-vigilance
Severe distractibility
Regressive behavior
Blunted emotions
Regression in social functioning and play
Oppositional and aggressive behaviors
Classic PTSD not common in children but incidence increases
with age (especially adolescents)
Adults
Responses and Treatment
Common Fantasies
 to alter the precipitating event
 to interrupt the traumatic action
 to reverse the lethal or injurious consequences
 to gain safe retaliation (fantasies of revenge)
 to be able to anticipate or prevent future traumas
 to bring back lost loved ones, friends, places,
activities, or states of mind (trust) or body (peace)
Common Stress Reactions To Disaster
Emotional Effects
Cognitive Effects
Shock
Anger
Despair
Emotional numbing
Terror
Guilt
Irritability
Helplessness
Loss of derived pleasure from regular activities
Dissociation (e.g., perceptual experience seems “dreamlike,
“tunnel vision,” “spacey,” or on “automatic pilot”)
Impaired concentration
Impaired decision-making ability
Memory impairment
Disbelief
Confusion
Distortion
Decreased self-esteem
Decreased self-efficacy
Self-blame
Intrusive thoughts and memories
Worry
Physical Effects
Interpersonal Effects
Fatigue
Insomnia
Sleep disturbance
Hyperarousal
Somatic complaints
Impaired immune response
Headaches
Gastrointestinal problems
Decreased appetite
Decreased libido
Startle response
Alienation
Social withdrawal
Increased conflict within relationships
Vocational impairment
School impairment
Young, BH, et. al. Disaster Mental Health Services: A Guidebook For Clinicians and Administrators. The National Center for
Post-Traumatic Stress Disorder, Department of Veterans Affairs
Acute Stress Disorder
 3+ of 5 Dissociative Sx (Detached, Dazed,
Derealization, Depersonalization, Amnesia)
 Recurrent Unwanted Memories Awake/Asleep or
Biopsychological Distress Due to Reminders
 Avoidance of Internal/External Reminders
 Hyperarousal (Anxious, Irritable, Insomnia, Poor
Concentration, Hypervigilant, Reactive)
 Significant psychosocial/healthcare impairment
 Duration 2-30 days post traumatic event
Treatment and Intervention
In the immediate aftermath
There is no one approach to treatment that
current research singles out as effective
One time intervention models have been
shown to be ineffective
Critical Incident Stress Management (CISM)
has no proven effectiveness in prevention of
late onset psychological disorders (e.g.
PTSD)
Treatment and Intervention
In the immediate aftermath
(cont.)
Psychotherapeutic interventions in the the
absence of structure and organization will
not be effective.
Provide real and concrete information about
event, explain actions of authorities
Provide basic necessities
Key Principles of Immediate
Intervention
 Engagement: Empathic, non directive inquiry(
not what happened?, but, how are you
feeling?, delving into detail can retraumatize)
 Manage Overwhelming Feelings: agitation,
pressured speech, uncontrollable crying, out of
touch with reality
 Request person to look at you and listen to what
you are telling them
 Hold their attention, talk about positive or nonemotional topics
 Ask them to describe the place they’re in and say
where they are
 Support: Confer control in therapeutic contact
Key Principles of Immediate
Intervention (cont.)
Affect: Identify, label and link to ideation
and somatic experience (noting differences
from beginning to end of contact and with
reports about pre-morbid functioning)
Cognition: Assess quality and nature of
thought processes and link to affective
impact of event and associated ideas
Key Principles of Immediate
Intervention (cont.)
Psycho-education: Explain the normal
post-traumatic response (what to expect,
what is normal and when additional
support/intervention is needed)
Follow-up: Arrange for series of contacts to
assess symptoms and adaptive functioning
4-6 Months After Disaster
 Persistent physical, mental, relational, and
work problems are taking a toll
 Helping professionals (behavioral health,
medical/nursing, human services, clergy)
and natural helpers are frayed and feeling
the burden of answering the unanswerable
 Delayed psychiatric sequel are emerging
(unresolved bereavement, depression,
PTSD, anxiety disorders, addictions)
Target Groups At Risk for Persistent
Post-Traumatic Sequelae
On-Site Survivors
Bereaved Families/Primary Relationships
On-Site Rescue/Recovery Workers
Terror: Exposure to threat of imminent/actual death
Horror: Witnessing death, destruction, terror & shock
Physical Insult: injury, exhaustion, toxic exposure
Traumatic Reactivation (past & subsequent crisis work)
Separation/Detachment from Family and Community
Target Groups At Risk for Persistent
Post-Traumatic Sequelae
Helpers Caring for Survivors, the Bereaved, Workers
(e.g., Behavioral Health, EAP, Health Care, Clergy)
Family/Community Members Living and Working with
Survivors, the Bereaved & Rescue Workers
 Vicarious Shock: Exposure to terror, helplessness, grief
 Uncertainty: Wanting to help but not knowing when/how
 Physical/Workload Strain: Carrying the added load while
others are focused on coping with impairment or recovery
 Loss: Disconnection from traumatized significant others
 Traumatic Reactivation: Unresolved direct/vicarious trauma
Target Groups At Risk for
Persistent Post-Traumatic Sequelae
People in Recovery from Behavioral Health Disorders
Vulnerable Groups
(e.g., children, elders, disenfranchised)
Treatment Issues 4-6 Months
Later:
 Intrusive Re-experiencing: Overwhelming memories
 Numbing: Feeling stunned, empty, dead inside
 Hypervigilance: Prolonged Survival Alarm State
 Dissociation: Disconnection from Alarm Awareness
 Affect Dysregulation: Overwhelming emotions
 Somatization: Bodily exhaustion and breakdown
 Alienation: Loss of sustaining perceptions of future &
attachments
 Defeat: Loss of personal/spiritual trust & goals
Post Traumatic Disorders: Not
Automatic & More than PTSD
 Most adults and children recover without a lasting
post-traumatic psychiatric disorder
 10-20% develop depression or PTSD (often both)
 Alcohol/substance use disorders not prevalent
 Subclinical depression or substance use common
Posttraumatic Stress Disorder
(PTSD)
 Recurrent Unwanted Memories Awake/Asleep or
Biopsychological Distress to Reminders
 Avoidance of Internal/External Reminders,
Emotional Numbing, Social Detachment, Amnesia
 Hyperarousal (Anxious, Irritable, Insomnia, Poor
Concentration, Hypervigilant, Reactive)
 Significant psychosocial/healthcare impairment
 Duration 30+ days (may be delayed or chronic)
Issues to be Assessed in the
Treatment of Traumatic Sequelae of
Disaster
Criteria for Referral





