Download 4 Problems o ecological psychiatry

Problems of ecological
psychiatry.
Lyudmyla T. Snovyda
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Disaster Classification
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Hydrometeorological Disasters (Weather-related)
– Floods and Related Disasters
 Floods
 Landslides/mudslides
 Avalanches
– Windstorms
 Tropical cyclones (hurricanes, cyclones, typhoons,
tropical storms)
 Tornadoes
 Storms: thunderstorms, winter storms
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Geophysical Disasters
– Earthquakes
– Volcanic Eruptions
– Tsunamis/Tidal waves
Droughts and Related Disasters
– Extreme Temperatures
– Wildfires
– Droughts
– Famine
– Insect Infestation
Pandemic Diseases
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Human-Generated Disasters
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Non-intentional/Technological
– Industrial Accidents
– Transportation Accidents
– Ecological/environmental destruction
– Miscellaneous Accidents
Intentional
– Declared War
– Civil Strife
– Ethnic Conflict
– Mass Gatherings
– Terrorism
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Disaster ecology examines the interrelationships and
interdependence of the social, psychological,
anthropological, cultural, geographic,economic, and
human context surrounding disasters and extreme public
health events such as severe storms, earthquakes, acts
of terrorism, industrial accidents, and disease epidemics
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Psychosocial reactions to trauma are recognized to be
among the most long-term and debilitating outcomes of
disasters . The extent and extremity of psychosocial
responses, ranging from transient fear and distress to
chronic psychopathology, relate directly to the nature of
disaster itself and to the complex interplay of factors
including the exposure of vulnerable human communities
to massive forces of harm or widespread perception of
imminent threat. Exposure, loss, and change—the forces
of harm—represent disaster consequences and powerful
stressors
Natural disasters
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Natural disasters, in which harm to huma populations is
primarily caused by the forces of nature, can be further
categorized into hydrometeorological disasters (typically
weather-related) such as floods and windstorms;
geophysical disasters such as earthquakes and tsunamis,
and volcanic eruptions; droughts and related
phenomena; and pandemic waves of disease
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The United Nations Development Program provides a strong
statement regarding the impact of natural disasters: ―In the
last two decades, more than 1.5 million people have been killed
by natural disasters. Worldwide, for every person killed, about
3,000 people are exposed to natural hazards. Some 75 percent
of the world‘s population lives in areas affected at least once by
earthquake, tropical cyclone, flood or drought between 1980
and 2000. At the global level,and with respect to large- and
medium-scale disasters, these four hazard types
(earthquakes,tropical cyclones, floods and droughts) account
for approximately 94 percent of total mortality.
Human-generated disasters
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Disasters caused or exacerbated by human action are
subdivided into intentional versus non-intentional events based
upon the presence or absence of purposeful human causation.
Industrial disasters, transportation disasters, and progressive or
precipitous destruction of ecosystems reflect failures or sideeffects of human-devised technologies (frequently referenced
as ―technological disasters), failures of human judgment, or
even flagrant human neglect. However, harm and destruction
are not intentionally perpetrated. Several particularly
memorable technological disasters are the accidental toxic gas
release in Bhopal, India and the nuclear meltdown in
Chernobyl, Russia.
Human-generated disasters
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In contrast, intentional harm is a defining feature during
acts of mass violence including declared war, civil strife,
ethnic or religious conflict, and acts of terrorism.
Terrorist actions threaten harm, or overtly inflict harm,
with the intent of provoking widespread fear that
extends beyond those who are directly targeted (Ursano,
et al., 2002, Butler, et al., 2003). Civilians,rather than
soldiers or police, are increasingly targeted, and
represent a growing proportion of casualties, from all
types of mass violence, especially acts of terrorism.
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Disasters are common phenomena. Once every 19
hours, a natural disaster is recorded in the international
disaster registry located at the Centre for Research on
the Epidemiology of Disasters (CRED) in Brussels,
Belgium (CRED, 2006). Once every 25 hours, a humangenerated ―technological disaster is registered.
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Many types of natural disasters, particularly the large
class of hydrometeorological events, tend to be seasonal.
Tropical cyclones seasons are determined by annual
fluctuations inocean temperature. Winter storms are
seasonal by definition and flooding occurs with spring
thaws, rainy seasons, or monsoons. Some infectious
diseases such as influenza circulate globally, rising and
falling on a seasonal basis within a particular geographic
area.
