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Little prospectively assessed post-disaster longitudinal research has been done on mental health (MH) outcomes of disaster rescue and recovery workers. This longitudinal prospective study, which is examining first responders to a terrorist bombing in Oklahoma City after nearly a quarter century, was conducted to investigate their long-term MH outcomes using full diagnostic assessments. This will most accurately inform planning for longitudinal MH care needs.
Longitudinal follow-up interviews of 124 rescue and recovery workers, from an original volunteer sample of 181 volunteer workers, were completed 3 years after the bombing, and reassessed 23 years after using consistent research methods. Structured diagnostic interviews were conducted at both assessments, but these were limited to posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) with additional questions about alcohol use, problems, and major psychosocial problems of life at follow up.
Initially, the rescue and recovery workers had a lower prevalence of post-disaster PTSD and MDD than directly exposed survivors. They also showed higher rates of PTSD than MDD. However, over time, PTSD increased a little while MDD increased 4-fold though fewer than 50% of the cases were remitted.
Low remission and increasing MDD provide incentives for surveillance and availability of treatment for decades after disaster, regardless of whether they were pre-existing conditions or disaster related.
Terrorist incidents occur with alarming frequency. Much is known about acute injuries and psychopathology arising from terrorism, as well as medical care and functional status assessed in early post-disaster periods. Survivors’ memories of these experiences may change over subsequent decades, and their perspectives may evolve. Little information is available on how survivors describe these experiences decades later.
This longitudinal qualitative study of directly-exposed survivors of the 1995 Oklahoma City bombing was conducted nearly a quarter century after the disaster. It collected systematic, open-ended descriptions of survivors’ injuries and medical care, assistance received and given, and disaster-associated losses. It sought to illuminate whether survivors recall long-term consequences of disaster exposure so long after the event, providing important details with great clarity and associated emotion, or alternatively lose memory and sharpness of recollection for these aspects of their bombing experience.
A sample of 182 bombing survivors was randomly recruited from a state registry of 1,092 bombing survivors and interviewed at approximately six months after the bombing (71% participation). The sample was re-interviewed an average of 23 years after the disaster (72% follow-up participation) using an open-ended interview with survivors describing in their own words their personal experience of the bombing and its effects on their lives. The interviews were audio recorded and professionally transcribed. Themes were identified in the text of the interviews, and passages were coded using qualitative software, achieving excellent inter-rater reliability for each theme. This article covers three of twelve total themes identified.
Nearly a quarter century after the bombing, this highly trauma-exposed Oklahoma City bombing survivor sample had memories that were still vivid, graphic, and evocative. They described injuries and medical care, assistance given and received, and losses with great detail and intensity. Despite the continuing strong emotions expressed by these survivors in relation to the bombing, the qualitative content suggested that lasting psychopathology was not a central concern.
This is one of the longest prospective longitudinal, qualitative studies ever conducted with highly trauma-exposed survivors of a terrorist bombing. These findings are critical to disaster emergency response and effective management of the disaster response and early care for the survivors, as the effects of the disaster may shape the rest of their lives.
The use of older data and references is becoming increasingly disfavored for publication. A myopic focus on newer research risks losing sight of important research questions already addressed by now-invisible older studies. This creates a ‘Groundhog Day’ effect as illustrated by the 1993 movie of this name in which the protagonist has to relive the same day (Groundhog Day) over and over and over within a world with no memory of it. This article examines the consequences of the recent preference for newer data and references in current publication practices and is intended to stimulate new consideration of the utility of selected older data and references for the advancement of scientific knowledge.
Examples from the literature are used to exemplify the value of older data and older references. To illustrate the recency of references published in original medical research articles in a selected sample of recent academic medical journals, original research articles were examined in recent issues in selected psychiatry, medicine, and surgery journals.
The literature examined reflected this article's initial assertion that journals are emphasizing the publication of research with newer data and more recent references.
The current valuation of newer data above older data fails to appreciate the fact that new data eventually become old, and that old data were once new. The bias demonstrated in arbitrary policies pertaining to older data and older references can be addressed by instituting comparable treatment of older and newer data and references.