Presence of depression, PTSD, panic attacks,
disabling grief of six months duration and no
improvement over time
Worsening of prior psychological problems
Memories of prior traumatic experiences are now
causing distress
Presence of sustained psychological or physical
stress
Poor or absent social supports
Issues to be Assessed in the
Treatment of Traumatic Sequelae of
Disaster (cont.)
Criteria for Immediate Referral
 Suicidal
thoughts with a plan and/or means
 Excessive substance use causing person or
others to be placed at risk
 Poor functioning to the point that individual’s
(or dependent’s) safety/welfare is in danger
Issues to be Assessed in the
Treatment of Traumatic Sequelae of
Disaster (cont.)
Major Issues in Making Referrals

Stigma
 Explain feelings and behavior (note: not called
symptoms) are normal under these circumstances and so
is getting some help to deal with them
 Take the “shrink” out of counseling
 Explain you are sending them for information and
potential support
 Explain they will get help in problem solving and
coping
 Tell them what you are doing to cope
A State Mental Health Care
System Response to 9-11
A Statewide Network of Local Behavioral
Health Teams: Helping Communities with the
Stress of Disasters or Public Health Crises
Center for Trauma Response, Recovery, and Preparedness
University of Connecticut Health Center
Julian D. Ford, Ph.D.
CT Department of Mental Health and Addiction Services
Arthur C. Evans, Ph.D.
James Siemianowski, MSW
Wayne Dailey, PhD
Center for Trauma Response, Recovery and Preparedness
Yale University School of Medicine, Dept. of Psychiatry
Steven Berkowitz, MD
Steve Bunney, M.D
Steven Marans, PhD.
Steve Southwick, MD
CT Department of Children and Families
Thomas Gilman, MSW
What have we done since 9/11?
A Statewide Behavioral Health
Preparedness Plan






800+ professionals trained to serve as volunteers on
local behavioral health crisis response teams
150+ prevention providers and natural helpers trained as
resources for community preparedness
50+ behavioral health consumer advocates trained to
help communities support people in recovery
Local volunteer teams receiving ongoing technical
assistance to prepare them for disaster response
Planning for mobilization and activation of these teams
in the event of a major disaster
Behavioral health resources disseminated via
www.ctrp.org and www.clearinghouse.org
Linking Behavioral Health to the OEM & DPH
Disaster/Crisis Response System
Statewide,
Local Incident
Command
System
Municipal officials,
public health, fire,
police, emergency
management,
EMS, health care,
schools, social
service agencies
OEM - Office of Emergency Management
DPH - Department of Public Health
BH - Behavioral Health
Statewide,
Regional, Local
Behavioral
Health System
BH Agencies +
Professionals+
Natural Helpers
Local Behavioral
Health Response
Teams
How does the state behavioral health
system support local crisis responses?
RC = Regional
Behavioral Health
Coordinators
Gov = Governor
Gov/OEM/DPH
OEM = Office of Emergency Mgmt
DMHAS/DCF
DMHAS = Dept of
Mental Health &
Addiction Svs
DPH = Dept of Public Health
CTRP = Ctr. for Trauma
Response/Recovery & Preparedness
CTRP
DCF = Dept of Children & Families
RC
T
RC
T
T
RC
T
T
RC
T
T
RC
T
T
T
Local teams comprised of specially trained state staff, Private Non-Profit and
private volunteers, work closely with municipal and community leaders, public
health department directors, EMS, clergy, school officials, employers
Taken in Part from a
Center for Trauma Response, Recovery
and Preparedness (CTRP) Presentation
 University of Connecticut School of Medicine
 Julian D. Ford, PhD
 Yale University School of Medicine
 Steven Berkowitz, MD
 Benjamin S. Bunney, MD
 Steven Marans, PhD
 Steve Southwick, MD
 CT Department of Mental Health and Addiction Services
 Arthur C. Evans, PhD
 Wayne Dailey, PhD
 James Siemianowski, MSW
 CT Department of Children and Families
 Thomas Gilman, MSW