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A time factor of great import is duration of impact and duration
of disruption. Impact varies from seconds (earthquakes and
landslides, conventional bomb blasts) to minutes (tornadoes,
flash floods, tsunamis) to hours and days (hurricanes) to weeks
and months (riverine flooding, volcanic eruption, pandemics
and bioterrorist disease outbreaks) to years (famine,drought)
to decades and centuries (radioactive contamination).
Moreover, the period of disruption of vital services may be
protracted if power is disrupted, and schools and businesses
are closed due to damage. Population displacement is one of
the hallmarks of humanitarian crises and complex emergencies.
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. In some cases persons can never return home due to
physical destruction so catastrophic that the area is
deemed unsalvageable. Events such as extreme
contamination, profound depletion of vital resources, or
change in ownership following warfare or ongoing
militant threat may displace and dispossess persons in a
manner that may be life-long.
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Hyperthyroidism
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which is much more common among females than
males, results from an excessive elevation of free
thyroxine levels or, rarely, solely from an elevation
of free triiodothyronine levels. The most common
causes are Graves' disease, toxic multinodular
goiter, or a thyroiditis, most commonly Hashimoto's
thyroiditis..
CLINICAL FEATURES
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Typically, patients are apprehensive, and, although fatigued
and tired, they are often restless and unable to sit still. They
may complain of diaphoresis and heat intolerance, an increased
frequency of bowel movements, and weight loss despite an
increased appetite and an increased food intake. On
examination one generally finds tachycardia, widened
palpebral fissures , a fine tremor and generalized hyperreflexia.
Women may complain of menstrual irregularities and men may
experience erectile dysfunction. A proximal mopathy, affecting
primarily the pelvic musculature, is not uncommon, and, rarely,
chorea may appear.
CLINICAL FEATURES
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Although anxiety is classically associated with
hyperthyroidism, depressive symptoms are more common,
being seen in anywhere from one-quarter to one-half of all
patients. Rarely one may see a mania or hypomania, and even
more rarely there may be a psychosis.
Hypothyroidism
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Hypothyroidism is relatively common among adults,
occurring in about 1.4% of females and about 0.1%
of males. The vast majority of cases are secondary
to Hashimoto's thyroiditis, thyroidectomy, or
radioactive iodine treatment; it is also not
uncommon to see hypothyroidism occur in patients
who have abruptly discontinued long-term treatment
with thyroid supplementation.
CLINICAL FEATURES
Typically, speech and action become slowed and retarded.
Minutes may pass before the patient answers a question, and
loosening one button may require a full minute. Initiative is
diminished; memory seems fogged, and patients have difficulty
comprehending what is said to them. In severe cases a
lethargic, withdrawn dementia may occur.
– Depression occurs in a substantial minority of patients,
and this may be accompanied by anxiety, irritability and
querulousness.
Psychosis, or "myxedema madness," is typically characterized by
delusions of persecution; less commonly, patients may experience
hallucinations that tend to be either auditory or visual, or, much less
commonly, olfactory or gustatory.
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CLINICAL FEATURES
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Hypothyroidism typically causes a distinctive dullness and slowing of
thought that, when severe, may progress to a dementia; depression may
also be seen, and, rarely, patients may become psychotic.
Hypothyroidism, when severe, is traditionally referred to as
"myxedema," and in cases where psychosis does occur, one may speak
of "myxedema madness."
Chronic adrenocortical
insufficiency
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typically presents with depressed mood, irritability, apathy,
fatigue, and weakness. Concentration may be poor, and
insomnia may occur. Almost all patients lose their appetite and
lose some weight. ."
Manganism
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Chronic exposure to manganese may be followed by
the development of a personality change, an atypical
parkinsonism, and, less commonly, a dementia or
psychosis. Although such exposure is generally
restricted to manganese miners or to those who work
in steel or battery factories, cases have also occurred
among those who drank contaminated well water,
and, rarely, in patients undergoing total parenteral
nutrition.
CLINICAL FEATURES
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The personality change is characterized by asthenia, fatigue,
irritability, emotional lability and a peculiar tendency to laugh,
often for no particular reason. Insomnia or somnolence may
accompany these changes.
Parkinsonism may precede or follow the personality change
and is characterized by bradykinesia, rigidity and postural
instability with a tendency to fall backward; tremor is usually
absent. The main atypical feature of this parkinsonism is the
presence of dys-tonia, and patients may experience torticollis
or a peculiar dystonic gait, characterized by toe-walking. This
gait may at times be accompanied by flexion of the elbows,
creating the classic "cock-walk," wherein the overall picture is
reminiscent of the strutting of a rooster.
– Dementia, when it occurs, is marked by a prominent
amnestic component.
– The psychosis of manganism, also known as "manganese
madness," is characterized by hallucinations, delusions.