The objective of this study was to examine associations between media contact and posttraumatic stress in a sample with a large number of individuals who were directly exposed to the September 11, 2001 (9/11) attacks and to compare outcomes in exposed and unexposed participants.
Structured interviews and questionnaires were administered to a volunteer sample of 254 employees of New York City businesses 35 months after the attacks to document disaster trauma exposures, posttraumatic stress outcomes, and media contact and reactions.
Media variables were not associated with psychopathological outcomes in exposed participants, but media contact in the first week after the attacks and feeling moderately/extremely bothered by graphic 9/11 media images were associated with re-experiencing symptoms in both the exposed and unexposed participants. Feeling moderately/extremely bothered by graphic media images was associated with hyperarousal symptoms in exposed participants.
The findings suggest that media contact did not lead to psychopathology in exposed individuals, although it was associated with normative distress in both exposure groups. Because of the potential for adverse effects associated with media contact, clinicians and public health professionals are encouraged to discuss concerns about mass trauma media contact with their patients and the public at large.
In the nearly a quarter of a century since the addition of the clinically significant distress/impairment criterion to the definition of PTSD in DSM-IV, little research has been done to examine the association of this criterion with symptom group criteria and with the numbing subgroup specifically. This study was conducted to examine these relationships in a large database of disaster survivors consistently studied across 12 different incidents of the full range of disaster typology.
Analysis was conducted on a merged database representing 1187 trauma-exposed survivors of 12 different disasters studied systematically. DSM-IV-TR criteria for disaster-related PTSD were assessed with the Diagnostic Interview Schedule.
PTSD Group C (avoidance/numbing) and numbing specifically were less common and more associated than other symptom groups with criterion F (distress/impairment). Consistently in multivariable models, group C and numbing were independently associated with criterion F. Group D (hyperarousal) was less strongly associated with criterion F. Neither group B (intrusion) nor avoidance were associated with criterion F.
In this and other studies, group C and numbing specifically have been shown to be associated with criterion F, which is consistent with the demonstration that group C and the numbing component specifically are central to the psychopathology of PTSD. The addition of the distress/impairment requirement broadly across the psychiatric diagnoses in DSM-IV added little value to PTSD symptom criteria. Future revisions of diagnostic criteria may benefit by carefully considering these findings to possibly re-include a prominent numbing symptom section.
To investigate the relative importance of 10 attributes identified in prior studies as essential for effective disaster medical responders and leaders.
Emergency and disaster medical response personnel (N=220) ranked 10 categories of disaster worker attributes in order of their importance in contributing to the effectiveness of disaster responders and leaders.
Attributes of disaster medical leaders and responders were rank ordered, and the rankings differed for leaders and responders. For leaders, problem-solving/decision-making and communication skills were the highest ranked, whereas teamwork/interpersonal skills and calm/cool were the highest ranked for responders.
The 10 previously identified attributes of effective disaster medical responders and leaders include personal characteristics and general skills in addition to knowledge of incident command and disaster medicine. The differences in rank orders of attributes for leaders and responders suggest that when applying these attributes in personnel recruitment, selection, and training, the proper emphasis and priority given to each attribute may vary by role. (Disaster Med Public Health Preparedness. 2019;13:700–703)
Following chemical, biological, radiological, and nuclear disasters, medically unexplained symptoms have been observed among unexposed persons.
This study examined belief in exposure in relation to postdisaster symptoms in a volunteer sample of 137 congressional workers after the 2001 anthrax attacks on Capitol Hill.
Postdisaster symptoms, belief in exposure, and actual exposure status were obtained through structured diagnostic interviews and self-reported presence in offices officially designated as exposed through environmental sampling. Multivariate models were tested for associations of number of postdisaster symptoms with exposure and belief in exposure, controlling for sex and use of antibiotics.
The sample was divided into 3 main subgroups: exposed, 41%; unexposed but believed they were exposed, 17%; and unexposed and did not believe that they were exposed, 42%. Nearly two-thirds (64%) of the volunteers reported experiencing symptoms after the anthrax attacks. Belief in anthrax exposure was significantly associated with the number of ear/nose/throat, musculoskeletal, and all physical symptoms. No significant associations were found between anthrax exposure and the number of postdisaster symptoms.
