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Addressing the terror in Terrorism: Resources and Strategies for Advanced Practice Nurses

Julian D. Ford, Ph.D. Department of Psychiatry University of Connecticut Health Center Center for Trauma Response, Recovery and Preparedness (CTRP)

Understanding the terror in Terrorism: Psychological Trauma

Overwhelming, unanticipated danger that leads to extreme physical survival responses Helplessness in the face of extreme danger and overwhelming anxiety Abandonment or betrayal by trusted caregivers that threatens a vulnerable individuals life or basic sense of security

Phases of Coping with Terrorism From THREAT to HYPERVIGILANCE


Posttraumatic Stress Disorder (PTSD)

Recurrent Unwanted Memories Awake/Asleep or Biopsychological Distress 2 Reminders Avoidance of Internal/External Reminders, Emotional Numbing, Social Detachment, Amnesia Hyperarousal (Anxious, Irritable, Insomnia, Poor Concentration, Hypervigilance, Reactive) Significant psychosocial/healthcare impairment Duration 30+ days (may be delayed or chronic)

What is PTSD?

Post =


Traumatic = Life-and-Death Danger A Horrible Violation or Loss

Stress = Disorder =

The Bodys Alarm System Interferes w/Normal Living

PTSDs Impact on Healthcare

Somatization and Somatic Amplification Excess or Under Utilization Emergency (vs. Preventive) Care Testing of the Provider & Alliance Avoidance of Healthcare Services Family/Relational Conflict/Estrangement Increased risk of substance misuse Reactivation of pre-existing psychiatric disorder

Patterns of Risk for PTSD


Traumatic Shock + Acute Stress Symptomatology = first month Traumatic Grief = 3-6 months Extent and Nature of Exposure or Loss Females > Males Old Age = Risk & Reslience Children: Caregiver Contagion, not age Socioeconomic or Ethnocultural Adversity



Facts About PTSD

Everyone exposed to disaster experiences stress, but

isnt automatically traumatic (Depends on severity of Exposure) And It doesnt always become a disorder (10-20% trauma-exposed people)

Facts about PTSD Regardless of whether your life is in danger or you are directly physically harmed, the closer you are to death or danger (including as a witness or as a bereaved friend or loved one) the more likely (but not definitely) you will experience traumatic stress

Facts about PTSD The natural tendency is to avoid thinking about or getting help for traumatic stress reactions But the best way to prevent or recover from PTSD is to recognize and deal with stress reactions before or as soon as possible after they are a disorder

The Brain and Self-Regulation

External stimuli

Novelty & Threat Detection


Cognitive Map/Categories Working Memory

Locus Coeruleus
Memory Encoding Activation

Prefrontal Cortex Limbic Cortex (Orbito/Dorsolateral) (Anterior Cingulate)

Integration/Decisions Narrative Memory Awareness of Body, Self, Others Self-Calming/Reguulation

What Prevents or Ameliorates PTSD? Reinstating Adaptive Self-Regulation

The brains survival alarm wont turn off until you show your body that youre going to survive

If you keep reacting to daily stressors as if you wont survive, the body assumes youre still in danger and wont turn off the brains alarm! If you deal with daily stressors by using your brains organizing system, youre showing your body that youre safe--& the alarm turns down

Practical Steps Toward Preventing and Recovering From PTSD

STEP 1: Increase your safety and security by Reuniting with separated family members Restoring healthy rhythms/routines Getting practical factual information Getting support as a parent & caregiver Getting help with basic necessities Finding ways to be of help to others

Practical Steps Toward Preventing and Recovering From PTSD

STEP 2: help the brain & mind re-organize: Take time outs to de-stress, especially when starting to feel pressured or shut down or when in a new place/activity/relationship Take a time-out at the beginning & end of each day to review personal learning Dont try to force relaxation -- pause, slow down, and reflect on lessons learned

Practical Steps Toward Preventing and Recovering From PTSD

STEP 3: Engage the brain in processing new experiences: Engage associative thinking/memory to avoid overfilling the brains in-basket (hippocampus) by taking one part of each new experience at-a-time dont try to deal with it all Identify specific triggers that push your buttons Look for one main feeling, thought, and goal these usually happen so fast you dont even know until later! Focus on small successes rather than failures, as well as choices that can be made differently in the future Discover the contribution one makes to other peoples lives

FREEDOM as a Framework for Trauma Recovery

Focus (Slow Down, Orient, Self-Check) Recognize Triggers

Emotion Self-Check
Evaluate Thoughts Define Personal Needs/Goals Open New Options for Achieving Goals Make a Contribution (Live Your Values)