Arsenic
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Although elemental arsenic is not toxic to the central
nervous system, the ingestion of pentavalent or
trivalent arsenic may cause a delirium or dementia.
Such salts are found in some weed and rat killers
and occasionally contaminate beer or moonshine
whiskey. Occupational exposure, although rare, still
at times occurs, and arsenic may at times be used in
suicide or homicide attempts.
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Acute toxicity is manifested by abdominal pain,
diarrhea, delirium, and, classically, the odor of garlic
on the breath; within one to three weeks a
sensorimotor peripheral polyneuropathy appears,
which may be severe. Some cases are also
characterized by grand mal seizures, and cardiac,
renal and bone marrow toxicity may also occur.
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CLINICAL FEATURES
Typically, patients present with a peculiar expressive
aphasia characterized by stuttering. With
progression, the aphasia worsens and is joined by
myoclonus, seizures and dementia. Rarely, the
clinical picture may be marked by a psychosis or by
mania.
Vit.B12 deficiency
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CLINICAL FEATURES.Cerebral involvement may
manifest with dementia, depression, or, rarely, with either mania or
psychosis. Dementia is the most common manifestation of cerebral
involvement, and may be complicated by delusions and
hallucinations. When B12 deficiency manifests with psychosis, one
speaks of "megaloblastic madness."Spinal cord and peripheral nerve
involvement generally go hand in hand. Pathologically, one sees
demyelinization in the peripheral sensory nerves and in the posterior
columns and lateral corticospinal tracts. Clinically, in fully developed
cases, there is a loss of vibratory sense in the lower extremities,
ataxia, a positive Romberg test, spastic weakness, extensor plantar
responses, and either hyperreflexia or, if the sensory neuropathy is
severe, hypore-flexia. Patients may complain of numbness and
tingling in the lower extremities, and incontinence may occur.
Neurosyphilis
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Infection with the spirochete Treponema pallidum
occurs in primary, secondary and tertiary forms.
Primary syphilis typically presents with a
painless chancre, and secondary syphilis with a
widespread rash; following the resolution of the
rash, there is a more or less lengthy "latent"
interval after which tertiary syphilis may appear.
Tertiary syphilis may affect a variety of organs,
including the central nervous system, in which
case one speaks of neurosyphilis.
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The majority of patients display the simple
dementia, without prominent affective symptoms.
The patient begins to neglect dress and personal
hygiene. Judgment and self-restraint fail, and the
patient may embark on ruinous financial or personal
ventures. Hallucinations and delusions may occur,
but they generally play only a minor role in the
overall symptomatology. The hallucinations fflay be
either visual or auditory. The delusions, though
frequent, tend to be neither fixed nor systematized
and often change concomitantly with the patient's
shifting moods. Memory and concentration fail.
The manic type may be almost indistinguishable from a manic
episode of bipolar disorder. The patients are euphoric and
extremely energetic. Delusions of grandeur are common. They
are presidents, kings, and titans of industry and often attempt
to act as such exalted persons might. Life savings may be
squandered overnight. This presentation, in connection with
some of the symptoms of a simple dementia, is so
characteristic that in the nineteenth and early twentieth century
it was considered virtually pathognomonic for general paresis.
The melancholic, or depressive, type bears, as might be expected, a
strong resemblance to a typical depressive episode. The patients are
downcast, drained, agitated, and sleepless. They feel they have
committed unpardonable sins and are to be executed. Suicide may
occur.
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Regardless of the typology of the dementia of general paresis, certain
other signs and symptoms may be seen. Typically, however, they
become apparent only after the dementia has been established. Focal or
generalized seizures occur in about one half of the cases, and they tend
to become more common as the dementia progresses. Speech gradually
becomes slow, slurred, and monotonous; dysnomia may occur, and
echolalia may occasionally be seen. Dysgraphia occurs—handwritten
letters become misshapen, misspellings are common, and eventually
sentences become unintelligible. Very typically, the facial musculature
loses its tone and becomes flabby, giving the patient a vacant, almost
stupid, facial appearance. The Argyll Robertson pupil is present in
almost all patients but may not be complete. Coarse tremor is common,
and, in addition to the fingers and hands, it is also apparent in the lips
and tongue. Unless the patient has tabes dorsalis, the deep tendon
reflexes tend to be hyperactive, and the plantar responses may be
extensor.
