Assessment and treatment of adult acute responses to traumatic stress following mass traumatic events

Trauma reactivation under propranolol among traumatized Syrian refugee children: preliminary evidence regarding efficacy

Background: There is a dearth of therapeutic solutions for traumatized young patients. Trauma reactivation conducted under the influence of the reconsolidation blocker propranolol (Reconsolidation Therapy) is a simple, cost-effective treatment option that has some promising initial results in adults suffering from posttraumatic stress disorder (PTSD). Objective: To explore the usefulness of this novel treatment in children. The primary outcome was the reduction of PTSD symptoms at the end of treatment, while secondary outcomes included reduction in anxiety and in depressive symptoms. Method: An open-label clinical trial was conducted in a refugee camp in Syria, investigating the safety and efficacy of this therapeutic strategy in 117 children suffering from enduring PTSD symptoms. Participants received propranolol 90 minutes before briefly recalling (i.e. reactivating) a single personal traumatic memory, for 5 consecutive days. Self-reported anxiety, depressive, and PTSD symptoms were assessed at baseline, as well as 4 and 13 weeks after treatment. Results: A significant, clinically meaningful symptom reduction was observed at all post-treatment measurement times vs. baseline. More specifically, between baseline and the 13-week follow-up we observed a 64% PTSD symptoms reduction (d = 2.71). In a similar vein, we obtained a 39% symptoms reduction for depressive symptoms (d = 1.01). The general anxiety symptoms improved, but eventually returned to prior level, probably because of the deteriorating living conditions in the camp. Conclusions: This therapy appeared as a potentially safe and useful treatment strategy for children suffering from PTSD symptoms, warranting replication studies using stronger study designs. The social acceptability and ease of implementation of the treatment should also be noted.

Post-traumatic stress disorder--a diagnostic and therapeutic challenge

BACKGROUND

In Germany, the one-month prevalence of post-traumatic stress disorder (PTSD) is in the range of 1% to 3%. Soldiers, persons injured in accidents, and victims of domestic violence increasingly seek medical help for symptoms of emotional stress. Days lost from work and monetary compensation for emotional disturbances are markedly on the rise. The term "PTSD" is commonly used uncritically and imprecisely, with too little regard for the existing diagnostic criteria. It is at risk of turning into a nonspecific collective term for emotional stress of any kind.

METHODS

We selectively reviewed the literature in the PubMed database and pertinent journals, with additional consideration of the recommendations and guidelines of medical societies from Germany and abroad.

RESULTS

The characteristic types of reactions seen in PTSD are nightmares and an intense, repetitive, intrusive "reliving" of the traumatic event(s). Emotional traumatization manifests itself not only as PTSD but also through major effects on other mental and somatic diseases. An early, trauma-focused behavioral therapeutic intervention involving several sessions, generally on an outpatient basis, can prevent the development of PTSD. The most important components of effective treatment are a focus on the particular trauma experienced and confrontation with the patient's memories of the trauma. The best existing evidence is for cognitive therapy, behavioral therapy according to the exposure paradigm of Foa, and eye movement desensitization and reprocessing therapy. The most recent meta-analysis reveals effect strengths of g = 1.14 for all types of psychotherapy and g = 0.42 for all types of pharmacotherapy taken together (with considerable differences among psychotherapeutic methods and among drugs). The efficacy of psychodynamic therapy, systemic therapy, body-oriented therapy, and hypnotherapy has not been adequately documented in randomized controlled trials.

CONCLUSION

PTSD can be precisely diagnosed and effectively treated when the diagnostic criteria and guideline recommendations are taken into account. Referral for trauma-focused psychotherapy should be considered if the acute symptoms persist for several weeks.

Support, opinion of support and psychological health among survivors of a natural disaster

BACKGROUND

Although formal intervention after disasters is recommended, the evidence base for this is weak. Satisfaction with support after disasters is seldom investigated and the relation to psychological symptoms is unknown.

AIMS

To investigate whether dissatisfaction with social and formalized support are associated with post-disaster psychological symptoms.

METHODS

A total of 1,505 Swedish survivors of the 2004 Indian Ocean tsunami responded to a questionnaire 14 months after the disaster, including the General Health Questionnaire-12, the Impact of Events Scale - Revised, the Crisis Support Scale, and questions concerning the reception and appraisal of social and formalized support from health care, psychological services and insurance agencies. Disaster exposure and background factors were controlled for in the analyses.

RESULTS

Reception of formalized support, but not social support, was associated with both psychological distress and post-traumatic stress. Dissatisfaction with social but not formalized support, with the exception of support from insurance agencies, was associated with psychological distress.

CONCLUSIONS

Social support and formalized support should be differentiated in future studies in order to improve preventive intervention efforts after disasters. The reporting of dissatisfaction with social support merits special attention, since this may indicate increased risk for psychological symptoms.

