Posttraumatic symptoms following a campus shooting: the role of psychosocial resource loss

Conservation of resources (COR) theory has proven a useful framework for understanding posttrauma adjustment. A key tenet of this theory is the centrality of resource loss in determining adjustment. However, COR theory research has often been limited by retrospective research design, a focus on material loss (e.g., one's home), and a lack of attention to other adjustment predictors. This study examined whether psychosocial resource loss prospectively predicted PTSD symptomatology both immediately and 8 months following a campus shooting in a sample of college women (n = 691). Results supported that resource loss predicted symptomatology, even after controlling for other predictors, including prior trauma, psychological distress, initial PTSD symptomatology, and shooting exposure. Implications of the results for research and intervention following mass trauma are discussed.

Radiology leadership during a disaster event

The trauma of a mass casualty event in Fort Hood, TX very quickly impacted the imaging departments of 3 healthcare facilities in central Texas. In the aftermath,there was an opportunity to reflect and learn. When a mass casualty event or disaster takes place, radiology administration needs to be visible, lead staff, manage media attention and law enforcement presence,all while maintaining a high level of quality patient care. Issues of particular concern are training, coping mechanisms, and the impact of leadership. Military and civilian healthcare facilities have different capabilities in terms of training and operations when it comes to managing such an event.

Critical incident stress management (CISM) in support of special agents and other first responders responding to the Fort Hood shooting: summary and recommendations

On November 5, 2009, an individual entered the Fort Hood Soldier Readiness Processing (SRP) site and opened fire with a handgun. The result of the shooting was a total of 13 people killed and 31 wounded. A two-person critical incident peer support (CIPS) team from the United States Army Military Police School (USAMPS) provided critical incident stress management (CISM) in the forms of critical incident stress debriefings (CISD) and one-on-one crisis intervention for investigators and their spouses. This article provides a summary and discussion of the results of the interventions that were conducted. Key results for successful CISM were accessibility of CIPS team, the credibility of trained peers and the development of supportive relationships, the reduction of stigma by requiring attendance at interventions, and the commitment of the CIPS team to the principles of CISM (e.g., homogenous groups, utilizing a multicomponent approach, and facilitating the normalization of emotional reactions to the crisis). Recommendations include mandating critical incident peer support cells for Criminal Investigation Division (CID) units, Director of Emergency Services (DES) on military installations, and Military Police units; providing a pool of trained peers in the above-mentioned organizations; providing permanent funding for USAMPS' CIPS Course; and recognition of CIPS/CISMas an essential element of Comprehensive Soldier Fitness and Army Human Capital in promoting Soldier Family, and Civilian well-being and resiliency. This article would benefit leaders, chaplains, mental health professionals, and emergency services personnel in investigative, operational, and U.S. Army Garrison units.

Alert: the dark side of chats--internet without boundaries

The web has some unique advantages: It eliminates barriers of space and time; information flows quicker and is more accessible to all; the markets are more effective; community and interpersonal communication is more evolved. However, the web is also anonymous, without supervision, freedom of speech is exploited, minors and other web users are exploited, racism and prejudice are encouraged. These manifestations of violence not only hurt many people but actually pose a threat to the existence of the web as a place for exchanging ideas and thoughts, as a tool for relaying messages in a liberal and democratic fashion. Today, it is not legally possible to stop any discussion group or chats, like the one in which Eran participated, which develop dialogues regarding death or suicide. A wise and proper use of the web will be achieved by agreements and not enforcement. It is a process of education in its widest meaning that will be accomplished through the acceptance of norms. Proper use of the web will be possible when all sides--users, site owners and suppliers--willingly commit to values of mutual respect, decency and protection of individual fundamental rights to freedom. The web, which is a great blessing to the communication between people, organizations and cultures, carries with it substantial risks, especially to young users. The rapid expansion of the web and the increase in the number of users has brought many social-ideological dangers alongside the many advantages. In order to deal with these issues, a few years ago I initiated an association known as Eshnav (www.eshnav.org.il) which acts to increase public awareness to the risks and dangers of the web. Eshnav's mission, established to commemorate Eran's memory, is to promote public awareness to the positive and negative aspects of using the web on society and its values, and to promote the wise and safe use of the web. Eran was in great distress and needed empathy, encouragement and support. Sadly, when his mind was filled with suicidal thoughts he stumbled upon a group on the web that embraced the culture of death and suicide discussions. In his darkest moments, when he was on the verge of an abyss, he was probably pushed by these discussions into his death, and he was only 19-years-old. When Eshnav was created we saw the dangers of an Internet with no boundaries, a place where this remarkable technology was grossly misused. This is from the association's statement: "In a world without fences and boundaries clearer rules of conduct are needed." We emphasized that "the web is like a new world that has yet to determine its own boundaries. As such, it poses new challenges, both moral and ideological, which cannot be met based on past experience as this phenomenon is still too new and uncharted. We must do the utmost to be vigil about making the Internet as safe as possible even when this new frontier is constantly shifting and evolving." Let us bow our heads in sadness in memory of Eran whose strength did not withstand the great distress he was in, and who let himself be dragged by the death culture and darkness on the web into an untimely grave. We shall find strength in our determination to create a responsible web community in which freedom of speech will not be abused to hurt the individual rights of each and every human being to life, respect, reputation and privacy.

