DISASTER, MENTAL HEALTH AND RESCUING MEDICAL PROFESSIONALS
AbstractThe human beings have a certain threshold to copewith the adverse life events which depends on thestrength of coping abilities which are a part ofpersonality make-up and augmented by effects ofenvironment, type of up bringing and related socialcircumstances to which exposure has occurred duringthe various stages of life cycle. The neurochemistrydoes have an important part to play and of specialmention is the stress related hormones, which play aneffective role in helping the individual to withstandthe jolts of life. The more one is exposed toadversities the better sensitization leading to relativeindifference is acquired that leads to somepsychological strength which can help in maintainingemotional equilibrium in times of severe stress.Human beings build new learned behavior on top ofbio-genetically predetermined templates. Brainplasticity makes humans extremely sensitive toenvironment which can have major health-relatedpathogenic effects. Most adverse mental healthconsequences of disasters may, therefore, beattributed to our immense ability to learn, remember,and re-shape behavior on the basis of new-includingcatastrophic-experiences. Medical doctors fall underthe category of those who deal with illnesses,casualties and emergencies. During the process oftraining and until assuming the full role as medicalpractitioners they would have developed adequatepsychological strength, which helps in addressing theproblems of the patients. However, there arecircumstances where there is an encounter withnatural disasters which is characterized by severedisruption in ecological and psychological systemsexceeding the coping capacity of the individuals andcommunities,1 this can be nerve wrecking and mayhave serious effects on the psyche of even therescuers. Recent disaster in Pakistan, cameunexpected and brought in heavy magnitude ofdestruction which affected the people both physicallyand psychologically while causing a tremendousamount of fear and uncertainty among those whowere not directly affected by this disaster. Printmedia reported the contributions made by mentalhealth professionals and others in helping the victimscoming to terms with the consequences of thedisaster but the important issue which needs attentionhere is about the direct care givers, many of whomwere affectees and at the same time were required toattend to the medical needs of thousands andthousands of victims. As an individual, the doctorsalso fall in the parameter of other human beings whenit comes to their personality make up, psychologicalstrength, personal sensitivities and previous personalsocial and psychological issues. The issue of“secondary traumatic stress” which currently is notrecognized as a clinical disorder2 may producesymptoms among medical rescuers like: hyperarousal, intrusive symptoms, emotional numbing,anxiety and depression along with “compassionstress” which includes helplessness, confusion,isolation, secondary traumatic stress symptomsultimately leading to a state of exhaustion anddysfunction.3 There is also a possibility of developing“vicarious traumatization” which is a featuredeveloping in therapeutic workers helping traumasurvivors affecting: relationship with meaning andhope, intelligence, will power, sense of humor, abilityto protect oneself, memory, sense of connection toothers, self tolerance, cognitive reactions, and causephysical symptoms like: tension, fatigue, edginess,difficulty sleeping, bodily aches, change in biologicalneeds, etc, which are associated with behavioralchanges like: becoming judgmental of others,becoming cynical or angry, becoming over involved,developing rigid boundaries, heightenedprotectiveness, avoiding social and work contacts.Studies4, 5 have shown the incidence of PTSD (posttraumatic stress disorder) among the rescuers uptothe magnitude of 14%, the other serious outcome isin the form of depression which is noted to be about40%, acute stress disorder develops mostly amongyoung and single, 16% of the rescuers may developanxiety disorder and substance abuse. It is worthnoting that risk for PTSD is four times than thegeneral population.6 Reports indicated that in thecurrent circumstances doctors are also vulnerable todepression in the background of 6% prevalence ofclinical depression in Pakistan.7 There is also a risk ofprecipitation of psychosis subject to geneticvulnerability. There is evidence that the immunesystem gets compromised and open avenues for manyphysical illnesses to manifest apart from the socialdecompensation.8 However, in minority of cases therescuing physician may emerge as a changed personwith positive attributions to personality acquiringgreat emotional strength, becoming more humane andthe transformation into a refined person.It is utmost important to address the mentalhealth issues among the general doctors who areinvolved in rescue efforts and therapeuticrelationship. Who should help? The