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1/27/2011
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PSYCHOLOGICAL TRAUMA
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Identify a Critical Incident Stress Event
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Recognize the various types of stress g
yp
responses
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Identify the various Critical Incident Stress Management Principles
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“Psychological trauma is the unique individual
experience of an event or enduring conditions
in which: The individual's ability to integrate
his/her emotional experience is overwhelmed
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or the individual experiences (subjectively) a
threat to life, bodily integrity, or sanity.”
Trauma: which involves a physical threat to life or bodily integrity which include the following:
 exposure  witnessing a traumatic event  being confronted with a trauma
Pearlman & Saakvitne, 1995, p. 60
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Intrusive, re
experiencing symptoms
Intrusive, re‐experiencing symptoms
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Avoidance
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Hyperarousal
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Duration of symptoms more than 1 month
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Syndrome is acute if it has lasted less than 3 months and chronic if it lasts more then 3 months
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PTSD has delayed onset if the onset of symptoms is greater then 6 months after the trauma
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What is a Critical Incident Stress Event?
“Any event in which there is a stressful impact
sufficient enough to overwhelm
the usually effective coping skills
of either an individual or a group.”
(Everly & Mitchell, 1999)
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Unexpected
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Unknown Cause
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Many Deaths, especially of children
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Long Duration of Event
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Affects a Sensitive/Significant Place
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Affects a Large Area
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Haitian Presidential Palace
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Preparation
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Training
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Teamwork, cooperation, camaraderie
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High level of pre‐event well being
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A normal reaction to an abnormal situation…
Post Traumatic Stress:
A normal reaction in a normal person to an
abnormal event.
event It is an intrinsic
mechanism.
Post Traumatic Stress Disorder is a
pathogenic variation of that normal
survival mechanism
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Physiologic Stress Reactions
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Physiologic
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Emotional
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Cognitive
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Behavioral
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Spiritual
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 Tachycardia
 Fear and anxiety
 Hypertension
 Sadness and depression
 Hyperglycemia  Anger and irritability
 Increased Gastrointestinal Motility  Feeling numb, withdrawn, or disconnected
 Insomnia  Feeling a lack of involvement or enjoyment in  Acute‐ Increase in Immune Response
favorite activities
 Chronic‐ suppression of Response
 Feeling a sense of emptiness or hopelessness about the future
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 Increased Social Confrontations  Substance Abuse‐ most commonly alcohol
 Overly Security Conscious
 Overly Engaged in Activity  Isolating‐ to the point of alienation of family
 Easily Alarmed‐ especially by sudden noise
 Problems falling asleep and/or staying asleep
 Avoiding Psychological Triggers of Memory
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ACUTE STESS
CHRONIC STRESS
 Improved  Poor concentration
concentration
 Improved memory
I
d  Difficulty communicating
 Difficulty with performing multistep tasks
 Poor memory
 Intrusive thoughts or memories‐ graphic
 Dreams or Nightmares‐ often recurring
 Flashbacks
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Increased Devotion or Faith
Reexamining Values and Beliefs
Feeling a Loss of Meaning in Life
 Anger Toward a Higher Power
A
T
d Hi h P
 Cynicism‐ Outright Spiritual Rejection
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Post Traumatic Stress Disorder
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What is CISM?
 Opportunity to assess and risk stratify
 Opportunity to set up follow-up based
upon that assessment of need.
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Posttraumatic Stress Disorder in a Community Sample..., Brian Engdahl et al,
American Journal of Psychiatry, 1997, pp. 1576-81.
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What CISM is not?
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CISM Principles
Not an Intervention
 CISM = Postvention
 It is not a cure
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B -I -S -E –P
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 It improves outcome
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Opportunity to improve outcome
Not equivalent to psychosocial support
Brevity- few minutes up to 1 hour
Immediacy – Rapid Intervention
Simplicity – Supportive Approach
Expectancy – Expect emotional response
Proximity – Close to site of incident
 It is an opportunity to bring people together
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Avoid interruption
Use open ended questions to clarify
Occasionally summarize
Establish chronologic sequence
Common Pitfalls:
 “Why?” and “Why not?”