Disaster exposure as a risk factor for mental health problems, eighteen months, four and ten years post-disaster--a longitudinal study

BACKGROUND

Disaster experiences have been associated with higher prevalence rates of (mental) health problems. The objective of this study was to examine the independent relation between a series of single disaster experiences versus the independent predictive value of a accumulation of disaster experiences, i.e. a sum score of experiences and symptoms of distress and post-traumatic stress disorder (PTSD).

METHODS

Survivors of a fireworks disaster participated in a longitudinal study and completed a questionnaire three weeks (wave 1), eighteen months (wave 2) and four years post-disaster (wave 3). Ten years post-disaster (wave 4) the respondents consisted of native Dutch survivors only. Main outcome measures were general distress and symptoms of PTSD.

RESULTS

Degree of disaster exposure (sum score) and some disaster-related experiences (such as house destroyed, injured, confusion) were related to distress at waves 2 and 3. This relation was mediated by distress at an earlier point in time. None of the individual disaster-related experiences was independently related to symptoms of distress. The association between the degree of disaster exposure and symptoms of PTSD at waves 2 and 3 was still statistically significant after controlling for symptoms of distress and PTSD at earlier point in time. The variable 'house destroyed' was the only factor that was independently related to symptoms of PTSD at wave 2. Ten years after the disaster, disaster exposure was mediated by symptoms of PTSD at waves 2 and 3. Disaster exposure was not independently related to symptoms of PTSD ten years post-disaster.

CONCLUSIONS

Until 4 years after the disaster, degree of exposure (a sum score) was a risk factor for PTSD symptoms while none of the individual disaster experiences could be identified as an independent risk factor. Ten years post-disaster, disaster exposure was no longer an independent risk factor for symptoms of PTSD. Since symptoms of PTSD and distress at earlier waves perpetuate the symptoms at later waves, health care workers should aim their resources at those who still have symptoms after one and a half year post-disaster, to prevent health problems at medium and long-term.

Physical symptoms 14 months after a natural disaster in individuals with or without injury are associated with different types of exposure

OBJECTIVE

To investigate whether different types of exposure to the 2004 tsunami were associated with physical symptoms 14 months after the disaster and to study correlations between survivors' physical and psychological symptoms.

METHODS

Using a cross-sectional design, 1505 survivors from the 2004 Indian Ocean Tsunami, tourists from Stockholm, who had been present in the disaster areas, responded to a postal questionnaire. Eight groups based on type of exposure were created. Physical symptoms occurring on a daily or weekly basis over the past year were investigated in four indices: musculoskeletal, cardiorespiratory, neurological, and gastrointestinal. Mental health symptoms (General Health Questionnaire-12) and posttraumatic stress symptoms (Impact of Event Scale-Revised) were also investigated. Multiple logistic regression analyses were conducted with controls for background variables and exposure, with physical symptoms as outcome variables. The association between physical and psychological symptoms was studied with the Spearman Rank Order Correlation.

RESULTS

Different types of exposure during the disaster were associated with physical symptoms 14 months later for survivors both with and without severe physical injury. The single exposure of life threat, also in combination with other exposures, was associated with a higher risk for reporting of physical symptoms. Physical symptoms showed modest yet significant correlation with psychological symptoms.

CONCLUSION

It is important to pay attention to both physical and psychological symptoms among disaster survivors whether they have been injured or not. A relatively simple questionnaire about physical symptoms may be a good complement to the scales used to assess psychological problems after disaster.

Sample and design considerations in post-disaster mental health needs assessment tracking surveys

Although needs assessment surveys are carried out after many large natural and man-made disasters, synthesis of findings across these surveys and disaster situations about patterns and correlates of need is hampered by inconsistencies in study designs and measures. Recognizing this problem, the US Substance Abuse and Mental Health Services Administration (SAMHSA) assembled a task force in 2004 to develop a model study design and interview schedule for use in post-disaster needs assessment surveys. The US National Institute of Mental Health subsequently approved a plan to establish a center to implement post-disaster mental health needs assessment surveys in the future using an integrated series of measures and designs of the sort proposed by the SAMHSA task force. A wide range of measurement, design, and analysis issues will arise in developing this center. Given that the least widely discussed of these issues concerns study design, the current report focuses on the most important sampling and design issues proposed for this center based on our experiences with the SAMHSA task force, subsequent Katrina surveys, and earlier work in other disaster situations.

Different types of exposure to the 2004 tsunami are associated with different levels of psychological distress and posttraumatic stress

The impact of traumatic exposure on psychological distress and posttraumatic stress was investigated at 14 months through self-report in 1,505 Swedish tourists who survived the 2004 Indian Ocean Tsunami. Exposure, differentiated in single and multiple types, was associated with different levels of impaired mental health measured by General Health Questionnaire (GHQ) and Impact of Event Scale-Revised (IES-R). Additionally, having sole exposure to subjective life threat brought about specific psychological effects. Some demographic factors are associated with outcome on either the GHQ or the IES-R. Identifying specific types of exposure of disaster survivors may be a way to identify individuals who could be screened for psychological ill health at a later point in time.