Using FREEDOM to Recover from Traumatic Stress

Focus (Slow Down, Orient, Self-Check) Recognize One Main Trigger Emotion Check: One Main Feeling Evaluate One Main Thought Define One Main Personal Goal Open Your Mind to See How You ALREADY ARE Achieving Goals Even When You are Stressed Make a Contribution: Recognize How you Make a Positive Difference Even Under Stress

Using FREEDOM to Recover from Traumatic Grief

Focus (Slow Down, Orient, Self-Check) Recognize Moments You Cherish with Lost Loved One Emotion Check: Your Main Feeling About Her/Him Evaluate Your Main Thought About Her/Him Define Your Main Goal to Honor Her/Him Open New Options: How Are You Honoring Her/Him Make a Contribution By Moving Forward with Your Life in Ways that Honor Lost Loved Ones

Phase-Oriented PTSD Intervention

Phase I Stabilization Understanding/Managing Trauma Symptoms: hippocampal processing and amygdala alarm override frontal cortex self-awareness/control Phase II Trauma Processing Restoring Prefrontal Self-Awareness/Control Phase III Readjustment/Renewal Restoring Prefrontal-Limbic Coordination

Role of the Healthcare Provider

Emotionally Contained Yet Compassionately Present Modeling Modulated Concern and Sadness Observe and Educate re: Stress/Grief Reactions Amelioration of Immediate Physical Impairment Facilitation of Personal Control/Choice Recognition of Role Concerns re:Significant Others Confident referral to mental health if indicated

Phase I Brief Intervention: Focusing

Step 1: Slow Down (Take a time out; Calm your body; One thought at a time) Step 2: Orient Yourself (Bring your mind & body back to the present time/place)

Step 3: Self Check (How much distress? How much control? The worst ever?)

Self-Check Rating Scales

Distress Thermometer: I feel 10 The worst Ive ever felt in my life my life 9 8 7 6 5 Some tension or distress but not life but not terrible or overwhelming ways 4 3 2 1 The best Ive ever felt in my life Personal Control: I am 10 In complete control of 9 8 7 6 5 Partly in control of my

not in control in some

4 3 2 1 Totally out of control

Phase I: Critical Incident Stress Management (CISM) Four Essential Steps, No Panacea
FACTS Non-intrusive inquiry into specifics THOUGHTS Encourage linkage of facts FEELINGS Support and encourage CLOSURE Normalization, education, reassurance

Phase I: Critical Incident Stress Management (CISM) Scientific Evidence: Not a Panacea
Potentially Effective (e.g., EMS Team post9/11) 1. For intact work teams or groups 2. To reconstruct a shared narrative Potentially Harmful (e.g., MVA survivors) 1. Single-session individual debriefing 2. To heighten distress or force recall of trauma

Phase I: Brief Cognitive Behavior Therapy Intervention Scientific Evidence: Promising

Potentially Effective (e.g., rape victims, Emergency Medical Department assault and MVA admissions) 1. Education about normal reactions and ASD 2. To begin filling in the personal narrative 3. To enhance immediate personal coping

To break the cycle of avoidance/intrusion

Phase II: Cognitive Behavior Therapy Scientific Evidence

Potentially Effective (e.g., disaster survivors or responders and bereaved families with PTSD) 1. Education about normal reactions and PTSD 2. To reconstruct a narrative of traumatic events 3. To enhance social problem solving

To reduce fearful or hopeless thinking

Phase II: Emotion Self-Regulation Therapy (e.g., TARGET) Scientific Evidence

Potentially Effective (e.g., PTSD + Addiction) 1. Education about the survival response and PTSD 2. To reconstruct a complete personal narrative 3. To enhance emotional/bodily selfregulation

To reduce anger, alienation, and mental

Conclusion: PTSD Can be Prevented and Treated Successfully Health Care Providers Role

Educate patients about stress and survival reactions, and ASD and PTSD 2. Teach Focusing Skills by Own Example 3. Identify Early Signs of PTSD and Refer to Qualified Trauma Treatment Specialists 4. Reinforce the FREEDOM Skills even in brief health care encounters

Conclusion: PTSD Can be Prevented and Treated Successfully

Health Care Providers Role (Continued)
5. Dont debrief your patients help them to mobilize inner & outer strengths/resources 6. Dont ask about the details of trauma experiences help patients recognize and resolve immediate stressors (including especially health problems) 7. Find a PTSD specialist whom you know and trust as a consultant BEFORE you need advice about specific patients who