Given the high incidence of these symptoms, these data suggest that even in the absence of physical injury or illness, there may be surges in health care utilization. (Disaster Med Public Health Preparedness. 2019;13:555-560)
Parents are a primary support for children following disasters, even though they face numerous challenges in addressing the physical and social consequences of an event. Parents who are directly exposed to a disaster and those who develop psychiatric disorders post-event are likely to be especially challenged and may be limited in their ability to support their children. This Brief Report describes a pilot study of survivors of the September 11, 2001 World Trade Center (New York USA) attacks who reported their own psychosocial consequences and the reactions of their children three years post-event.
The primary hypothesis of the study was that children’s September 11th reactions would be associated with their parents’ psychiatric status. Secondary hypotheses were that the children’s disaster reactions would be associated with direct exposure to the disaster in children and/or their parents, parent-child separation due to the disaster, and disaster-related school absence.
Approximately three years after the 2001 World Trade Center attacks, 116 parents recruited from disaster-affected or disaster-related organizations were assessed using structured diagnostic interviews and queried about their children’s (188 youths, aged three to 17 years at the time of the attacks) posttraumatic stress symptoms and behavioral changes.
Almost one-half of the parents had a post-disaster psychiatric disorder, including major depression in 27% and disaster-related posttraumatic stress disorder (PTSD) in 11%. More than three-fourths of the children had at least one disaster-related posttraumatic stress symptom, and more than one-half experienced at least one post-disaster behavior change. A minority of the children were reported to have increased school behavior problems or a decline in their grades. Key correlates of children’s disaster-related posttraumatic stress symptoms and post-disaster behavior changes were parent-child separation due to the disaster and parental post-disaster psychiatric disorders.
Because parents provide primary caretaking and support for children post-disaster, addressing the needs of parents is critical to their ability to assist their children. Reducing parents’ symptoms should increase their emotional availability and enhance their ability to address the needs of their children. Given the challenges in providing disaster interventions directly to children, especially when resources are limited, addressing parent psychopathology and distress (even in the absence of focusing on children’s symptoms) may benefit children.
PfefferbaumB, SimicZ, NorthCS. Parent-Reported Child Reactions to the September 11, 2001 World Trade Center Attacks (New York USA) in Relation to Parent Post-Disaster Psychopathology Three Years After the Event. Prehosp Disaster Med. 2018;33(5):558–564.
The purpose of this study was to investigate potential association between psychopathology and subjective evaluation of the experience of debriefing in disaster-exposed rescue and recovery workers.
Structured diagnostic interviews for DSM-III-R psychiatric disorders were conducted with 166 firefighters who served as rescue and recovery workers for the 1995 Oklahoma City bombing, who categorized their satisfaction with the debriefing on 4 levels. “Very dissatisfied” responses were examined for their association with post-traumatic stress disorder (PTSD) and with PTSD symptom groups.
Being “very dissatisfied” with the debriefing was significantly associated with the DSM-III-R avoidance and numbing group and with PTSD.
These findings suggest that debriefing may be an unsatisfactory intervention for people with prominent avoidance and numbing symptoms, such as those with PTSD. These individuals might be better served by referral directly to psychiatric treatment (Disaster Med Public Health Preparedness. 2018;12:718-722).
Despite the frequency of disasters in Africa, almost nothing is known about ethnic affiliations in relation to psychopathology after such incidents. This study examined the mental health outcomes of members of 7 major ethnic groups exposed to the 1998 terrorist bombing of the US Embassy in Nairobi, Kenya.
Approximately 8 to 10 months after the disaster, 229 civilian employees, 99 locally engaged staff workers of the US State Department and the US Agency for International Development, and 64 workers of the Kenyan Red Cross Society (total N=392) were assessed with the Diagnostic Interview Schedule for the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). Additional data were gathered on demographic characteristics, disaster exposures and injuries, and ethnic affiliations.
Disaster-related post-traumatic stress disorder (PTSD) was significantly less prevalent among members of the Kikuyu group (28%) and post-disaster major depression was significantly more prevalent among members of the Meru group (64%), compared with all others in the sample. Preexisting psychopathology and disaster injury were independently associated with bombing-related psychopathology.