First responders: mental health consequences of natural and human-made disasters for public health and public safety workers

First responders, including military health care workers, public health service workers, and state, local, and volunteer first responders serve an important role in protecting our nation's citizenry in the aftermath of disaster. Protecting our nation's health is a vital part of preserving national security and the continuity of critical national functions. However, public health and public safety workers experience a broad range of health and mental health consequences as a result of work-related exposures to natural or man-made disasters. This chapter reviews recent epidemiologic studies that broaden our understanding of the range of health and mental health consequences for first responders. Evidence-based psychopharmacologic and psychotherapeutic interventions for posttraumatic distress reactions and psychiatric disorders are outlined. Finally, the application of public health intervention models for the assessment and management of distress responses and mental disorders in first-responder communities is discussed.

European first aid guidelines

AIM

Our objectives were to determine the most effective, safe, and feasible first aid (FA) techniques and procedures, and to formulate valid recommendations for training. We focussed on emergencies involving few casualties, where emergency medical services or healthcare professionals are not immediately present at the scene, but are available within a short space of time. Due to time and resource constraints, we limited ourselves to safety, emergency removal, psychosocial FA, traumatology, and poisoning. Cardiopulmonary resuscitation (CPR) was not included because guidelines are already available from the European Resuscitation Council (ERC). The FA guidelines are intended to provide guidance to authors of FA handbooks and those responsible for FA programmes. These guidelines, together with the ERC resuscitation guidelines, will be integrated into a European FA Reference Guide and a European FA Manual.

METHODS

To create these guidelines we used an evidence-based guideline development process, based on the methodology of the Scottish Intercollegiate Guidelines Network (SIGN).

RESULTS

The recommendations cover FA for bleeding, wounds, burns, spinal and head trauma, musculoskeletal trauma, and poisoning, as well as safety and psychosocial FA.

CONCLUSIONS

Where good evidence was available, we were able to turn science into practice. Where evidence was lacking, the recommendations were consensus-based. These guidelines provide systematically developed recommendations and justifications for the procedures and techniques that should be included in FA manuals and training programmes.

Delayed-onset PTSD: a prospective study of injury survivors

BACKGROUND

Recent studies have indicated that delayed-onset posttraumatic stress disorder (PTSD) (i.e., the development of PTSD more than 6 months posttrauma) is generally characterised by subsyndromal diagnoses within the first 6 months. This study sought to examine the relationship between sub-clinical levels of PTSD symptoms at 3 months posttrauma and delayed onset PTSD at 12 months in a large sample of traumatic injury survivors.

METHODS

Three hundred and one consecutively admitted injury survivors were assessed at 3 and 12 months posttrauma. PTSD was diagnosed according to DSM-IV criteria, while partial and subsyndromal diagnoses were based on recent definitions developed by Mylle and Maes [Mylle, J., Maes, M., 2004. Partial posttraumatic stress disorder revisited. J. Affect. Disord. 78, 37-48].

RESULTS

Eight percent of participants was diagnosed with 3-month PTSD while 10% was diagnosed with 12-month PTSD. Nearly half (47%) of 12-month PTSD cases were of delayed onset. The majority of those with delayed-onset were diagnosed with partial or subsyndromal PTSD at 3 months. Ten percent of delayed onset cases did not meet partial or subsyndromal criteria.

LIMITATIONS

As symptoms were not assessed at 6 months (the DSM cut-off for delayed PTSD), it could not be conclusively determined that delayed-onset cases had not developed PTSD between 3 and 6 months posttrauma.

CONCLUSION

A considerable proportion of 12-month PTSD diagnoses was delayed in onset. While most demonstrated 3-month morbidity in the form of partial and subsyndromal diagnoses, a minority did not. Thus, clinicians should consider subthreshold diagnoses as potential risk factors for delayed-onset PTSD. Future research is required to identify factors that may predict delayed-onset PTSD in trauma survivors without evidence of prior PTSD pathology.

Challenges of post‐tsunami reconstruction in Sri Lanka: health care aid and the Health Alliance

The Indian Ocean tsunami of 26 December 2004 has drawn attention to the need for a process to ensure that health aid is provided in an efficient, coordinated and appropriate manner. In response to this, and with support from various medical colleges and the Australian Government, we have established the Australian Health Alliance to Assist with Post-tsunami Reconstruction. In Sri Lanka, some of the current challenges include shortages of medical staff, damaged infrastructure and changing demands due to population shifts. Psychological services are particularly scarce. The psychological and cultural implications of disaster require specific attention when designing aid programs. The goals of the Health Alliance include providing a forum for discussion, identifying specific local needs, coordinating health services and helping local organisations to develop action plans.