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With progression most patients with general paresis, regardless
of the initial typology of the dementia, eventually come to a
common end. Short-term and eventually long-term memory
become profoundly deficient, and patients may confabulate
wildly. The mood becomes increasingly labile, and eventually
consciousness becomes profoundly clouded, with many
patients sinking into a torpor. The gait becomes unsteady, and
eventually a true "general paresis" occurs, with profound
widespread weakness of all voluntary musculature. At the end
the patient is unable to walk and becomes bedridden, existing
in a vegetative state until death occurs.
Tuberculosis

tuberculosis is an acid-fast intracellular bacillus that
in most cases is spread by droplets from persons
who have cavitary pulmonary disease. In many
patients a focus of infection may lie dormant in the
body for years or decades, held in check by adequate
host
defenses
until
some
loss
of
immunocompetence, as in AIDS, or some other
debilitating illness, is followed by reactivation and
hematogenous spread to various other organs,
including the meninges or the brain, where it may
cause a basilar meningitis or parenchymal
tuberculomas.
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Meningitis is characterized by delirium, often
marked by intervals of partial lucidity, headache,
stiff neck and fever. Tremor is common, and there
may be hyponatremia secondary to a syndrome of
inappropriate antidiuretic hormone secretion
(SIADH). Cranial nerve palsies may occur,
especially of the third, fourth, and sixth cranial
nerves, and in a small minority obstructive
hydrocephalus may occur, with an acute worsening
of the delirium.
Head trauma
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Head trauma may be usefully classified according to the
mechanism whereby the brain is injured: missile wounds,
which are relatively uncommon in civilian life; crush injuries,
wherein the stationary head is struck, as might happen when a
car falls off its jack striking the garage mechanic working
beneath it; and, most commonly, acceleration-deceleration
injuries. Acceleration-deceleration injury most frequently
occurs in motor vehicle accidents; for example, when a rapidly
moving car strikes an abutment and the freely moving head
comes to a violent instant deceleration on the dashboard.
Actual contact, however, need not occur, and significant
acceleration-deceleration injury may occur with a violent
whiplash: all that is necessary is that the cranium stop and the
still-moving gelatinous brain violently come to a halt against
the inside of the vault, thus injuring itself.
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The extent of brain damage after head injury is not
necessarily related to the presence or absence of a
fracture. Certainly, if a comminuted compound
fracture occurred and fragments of bone lacerated
the brain and came to a rest deeply embedded in the
parenchyma, this would be most significant.
However, severe, even fatal, brain damage may
occur without any damage to the cranium at all.
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In a crush injury the parenchyma underlying the point of
impact is contused and perhaps lacerated.
In acceleration-deceleration injuries, structures that extend for
some length, such as axons, capillaries, and penetrating
arterioles, are subject to enormous shearing and torsional strain
and consequently undergo various degrees of damage or actual
rupture. A condition known as diffuse axonal injury, or DAI,
results whenever widespread demyelinization or axonal rupture
occurs. Capillaries may also be ruptured, leading to petechial
hemorrhages, and ruptured arterioles may produce
intracerebral hematomas. In addition to DAI, such violent
acceleration or deceleration may also cause lacerations of the
parenchyma or contusions.
The personality change is typically characterized by irritability
and moodiness, and there may be violent outbursts; much less
commonly, there may be facetiousness and a shallow euphoria.
The dementia is of variable severity, and is often marked by
inattentiveness, difficulty with concentration, and poor memory;
typically there is also an amnesia for the trauma itself, and there is a
fair correlation between the extent of the amnesia surrounding the
trauma and the overall severity of the DAI. The patient may also
experience headache, dizziness. On examination, one may see focal
signs, reflecting areas of more severe damage, as in hemorrhage or
severe contusion. Cranial nerve palsies, seizures, and varying degrees
of aphasia or hemiparesis may be seen.
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AIDS
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CLINICAL FEATURES
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Patients typically complain of apathy, forgetfulness, and trouble
concentrating, and exhibit considerable psychomotor retardation;
some may also develop delusions and hallucinations. Ataxia and
dysarthria typically appear, and pyramidal tract signs and tremor may
also be seen. With progression of disease, the dementia may become
quite profound, with confusion, muteness, and double incontinence.
Myoclonus may eventually appear, as may seizures. Although
typically occurring subsequent to and in the setting of other symptoms
of AIDS, this dementia may rarely be the presenting symptom of
AIDS. Typically, however, the patient with an AIDS dementia also
has one or more of the following: generalized lymphadenopathy,
thrush, constitutional symptoms, diarrhea, cytopenia (including
thrombocytopenia), Kaposi's sarcoma, shingles and opportunistic
infections, such as pneumocystis carinii pneumonia. Of particular
importance are those infections and neoplasms that may themselves
cause a delirium or dementia
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