Further study of disaster-related psychopathology in relation to African ethnic affiliations is needed to better understand these associations and to assist in planning resources and interventions for African disaster survivors. (Disaster Med Public Health Preparedness. 2018; 12: 360–365)
To identify key attributes of effective disaster/mass casualty first responders and leaders, thereby informing the ongoing development of a capable disaster health workforce.
We surveyed emergency response practitioners attending a conference session, the EMS State of the Science: A Gathering of Eagles. We used open-ended questions to ask participants to describe key characteristics of successful disaster/mass casualty first responders and leaders.
Of the 140 session attendees, 132 (94%) participated in the survey. All responses were categorized by using a previously developed framework. The most frequently mentioned characteristics were related to incident command/disaster knowledge, teamwork/interpersonal skills, performing one’s role, and cognitive abilities. Other identified characteristics were related to communication skills, adaptability/flexibility, problem solving/decision-making, staying calm and cool under stress, personal character, and overall knowledge.
The survey findings support our prior focus group conclusion that important characteristics of disaster responders and leaders are not limited to the knowledge and skills typically included in disaster training. Further research should examine the extent to which these characteristics are consistently associated with actual effective performance of disaster response personnel and determine how best to incorporate these attributes into competency models, processes, and tools for the development of an effective disaster response workforce. (Disaster Med Public Health Preparedness. 2016;page 1 of 4)
Large numbers of evacuees arrived in Dallas, Texas, from Hurricanes Katrina and Rita just 3 weeks apart in 2005 and from Hurricanes Gustav and Ike just 3 weeks apart again in 2008. The Dallas community needed to locate, organize, and manage the response to provide shelter and health care with locally available resources. With each successive hurricane, disaster response leaders applied many lessons learned from prior operations to become more efficient and effective in the provision of services. Mental health services proved to be an essential component. From these experiences, a set of operating guidelines for large evacuee shelter mental health services in Dallas was developed, with involvement of key stakeholders. A generic description of the processes and procedures used in Dallas that highlights the important concepts, key considerations, and organizational steps was then created for potential adaptation by other communities. (Disaster Med Public Health Preparedness. 2015;9:423–429)
How did the 1995 Oklahoma City bombing differ from prior disasters and what implications did it have for disaster mental health services and service delivery? The federal disaster mental health approach in this country developed largely out of experiences with natural disasters. The 1995 Oklahoma City bombing differed in several important ways, including the large number of human casualties, higher rates of psychopathology, and an extended period of concern due to the criminal investigation and trials, which suggested the need to consider modifications in the program. Outreach was extensive, but psychiatric morbidity of direct victims was greater than that of victims of natural disasters, emphasizing the need for attention to the triage and referral process. Other concerns that warrant consideration include practices related to record keeping and program evaluation.
Empirical data from research studies are vital to guiding mental health interventions following disasters. However, few data are available for this purpose. Important advances in policy and procedures for the conduct of organized research emerged from the Oklahoma City bombing, yielding cooperative working relationships among researchers and culminating in the ethical attainment of informative research data. However, the academic community was again caught off guard after the September 11, 2001, terrorist attacks.
Suggestions to surmount these obstacles include incorporating research infrastructures into disaster preparedness plans in advance; organizing the community of researchers; and working closely with major funding organizations. Methodological issues pertaining to measurement of psychopathology include the importance of obtaining diagnostic data; interpreting the meaning of symptoms in the absence of a psychiatric disorder; differentiating preexisting symptoms from those that emerged after the disaster, and optimal timing of postdisaster assessment.
Objective: Several studies have provided prevalence estimates of posttraumatic stress disorder (PTSD) related to the September 11, 2001 (9/11) attacks in broadly affected populations, although without sufficiently addressing qualifying exposures required for assessing PTSD and estimating its prevalence. A premise that people throughout the New York City area were exposed to the attacks on the World Trade Center (WTC) towers and are thus at risk for developing PTSD has important implications for both prevalence estimates and service provision. This premise has not, however, been tested with respect to DSM-IV-TR criteria for PTSD. This study examined associations between geographic distance from the 9/11 attacks on the WTC and reported 9/11 trauma exposures, and the role of specific trauma exposures in the development of PTSD.