[Are near-death experiences following attempted suicide important for suicide risk assessment? A case report]

We describe a 59-year old patient who reported a near-death experience following attempted suicide. The near-death experience induced reduction of suicidality. Previous studies suggested a high prevalence of near-death experiences following attempted suicide and that near-death experiences may decrease rather than increase subsequent suicide risk. Implications for suicide risk assessment are discussed.

Torture against children in rebel captivity in Northern Uganda: physical and psychological effects and implications for clinical practice

BACKGROUND

Although torture in adults is well documented, studies that document its use against children, especially during war, are rare. This study documented the use of torture against children and its physical and psychological consequences during the war in Northern Uganda.

METHODOLOGY

Changes to the skin were examined by medical assistants, photographs taken, and allegations of torture verified in an interview and the case histories filed upon admission to the rehabilitation centres. The sample included 183 children aged 12 to 18 (mean age 14.8, SD 2.9) of which 60 were physically examined in two rehabilitation centres. The impact of torture was assessed using the Impact of Event Scale Revised (IES-R) in a multiple regression model.

RESULTS

Medical examinations showed visible evidence of physical trauma. Torture methods included burns, beatings, carrying heavy objects, gunshots, cuts with bayonets and machetes, long distance treks, etc. resulting into scars and keloids in different parts of the body. The scars were consistent with injuries inflicted on purpose. The children scored highly on the subscales of IES-R indicating severe symptoms of posttraumatic stress. The experience of torture explained between 26 to 37 per cent of the variance in symptoms of posttraumatic stress.

CONCLUSIONS

The physical trauma is consistent with histories and reports filed upon admission to the rehabilitation centres indicating that the children were indeed tortured. As a result of the torture, the children were psychologically distressed. The challenge for clinicians is to employ a holistic approach of treating survivors of torture by recognising not only the physical complaints but stress symptoms as well. This is because the mental states of debilitation, dependency, dread and disorientation that is induced in victims may have long-lasting consequences just like the physical and psychological consequences.

[Attempted suicide by firearms: a retrospective study of 161 cases]

OBJECTIVES

To determine the specific clinical aspects of patients with suicidal behaviour by firearm and investigate the specificities of the suicide method.

BACKGROUND

Suicidal behaviour represents a major public health problem throughout the world. Attempted suicide and completed suicide by firearms rates are very high both in Europe and in the United States. Preventive aspects presently preoccupy the physicians and the politicians. However, methods of suicide are understudied in Europe for the benefit of psychopathological and epidemiological aspects of suicide. Only a minority of studies enquire into the clinical aspects according to the method of suicide. Nevertheless, most of the international studies have already demonstrated the efficacy of reducing the accessibility of weapons.

METHODS

A retrospective study including suicide attempters by firearm hospitalized in the general hospital of Poitiers between 1992 and 2005.

RESULTS

We included 161 patients with self-inflicted gunshot wounds, among which 88% of patients were males. Most of them did not live alone and had children. Some of them had a past history of attempted suicide, some of them using a violent method. The acting out has mostly been committed at home and the firearm used was frequently a hunting gun. Interpersonal conflicts have been mostly reported by the patient with self-inflicted gunshot wounds. The prevalence of alcoholic behaviour and major depression is very important. Personality disorders are overrepresented in the study, notably paranoiac and borderline disorders.

DISCUSSION

Our sample is one of the largest compared to the other studies that often did not exceed 30 patients. Some results are contrary to those of populations of suicide attempters, whereas there are some similarities within the completed suicide population. Finally, paranoiac personality disorder is significantly associated with suicidal behaviour by firearm.