mental healthprofessionals who are trained in emergencyJ Ayub Med Coll Abbottabad 2005; 17(4)psychiatry can be of help but we have to keep inmind the extreme dearth of psychiatrists, lack oftraining in crises psychiatry and the fact that all themental health professionals cannot and should not getinvolved as it is important to address the personalsensitivities and fitness apart from having adequateinsight into the different psychotherapeutic issues.The role of religious workers appreciating theimportance of spiritual model of treatment and helpfrom allied mental health professionals is alsoimportant. Camp type services result in futility; hencelong-term follow up is desirable. It is also essentialthat the mental health professional is well versed withCISD and EMDR techniques and has insight into therole of pharmacological interventions in suchsituations.Critical incident stress debriefing (CISD)9 isa brief, structured, intervention technique usedimmediately or shortly after traumatic event thatattempts to assist participants in a group setting incognitively and emotionally processing theirexperience. CISD is now a part of a comprehensivespectrum of techniques called critical incident stressmanagement (CISM) which promote emotionalhealth through verbal expression, catharticventilation, normalization of reactions, healtheducation and preparation for possible futurereactions.EMDR (eye movement desensitizationreprocessing)10 can be an effective part of de-briefingsession. The physicians response to mass casualtymust address the high volume of patients withanxiety reactions and somatic symptoms likely topresent for care, supportive interventions includefostering a sense of safety and efficacy, connectingpatients with communities and services, and helpingpatient talk about the trauma, in the future, earlypharmacological interventions may prove to beeffective.At site, it is useful for the rescue doctors todevelop self therapeutic strategies in order to buildpsychological strength and prevent mental stress andits associated complications for example: developing“buddy” system with co-doctor, mutualencouragement and support, frequent time out,staying in touch with family and friends, ventilationof emotions and feelings, physical exercise, yoga,meditation, adequate nutrition and remaining ingroups whenever possible.The American Psychiatric Association(APA) has formed a committee on psychiatricdimensions of disasters and has produced guidelines,which is an important reading especially for mentalhealth professionals.11 Pakistan has suffered for along time the consequences of terrorism and maninitiated disasters, which have caused significantmental health morbidity, and the current calamity hasadded much more for the enduring capacity of thenation as a whole. As it is vitally important to addressthe issues related to mental health of the medicalpractitioners dealing with the rescue work andtreatment, the government should devise strategies,which can look into this matter in a beneficial way inorder to prevent the mental health morbidity amongthe healers. The medical practitioners at their end arerequired to be equipped well for the disasters in termsof further strength building and coping emotionallywith mass casualties and hence have to liaise withorganizations dealing with the issues in disasterpreparedness and training and to acquire adequateinsight into the bio-psycho-socio-spiritual models ofboth treatment as well as prevention.
Gadit A. Disaster Psychiatry: Need for Appraisal. Editorial. J
Coll Phys Surg Pk 2005;15(10): 667-8.
Stamm BH (Ed) Secondary traumatic stress: self care issues
for clinicians, researchers and educators. Lutherville,
Maryland. Sidran Press: 1995, p: 1-10.
Figley CR. Compassion Fatigue: coping with secondary
traumatic stress disorder in those who treat the traumatized.
New York, Brunner /Mazel:1995, p: 1-30.
North CS, Laura T, ,McMillen, JC, Pfefferbaun B, Spitznagel
EL, Cox J. Psychiatric disorders in rescue workers after
Oklahoma City bombing. Am J Psychiatry 2002;159:857-9.
Fullerton CS, Ursano RJ, Wang L. Acute stress disorder,
PTSD, Depression in disaster/rescue worker. Am J
Report from Mount Sinai Press office, September 9,2004,
Gadit A, Najeeb K. State of Mental Health in Pakistan:
Education, service and research. 2002, Hamdard Foundation,
Karachi. P: 36-41.
Ng V, Norwood A. Psychological trauma, physical health
and somatization. Ann Acad Med Singapore 2000;29:658-61.
Hammond J, Brooks J. The world trade center attack.
Helping the helpers: role of critical incident stress
management. Crit Care 2001;5:315-7.
McQuistion H, Katz C. The Sept. 11, 2001 disaster: some
lessons learned in the mental health preparedness.
Emergency Psychiatry 2002;7:61-4.
Young, BH, Ford JD, Watson JP. Disaster rescue and
response workers. National Centre for PTSD fact sheet, 2005,
USA, p: 1-5.
Hall RCW, Ng AT, Norwood AE. (Ed). American
Psychiatric Association: Disaster Psychiatry Hand Book,
; p: 3-44