Problems of ecological psychiatry.

1. Problems of ecological psychiatry. Lyudmyla T. Snovyda

2. Disaster Classification • 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

3. Geophysical Disasters • Earthquakes • Volcanic Eruptions • Tsunamis/Tidal waves • Droughts and Related Disasters • Extreme Temperatures • Wildfires • Droughts • Famine • Insect Infestation • Pandemic Diseases

4. Human-Generated Disasters • Non-intentional/Technological • Industrial Accidents • Transportation Accidents • Ecological/environmental destruction • Miscellaneous Accidents • Intentional • Declared War • Civil Strife • Ethnic Conflict • Mass Gatherings • Terrorism

5. 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

6. 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

7. Natural disasters • 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

8. 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.

9. Human-generated disasters • 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 side-effects 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.

10. Human-generated disasters • 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.

11. 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 human- generated ―technological disaster is registered.

12. 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.

14. 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.

15. . 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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17. Hyperthyroidism • 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..

18. CLINICAL FEATURES • 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.

19. CLINICAL FEATURES • 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.

20. Hypothyroidism • 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.

21. 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.

22. CLINICAL FEATURES • 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."

23. Chronic adrenocortical insufficiency • 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. ."

24. Manganism • 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.

25. CLINICAL FEATURES • 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.

26. Arsenic PoisoningArsenic • 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.

27. CLINICAL FEATURES • 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.

28. Dialysis Dementia • 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.

29. Vit.B12 deficiencyVit.B12 deficiency • 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.

30. NeurosyphilisNeurosyphilis • 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.

31. Neurosyphilis • 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.

32. Neurosyphilis • 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.

33. Neurosyphilis • 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.

34. Neurosyphilis • 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.

35. TuberculosisTuberculosis • 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.

36. Tuberculosis • 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.

37. Traumatic brain injury.Head trauma • 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.

38. Traumatic brain injury. • 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.

39. Traumatic brain injury. • 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.

40. Traumatic brain injury. • 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.

41. AIDSAIDS • CLINICAL FEATURES • 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

42. AIDS • THANK YOU FOR ATTENTION!