CONCLUSIONS

Some clinical characteristics have been reported as far as suicide attempters by firearm are concerned. Actually, there are some significant differences between suicide attempters by firearm and other suicide attempters. These results are very important for the perspective of preventing suicidal behaviour. However, it is essential to continue studies on the clinical aspects according to the method used in attempted and completed suicide.

Posttraumatic distress and physical functioning: a longitudinal study of injured survivors of community violence

This study examines the cross-lagged relationships between posttraumatic distress symptoms and physical functioning, using a sample of 413 persons who were hospitalized for injuries resulting from community violence. Posttraumatic distress was assessed at 1 week, 3 months, and 12 months postinjury, and posttraumatic physical functioning was assessed at 3 months and 12 months. Structural equation modeling was used to assess the prospective relationship between posttraumatic distress symptoms and physical functioning while controlling for demographic characteristics and objective measures of injury severity. Results indicate that posttraumatic distress and physical functioning are reciprocally related. Individuals with high levels of psychological distress at 1 week posttrauma have worse physical functioning at 3 months. Psychological distress at 3 months was not significantly associated with subsequent change in physical functioning at 12 months. Individuals with poor physical functioning at 3 months had higher than expected levels of psychological distress at 12 months. These findings demonstrate a reciprocal relationship between physical and mental health following traumatic injury. Interventions targeting physical recovery may influence subsequent mental health, and therapies aimed at improving early mental health may also have long-term benefits for physical recovery.

A Columbine study: giving voice, hearing meaning

On a quiet spring morning, the 20th of April 1999, Columbine High School emerged from relative anonymity as a typical suburban high school and became internationally recognized as a symbol of school violence and tragic loss. As a parent whose child was in the school at the time of the attack, I struggled to make sense of the tragedy. I decided to conduct research into the experience as a way to learn lessons that might help others exposed to community-wide trauma in the future. Through modified oral history interviews of other Columbine parents in combination with other qualitative research strategies, I collected and studied stories of the events of that day and the years following. An unexpected by-product emerged from the study, for it seemed that I was not only learning about crisis response and trauma care but also offering a means for parents to gain comfort in reflecting on their own experience. This paper describes the distinct approach that I employed to create a gateway to understanding this experience. It does not explicate the findings of the Columbine study but instead explores the potential for positive outcomes for those who, by giving voice to their stories, can connect to a deeper appreciation for their own experience.

Characteristics of persons with severe mental illness who have been incarcerated for murder

In this descriptive study, we analyzed data collected from multiple state agencies on 95 persons with severe mental illness who were convicted of murder in Indiana between 1990 and 2002. Subjects were predominantly suffering from a mood disorder, were white and male with a high school education or equivalent, were living in stabilized housing, and, to a lesser degree, were involved in significant intimate and familial relationships. Rage or anger, overwhelmingly directed toward intimate or familial relations by the use of a firearm or sharp object, was the most frequently mentioned motive for murder. Most of those studied had been raised in households with significant family dysfunction, had extensive histories of substance abuse and criminality, and had received little treatment for their mental and substance use disorders. Findings are contextualized and compared with similarly descriptive studies of nonlethal violence and persons with a mental illness; hospitalized, schizophrenic and psychotic murderers; and homicide offenders outside the United States.

Self-inflicted gunshot wound mimicking assault: a rare variant of factitious disorder

This paper presents the case of 52-year-old man who died in an attempt to prove factitious allegations of persecution. To the best of our knowledge, there are no other reported cases of a self-inflicted, long-distance gunshot injury causing death. We discuss other cases of crime-scene "staging" and review the literature on factitious disorders and malingering in our search for motive, and stress again the importance of crime scene analysis and investigation of circumstances in determining the manner of death.

Psychiatric Analysis of Suicide Attempt Subjects Due to Maxillofacial Gunshot

The studies of maxillofacial gunshot injuries mainly focused on evaluating the surgical interventions and physical outcomes of the procedures. In this study we aimed to analyze the pre- and post-injury psychiatric status of the patients with self-inflicted gunshot wounds to the face. This study is based on 12 subjects who attempted suicide resulting in extensive maxillofacial injuries using guns placed beneath their chins. The psychiatric evaluation was conducted by interview and using SCID-I, SCID-II, MMPI, Rosenberg Self-Esteem Scale and Suicide Probability Scale. Two subjects were healthy, 1 had bereavement, 6 had current and 5 had previous MDD (major depressive disorder), 2 had dysthymic disorder, 3 had alcohol abuse, 2 had drug abuse and 4 had antisocial personality disorder. The suicidal group was more socially introverted according to MMPI. According to Rosenberg self-esteem subscale, self esteem, the constancy of self respect and depressive mood subtests were statistically significant in the suicide group compared to the healthy controls (P < 0.01). Depressive spectrum disorders are the most common causes. It is obvious that untreated or undiagnosed depression may increase risk of committing suicide. The changes in the physical facial appearance after the suicide attempt caused impairment of self-esteem and the constancy of self-respect. Similar to other studies, none of our patients reattempted suicide and all tried to return to their pre-injury lifestyle and appeared to accommodate to the stigma of their physical deformities. Early diagnosis and treatment should be considered as a factor to reduce the risk for suicide attempt.

