Psychological Aspects of Trauma and Disasters ผลกระทบด้านจิตใจ จากการเผชิญเหตุร้ายและภัยพิบัติ

1. Psychological Aspects of Trauma and Disastersผลกระทบด้านจิตใจจากการเผชิญเหตุร้ายและภัยพิบัติ Damrong Waealee Psychiatric unit, Yala Hospital

2. TRAUMATIC EVENT • A person’s experience of actual/ threatened death or serious injury to himself or others. • Can generally be caused by atrocities or disasters.

3. ATROCITIES when the force is that of other human beings (e.g., rape, domestic violence, kidnapping, torture, captivity, all forms of abuse). ความรุนแรงในครอบครัว การถูกทารุณกรรม ทรมาน กักขัง ถูกลักพา การถูกข่มขืน เป็นต้น

4. DISASTERS • Disasters are events affecting a social group which produce such material and human losses that the resources of the community are overwhelmed and, therefore, the usual social mechanisms to cope with emergencies are insufficient • Can lead to or result in stress reactions, regardless of a person’s pre-disaster state. • (Jose Lopez-Iber,2000)

5. DISASTERS Natural Man Made terrorisms earthquakes airplane crashes floods tsunami fire blasts storms mudslides Mass shooting etc. etc.

6. Natural vs Man-made Disaster -In general, natural disasters are less traumatic than those that are man-made. -------------------------------------------------- % of people developing Post-Traumatic Stress Disorder (PTSD) after a disaster: Bombing 34% Mass shooting 33% Natural disaster 4-7% ----------------------------------------------------------- *In the US, there were higher rates of PTSD among the survivors of the 9/11 terrorist attack (4000+ deaths) than “Hurricane Andrew” (18000 deaths).

7. Consequences of disaster

8. Psychological response to disaster Distress response Behavioral change Mental disorder Sources: Ursano, 2002; Institute of Medicine, 2003

9. UNDERSTANDING TRAUMA AND THE RECOVERY PROCESS

10. COMMON REACTIONS TO A TRAUMATIC EVENT ปฏิกิริยาที่พบบ่อยจากการเผชิญเหตุร้าย

11. IMMEDIATE REACTIONS • SHOCK (ช็อค)– sudden and often intense disturbance that may leave you feeling stunned and dazed. • DENIAL (ปฏิเสธ)– not acknowledging that something stressful has happened, or not experiencing fully the intensity of the event. • ANGER (โกรธ)– may not be directed at anyone but comes from a desire to blame somebody/something for the event. Shock, Denial and Anger are NORMAL PROTECTIVE REACTIONS.As the initial shock subsides, reactions vary from one person to another.

12. NORMAL RESPONSES TO A TRAUMATIC EVENT • Feelings become intense and sometimes are unpredictable.People may become more irritable than usual and have mood swings. They might be especially anxious or nervous, or even become depressed. • มีความรู้สึกที่รุนแรง บางครั้งคาดเดาไม่ถูก อารมณ์แปรปรวน หงุดหงิด กระสับกระส่าย ซึมเศร้า

13. NORMAL RESPONSES TO A TRAUMATIC EVENT • Thought and behavior patterns are affected by trauma. People may have flashbacks and repeated vivid memories of the event which can result in rapid heartbeat or sweating. They may find it difficult to concentrate or make decisions, or become more easily confused. Sleep and eating patterns may also be disrupted. • มีความทรงจำที่เจ็บปวด ผุดขึ้นมาในใจ เกิดอาการทางกาย ใจสั่น เหงื่อแตก ไม่มีสมาธิ สับสน คิดอะไรไม่ออก ผลกระทบต่อการกินการนอน

14. NORMAL RESPONSES TO A TRAUMATIC EVENT • Recurring emotional reactions are common.Anniversaries of the event, such as at one month or one year, as well as reminders (e.g., aftershocks from earthquakes) can trigger upsetting memories of the traumatic experience. These ‘triggers’ may be accompanied by fears that the stressful event will be repeated. • หวนระลึกขึ้นมาได้อีก โดยเฉพาะเมื่อมีตัวกระตุ้นให้จดจำ

15. NORMAL RESPONSES TO A TRAUMATIC EVENT • Interpersonal relationships often become strained.Greater conflict, such as more frequent arguments with family and co-workers, is common. On the other hand, people may become withdrawn and isolated and avoid their usual activities. • ปัญหาในเรื่องความสัมพันธ์ มีความขัดแย้ง บางคนแยกตัว

16. NORMAL RESPONSES TO A TRAUMATIC EVENT • Physical symptoms may accompany the extreme stress.For example, headaches, nausea and chest pain may result and may require medical attention. Pre-existing medical conditions may worsen due to the stress. • มีอาการทางกาย ปวดหัว แน่นในอก หายใจขัด โรคทางกายเดิมแย่ลง