Methods: Approximately 3 years after the attacks, 379 surviving employees (102 with direct exposures, including 65 in the towers, and 277 with varied exposures) recruited from 8 affected organizations were interviewed using the Diagnostic Interview Schedule/Disaster Supplement and reassessed at 6 years. The estimated closest geographic distance from the WTC towers during the attacks and specific disaster exposures were compared with the development of 9/11–related PTSD as defined by the Diagnostic and Statistical Manual, Fourth Edition, Text Revision.
Results: The direct exposure zone was largely concentrated within a radius of 0.1 mi and completely contained within 0.75 mi of the towers. PTSD symptom criteria at any time after the disaster were met by 35% of people directly exposed to danger, 20% of those exposed only through witnessed experiences, and 35% of those exposed only through a close associate’s direct exposure. Outside these exposure groups, few possible sources of exposure were evident among the few who were symptomatic, most of whom had preexisting psychiatric illness.
Conclusions: Exposures deserve careful consideration among widely affected populations after large terrorist attacks when conducting clinical assessments, estimating the magnitude of population PTSD burdens, and projecting needs for specific mental health interventions.
(Disaster Med Public Health Preparedness. 2011;5:S205-S213)
Methods: An effective disaster response requires competent responders and leaders. The purpose of this study was to ask experts to identify attributes that distinguish effective from ineffective responders and leaders in a disaster. In this qualitative study, focus groups were held with jurisdictional medical directors for the 9-1-1 emergency medical services systems of the majority of the nation's largest cities. These sessions were recorded with audio equipment and later transcribed.
Results: The researchers identified themes within the transcriptions, created categories, and coded passages into these categories. Overall interrater reliability was excellent (κ = .8). The focus group transcripts yielded 138 codable passages. Ten categories were developed from analysis of the content: Incident Command System/Disaster Training/Experience, General Training/Experience, Teamwork/Interpersonal, Communication, Cognition, Problem Solving/Decision Making, Adaptable/Flexible, Calm/Cool, Character, and Performs Role. The contents of these categories included knowledge, skills, attitudes, behaviors, and personal characteristics.
Conclusions: Experts in focus groups identified a variety of competencies for disaster responders and leaders. These competencies will require validation through further research that involves input from the disaster response community at large.
(Disaster Med Public Health Preparedness. 2010;4:332-338)
We sought to determine attitudes toward patients with borderline personality disorder (BPD) among mental health clinicians at nine academic centers in the United States.
A self-report questionnaire was distributed to 706 mental health clinicians, including psychiatrists, psychiatry residents, social workers, nurses, and psychologists.
The study showed that most clinicians consider BPD a valid diagnosis, although nearly half reported that they preferred to avoid these patients. The clinician's occupational subgroup was significantly related to attitude. Staff nurses had the lowest self-ratings on overall caring attitudes, while social workers had the highest. Social workers and psychiatrists had the highest ratings on treatment optimism. Social workers and psychologists were most optimistic about psychotherapy effectiveness, while psychiatrists were most optimistic about medication effectiveness. Staff nurses had the lowest self-ratings on empathy toward patients with BPD and treatment optimism.
Negative attitudes persist among clinicians toward BPD, but differ among occupational subgroups. Overall, caring attitudes, empathy, and treatment optimism were all higher among care providers who had cared for a greater number of BPD patients in the past 12 months.
These findings hold important implications for clinician education and coordination of care for patients with BPD.
This chapter explains the potential impact of disaster response on uniformed first responders, including police officers and firefighters. A minority of responders may continue to experience psychological distress following disaster response, including symptoms of posttraumatic stress disorder (PTSD), depression, alcohol use, and other anxiety disorders. Trauma-exposed first responders are also at risk of developing other psychiatric symptoms and conditions such as depression, substance abuse, and other anxiety disorders. Degree and type of interaction with survivors and bereaved family members are linked to the level of distress among rescue workers. Peritraumatic reactions are shown to be strongly associated with PTSD symptoms. The participants receiving the cognitive-behavioral therapy (CBT) treatment showed a significantly greater decline in PTSD symptoms, with large effect sizes. Promising strategies for immediate management of acute stress disorders include the use of adrenaline-blocking medications and cognitive behaviorally informed antipanic interventions for peritraumatic distress.