Psychological responses to the sniper attacks: Washington DC area, October 2002

BACKGROUND

This study assessed the psychological and behavioral responses of residents of the Washington DC metropolitan area to the October 2002 sniper shootings, as well as the association between measures of exposure to the shootings and elevated traumatic stress symptoms.

METHODS

Random-digit-dial telephone survey of 1205 adults living in Washington DC and two surrounding counties during the shootings, conducted May 2003. Main outcome measures included self-reports regarding traumatic stress symptoms, perceptions of safety, behavioral responses, and exposures to incidents.

RESULTS

Forty-five percent of residents reported going to public spaces such as parks and shopping centers less than usual, and 5.5% reported missing at least 1 day of work because of the sniper attacks. Women who reported living within 5 miles of any shooting incident were significantly more likely to report elevated traumatic stress symptoms-consistent with a probable diagnosis of post-traumatic stress disorder-than women who reported living farther from incidents (odds ratio = 4.2, 95% confidence interval = 1.9-9.3). Among men, there was no significant association between reported residential proximity and elevated traumatic stress symptoms.

CONCLUSIONS

These results suggest the substantial behavioral and psychological impact that traumatic events such as these sniper shootings can have on communities. They support the importance of clinicians and community leaders addressing psychological functioning in the setting of such events that threaten a population. The results further suggest that women who report residing closest to such incidents are at greatest risk for experiencing elevated symptoms of traumatic stress, and perhaps warrant special attention.

Officer-involved shooting: reaction patterns, response protocols, and psychological intervention strategies

Psychologists who work with law enforcement agencies may be called upon to respond to an officer-involved shooting (OIS). These need not be the most traumatic critical incidents in policing, but when they are, the reasons usually involve a mix of incident characteristics, officer response styles, and departmental handling. This article describes some of the psychological reactions experienced by officers during and following an OIS and provides a model of administrative, legal, mental health, and peer support services for officers in need. Finally, the article discusses several key roles that the police psychologist can play in the process of managing an OIS.

Management of Close-Range, High-Energy Shotgun and Rifle Wounds to the Face

Close-range, high-energy shotgun wounds of the face are life-threatening and devastating traumas of the face. Suicidal attempts are the main reason in the great majority of the patients in civilian life. There is no consensus on the timing of reconstruction for bone and soft tissue defects resulting from high-energy shotgun wounds. The conventional method is primary repair as soon as possible and serial debridements and definitive reconstruction in the delayed stage. An alternative to this approach is the immediate definitive surgical reconstruction of the patient during the first operation for acute management of trauma. We had 15 patients with close-range, high-energy shotgun wounds in 10 years. Six of 15 patients referred to our center for definitive reconstruction after the acute management of the patients were performed in another center and the rest were all admitted in the acute period. Either conventional approach with delayed reconstruction for 10 patients or immediate definitive surgical reconstruction for 5 patients was used. Immediate reconstruction eliminated disadvantages of the conventional method such as high infection and scarring rate and deformities resulting from contraction of tissues. The emotional conditions of the patients were evaluated and major depression signs were determined. Functional evaluation showed that there was great correlation between facial appearance after reconstruction and social activity level.

The management of ballistic trauma: an infection control perspective

This article discusses the relationship between ballistic trauma, clostridial contamination and potential wound infection and considers the implications for care by nurses and infection control teams. An overview of ballistics is presented followed by an examination of the pathophysiology of wounding and its effects. The philosophy of war surgery is balanced against civilian concepts and the differing management strategies that prevail. It explores the causes of, and relationship between, wound contamination and the seriousness of wound infection. Nurses, inexperienced in dealing and caring for these types of patients, should be aware and understand the beliefs, arguments and controversies that surround ballistic trauma management. By so doing, nurses and infection control teams will be able to provide an enhanced level of holistic nursing care.