17. NORMAL RESPONSES TO A TRAUMATIC EVENT There is not one ‘standard’ pattern of reaction to a traumatic event.Some people respond immediately, while others have delayed reactions – sometimes months or years later. Some have adverse effects for a long period of time, while others recover rather quickly. อาการจะแตกต่างกันในแต่ละบุคคล ทั้งความรุนแรงหรือระยะเวลา

18. NORMAL RESPONSES TO A TRAUMATIC EVENT Reactions can change over time.Some who have suffered from trauma are energized initially by the event to help them with the challenge of coping, only to later become discouraged or depressed. อาการจะเปลี่ยนแปลงได้ จะค่อย ๆ ดีขึ้นเมื่อเวลาผ่านไป

19. VICARIOUS TRAUMATIZATION • A traumatic event can affect even those not directly affected by the event. • Even if a person is not in the actual traumatic event, s/he may experience a sense of vulnerability from witnessing the results of the traumatic event (e.g., neighboring communities, rescue and relief workers, media people covering the event, people watching the event on TV). • บางคนอาจมีอาการได้แม้ไม่ได้ประสบโดยตรงแต่ได้รับรู้จากสื่อหรือการเข้าไปช่วยเหลือ

20. SAVING GRACE -Stress reactions to disaster are a ‘normal’ reaction to an ‘abnormal’ situation. Survivors exhibit these reactions because they recognize the DANGER that disasters pose. เป็นปฏิกิริยาปกติในสถานการณ์ที่ไม่ปกติ -Most people recover fully from even moderate stress reactions within 6 to 16 months. ส่วนใหญ่จะกลับคืนสู่ปกติ

21. A FRAMEWORK FOR UNDERSTANDING TRAUMA

22. FRAMEWORK FOR UNDERSTANDING PSYCHOLOGICAL TRAUMA ความรู้สึกท่วมท้น การควบคุม การเชื่อมโยง การให้ความหมาย

23. FRAMEWORK FOR UNDERSTANDING PSYCHOLOGICAL TRAUMA

24. FRAMEWORK FOR UNDERSTANDING PSYCHOLOGICAL TRAUMA

25. TAKE NOTE Not everyone experiences a traumatic event in the same way. Some people will be more affected by a traumatic event for a longer period of time than others, depending on the nature of the event and the nature of the individual who experienced the event. ลักษณะและเวลาในการตอบสนองจะต่างกันในแต่ละคน

26. FACTORS… THAT MAY AFFECT RECOVERY PROCESS Level of exposure to trauma (most critical) - Life threat (to self or others) - Personal loss (parents, family, friends, property) - Disruption of everyday events (displaced from home, school, community, leisure activities)

27. FACTORS… THAT MAY AFFECT RECOVERY PROCESS Post-disaster recovery environment - Availability of social support (difficult where support providers are also disaster victims) - Occurrence of additional life events (death, hospitalization of family members). • In the case of children, parental reactions to disaster

28. FACTORS… THAT MAY AFFECT RECOVERY PROCESS Pre-existing characteristics, pre-traumatic event functioning - Serious health problems - Family-related difficulties - Socio-economic status - Pre-disaster psychiatric problems - Pre-disaster academic functioning - Vulnerable populations: children, the elderly, the sick and the poor

29. FACTORS… THAT MAY AFFECT RECOVERY PROCESS Coping strategies and personal efficacy • Individuals who have gone through challenging situations mayfind it easier to cope with the trauma. - Negative coping strategies for dealing with stress (e.g., anger, blaming others) show higher levels of PTSD symptoms in response to natural disasters.

30. SIGNS OF POST-TRAUMATIC GROWTH • RELATING TO OTHERS. They may develop even stronger bonds with loved ones, reestablish relationships with estranged family members and friends, or gain compassion for others, especially those who have suffered in similar situations. • NEW POSSIBILITIES. They may begin to make choices in a more conscious manner according to a plan. They may also be more likely to try to change things that need changing. • PERSONAL STRENGTH. They may express greater self-reliance and feel more able to accept how things turn out and develop personal strength that may help you through such hardships you encounter in the future.

31. SIGNS OF POST-TRAUMATIC GROWTH • SPIRITUAL CHANGE. They may reevaluate their spiritual beliefs, associate with a community of similar believers, or connect with their spiritual roots. • APPRECIATION OF LIFE. They may develop a greater appreciation of life as a result of their crisis. Some explain this as trying to live each day more fully. Some may rethink their values and priorities about what is important in their life and act differently if they change their priorities – e.g., by spending more time with their family or devoting their life to a cause.