 “I know how you feel”
 Evaluation of their experience 
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Expect and promote normal recovery
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Assume survivors are resilient
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Recognize survivor strengths
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Promote resiliency through a focus on strengths
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Support survivors to encourage empowerment
Silence is Golden
Sources: Glass et al. 2002; Pilch, 2004
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Difficultly thinking clearly or acting logically
Bizarre behavior
Lacking awareness of reality
Extreme stress reactions or grief
Confusion
Inability to concentrate or make decisions
Haunted by images or memories of the event
Complaining of ailments after investigation and
reassurance that there is no physical cause
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Disorientation
Psychotic behavior
Inability to care for self
Suicidal/homicidal thoughts, talk, or plans
S i id l/h i id l h
h lk l
Inappropriate anger or reactions to triggers
Excessively “flat” emotions
Regression
Alcohol or drug intoxication
Flashbacks, excessive nightmares, or crying
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Evaluate your level of readiness to respond
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Do not assume that because you are experienced
you must be ready to respond
Positive adaptation in
the face of adversity
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Give consideration to your physical and
emotional health
Ordinary--not
extraordinary
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If you have recently encountered a major life
stressor it may be better for you and those who
need assistance for you to NOT to respond
People commonly
demonstrate resilience
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The “rule” not the
exception
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Everyone who experiences a disaster,
whether first hand or not, is touched by it.
 We have the ability to “bounce back”
after a disaster to a “New Normal”
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Focus beyond short-term
Know your unique stressors and
Red Flags
Know unique stressors of the
event: extent of damage, death,
current suffering
Demystify/de-stigmatize common
reactions
Select from menu of coping
responses
Monitor on-going internal stress
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Educate and train
Build social support systems
Instill sense of mission and purpose
Create family communications plan
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If possible deploy as a team or use the buddy
system
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Focus on immediate tasks at hand
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Monitor occupational safety, personal health,
and psychological well-being
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Know your limits
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Activate family communication plans
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Monitor health and well-being
A Compassionate Presence
 Delayed reactions with increased demand for services
seen in
i generall public
bli andd emergency responders
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(onset >5 wks later)
 Give yourself time to recover
 Seek support when needed
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Arch Gen Psychiatry. 2007;64(9):1040‐1048. Parental Posttraumatic Stress Disorder as a Vulnerability Factor for Low Cortisol Trait in Offspring of Holocaust Survivors. Yehuda R, Teicher MH, Seckl JR, Grossman RA, Morris A, Bierer LM. J Clin Endocrinol Metab. 2005;90(7):4115‐4118. Transgenerational effects of posttraumatic stress disorder in babies of mothers exposed to the World Trade Center attacks during pregnancy. Yehuda R, Engel SM, Brand SR, Seckl J, Marcus SM, Berkowitz GS. 
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JAMA. 2008;299(1):23‐26. Scientists probe PTSD effects, treatments. Kuehn B. JAMA. 2008;299(1):1291‐1305. Association of FKBP5 polymorphisms and childhood abuse with risk of posttraumatic stress disorder symptoms in adults. Binder EB, Bradley RG, Wei L, et al. 
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National Institute of Mental Health. Last reviewed: June 25, 2008. The Numbers Count: Mental Disorders in America. Available at: http://www.nimh.nih.gov/health/publications/the‐numbers‐
count‐mental‐disorders‐in‐america.shtml#PTSD. Psychiatric Genetics. 2008;18(6):261‐266. Heritabilities of symptoms of posttraumatic stress disorder, anxiety, and depression in earthquake exposed Armenian families. Goenjian AK, Noble EP, Walling DP, Goenjuian HA, Karayan IS, Ritchie T, Bailey JN. 
American Red Cross American Psychological Association
Centers for Disease Control & Prevention (CDC)
Substance Abuse and Mental Health Services Administration (SAMHSA)
National Institute for Mental Health (NIMH)
National Center for PTSD, Terrorism & Disaster Branch
Tennessee Suicide Prevention Network
Rand Corporation. 2008. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Edited by Terri Tanielian and Lisa H. Jaycox. Available at: http://www.rand.org/pubs/monographs/MG720/. 42
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THANK YOU FOR YOUR ATTENTION
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