32. Psychological Responses on Disasters (Based on Crisis Theory) Disaster Stress Reactions Psychological Crisis Mental Disorders Equilibrium Restoration Crisis Resolution

33. The Stress Response

34. Common Stress Reactions after a Disaster • Physical reaction • Behavioral reaction • Emotional reaction • Cognitive reaction

35. Physical reaction • Agitation , hyper-arousal • Fatique , exhaustion • Hot or cold sensation • Gastrointestinal distress • Tightness in throat , chest • Appetite change • Worsening of health conditions

36. Behavioral reaction • Sleep problem , nightmares • Jumpiness , easily startled • Hyper-vigilance • Crying and tearfulness • Avoidance of reminder • increase family conflicts • Isolation , social withdrawal

37. Emotional reaction • Shock , disbelief • Anxiety , fear about safety • Irritabilities , anger , rage • Sadness , grief , depression • Numbness , disconnection • Hopelessness and despair • Survivor guilt , self-doubt

38. Cognitive reaction • confusion , disorientation • Intrusive thought , images • Recurring dreams , nightmares • Memory and concentration • difficulties • Difficulty making decisions • Focus on protective loved ones • Questioning spiritual beliefs

39. ปัจจัยที่กำหนดความรุนแรงของอาการปัจจัยที่กำหนดความรุนแรงของอาการ ธรรมชาติและความรุนแรงของภยันตรายที่เผชิญ สุขภาพจิตของบุคคล ประวัติการถูกเลี้ยงดูในวัยเด็ก บุคลิกภาพเดิม ความรวดเร็วในการได้รับความช่วยเหลือ

40. Psychosocial impact to children • เด็กไม่ได้รับการดูแลด้านสุขภาพอนามัย • เด็กไม่ได้รับการดูแลด้านการศึกษา • เด็กไม่ได้รับการดูแลด้านสิทธิและสวัสดิการต่าง ๆ • เจ้าหน้าที่เข้าไปดูแลได้น้อย ไม่ต่อเนื่อง • ปัญหาจากโรงเรียนปิด เลิกก่อนเวลาบ่อย ๆ • ปัญหาจากการที่แม่หรือพ่อต้องเลี้ยงลูกตามลำพัง • ปัญหาของวัยรุ่นที่ถูกมองจากภายนอก เช่นการเรียนต่อ • พฤติกรรมเลียนแบบ ชาชินกับความรุนแรง เล่นลักษณะรุนแรง(Traumatic play) • การช่วยเหลือที่ไม่ถูกต้องอาจเป็นการซ้ำเติม (Retraumatization)

41. The young victims could be categorized as follows: • children who loss one or both parents or caregivers. • children who were injured but survived from the events. • children who personally experienced the violence. • children who were influenced by the disasters via communication and mass media. • children whose families were collapsed by the crises. • children who originally live in the difficult situations.

42. Psychosocial effect to children Pre-school age • Clinging to mother or caregiver • Depressed , look unhappy • Ask for the loss one • Excessive crying • Regressive behavior, childish

43. Psychosocial effect to children Pre-school age • Sleeping problem, startled in sleep • Fear to strangers • Fear of separation, fear of darkness • Irritable, difficulty in raising

44. Psychosocial effect to children School age • Clinging to mother or caregiver • Ask for the loss one, waiting for coming back, depressed • Tremble, dread, horrified • Regressive behavior, become childish

45. Psychosocial effect to children School age • Fear to strangers, fear of separation • Eating, sleeping problems • School, relationship problem • Aggressive, stubborn, irritable, crying

46. Psychosocial effect to children Adolescent age • Tremble, dread, horrify, startle response • stress, excessive worrying, depressed • Sleeping problems, easily awakening • School problems, lack of study

47. Psychosocial effect to children Adolescent age • Problem in relationship • Aggressive, resisted behavior • Anger and willing to take revenge • Somatic symptoms

48. Factors influencing to psychosocial effects • Age, background personality of victims • Severity of incidence • Types of incidence • Status of affected family • Reaction and caring of the rest caregivers • Helping and supporting from outside • Speed of healing process

49. Severe Stress Reactions after a Disaster • Intrusive re-experiencing: terrifying memories, nightmares, or flashbacks • Extreme emotional numbing: completely unable to feel emotion, as if empty • Extreme attempts to avoid disturbingmemories:such as though substance use • Hyper-arousal: panic attacks, rage, extreme irritability, intense agitation, violence

50. Severe Stress Reactions after a Disaster (cont.) • Severe anxiety: debilitation worry, extreme helplessness, compulsions or obsessions • Severe depression: loss of the ability to feel hope, pleasure, or interest; feeling worthless, suicidal ideation or intent • Dissociation: fragmented thoughts,spaced put, unaware of surroundings, amnesia Source: National Center for PTSD at http://www.ncptsd.va.gov/topics/disaster_handout_pdfs/Reactions.pdf