Terrorism
and Disaster

WHAT
CLINICIANS
NEED TOKNOW

Emergency Mental
Health After a
Suicide Bombing

Sponsored for CME Credit by
Rush University Medical Center
Release Date: April 1, 2005
Expiration Date: March 31, 2007

errorism
Tand isaster
D
SERIESEDITORS
Rush University
Medical Center
Chicago, Illinois
Stephanie R. Black, MD*
Assistant Professor of Medicine
Section of Infectious Diseases
Department of Internal Medicine
Daniel Levin, MD*
Assistant Professor
General Psychiatry Residency Director
Department of Psychiatry
Gillian S. Gibbs, MPH*
Project Coordinator
Center of Excellence for Bioterrorism
Preparedness
Linnea S. Hauge, PhD*
Educational Specialist
Department of General Surgery

AUTHORS
Rush University
Medical Center
Chicago, Illinois

WHAT
CLINICIANS
NEED TO
KNOW

Uniformed Services University
Health Sciences
Bethesda, Maryland
David M. Benedek, MD, LTC, MC, USA
Associate Professor of Psychiatry
Steven J. Durning, MD, Maj, USAF, MC*
Associate Professor of Medicine
Thomas A. Grieger, MD, CAPT, MC, USN*
Associate Professor of Psychiatry
Associate Professor of Military &Emergency Medicine
Assistant Chair of Psychiatry for Graduate& Continuing Education
Molly J. Hall, MD, Col, USAF, MC, FS*
Assistant Chair & Associate Professor
Department of Psychiatry
Derrick Hamaoka, MD, Capt, USAF, MC, FS*
Director, Third Year Clerkship
Instructor of Psychiatry
Paul A. Hemmer, MD, MPH, Lt Col, USAF, MC*
Associate Professor of Medicine
Benjamin W. Jordan, MD, CDR, MC, USNR, FS*
Assistant Professor of Psychiatry

Stephanie R. Black, MD*
Assistant Professor of Medicine
Section of Infectious Diseases
Department of Internal Medicine

James M. Madsen, MD, MPH, COL, MC-FS, USA*
Associate Professor of Preventive Medicine
and Biometrics
Scientific Advisor, Chemical Casualty Care
Division, US Army Medical Research Instituteof Clinical Defense (USAMRICD), APG-EA

Daniel Levin, MD*
Assistant Professor
General Psychiatry Residency Director
Department of Psychiatry

Deborah Omori, MD, MPH, FACP, COL, MC, USA*
Associate Professor of Medicine
Michael J. Roy, MD, MPH, FACP, LTC, MC*
Associate Professor of Medicine
Director, Division of Internal Medicine
Jamie Waselenko, MD, FACP**
Assistant Professor of Medicine
Assistant Chief, Hematology/Oncology
Walter Reed Army Medical Center
Washington, DC

Guest Faculty
Ronald E. Goans, PhD, MD, MPH*
Clinical Associate Professor
Tulane University School of Public Health &Tropical Medicine
New Orleans, LA
Sunita Hanjura, MD*
Rockville Internal Medicine GroupRockville, MD
Niranjan Kanesa-Thasan, MD, MTMH*
Director, Medical Affairs & Pharmacovigilance
AcambisCambridge, MA
Jennifer C. Thompson, MD, MPH, FACP*
Chief, Department of Clinical Investigation
William Beaumont Army Medical Center
El Paso, TX

Faculty Disclosure Policy
It is the policy of the Rush University Medical
Center Office of Continuing Medical
Education to ensure that its CME activities
are independent, free of commercial bias
and beyond the control of persons or organizations with an economic interest in influencing the content of CME. Everyone who
is in a position to control the content of an
educational activity must disclose all relevant
financial relationships with any commercial
interest (including but not limited to pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject
matter of the presentation topic) within thepreceding 12 months If there are relationships that create a conflict of interest, thesemust be resolved by the CME Course
Director in consultation with the Office ofContinuing Medical Education prior to theparticipation of the faculty member in thedevelopment or presentation of course
content.
* Faculty member has nothing to disclose.
**Faculty disclosure: CBCE Speaker’s Corefor SuperGen.

Emergency Mental Health
After a Suicide Bombing
CASE AUTHOR: David M. Benedek, MD, LTC, MC, USA

ACCREDITATION & DESIGNATION STATEMENT
Rush University Medical Center is accredited by the Accreditation Council for Continuing
Medical Education (ACCME) to provide continuing medical education for physicians.
Rush University Medical Center designates this educational activity for a maximum of 1 credit of category 1 credit toward the AMA Physician’s Recognition Award. Each physician shouldclaim only those credits that he/she actually spent in the activity.
This CME activity was planned and produced in accordance with the ACCME Essentials.
CME credits are available free of charge through March 2007.

DISCLAIMER
This project was funded by the Metropolitan Chicago Healthcare Council (MCHC) througha grant from the Health Resources and Services Administration (HRSA).
The opinions or assertions contained herein are the private views of the authors and are not
to be construed as official or as representing the opinion of Rush University Medical Center,
the Department of the Army, Department of the Navy, Department of the Air Force,
Department of Defense, MCHC or HRSA.
FDA Approved Drug and Devices Assurance Statement
In accordance with requirements of the FDA, the audience is advised that information presented in this continuing medical education activity may contain references to unlabeled orunapproved uses of drugs or devices. Please refer to the FDA approved package insert for eachdrug/device for full prescribing/utilization information.

INSTRUCTIONS
The questions that appear throughout this case are intended as a self-assessment tool. For
each question, select or provide the answer that you think is most appropriate and compare
your answers to the key at the back of this booklet. The correct answer and a discussion of
the answer choices are included in the answer key.
Note: These self-assessment questions are not intended for CME credit. To apply for CME
credit, you must complete the CME Test at the back of this booklet and submit it according to
the directions provided.
In addition, a sign is provided in the back of this booklet for posting in your office or clinic.
Complete the sign by adding your local health department’s phone number.

Design and layout © 2005 Rush University Medical Center. The text contained herein falls under the U.S.
Copyright Act of 1976 as a “U.S. Government Work” and is therefore considered Public Domain Information,
however Rush University Medical Center reserves the right to copyright the design and layout of that information.

1

Emergency Mental Health
After a Suicide Bombing
CASE AUTHOR: David M. Benedek, MD, LTC, MC, USA

INTENDED AUDIENCE
Mental health professionals including psychiatrists, psychologists, social workers,
hospital chaplains, and other physicians who will provide evaluation and care in
the aftermath of a terrorist attack or other public health disasterE D U C AT I O N A L O B J E C T I V E S
Upon completion of this case, participants will be able to:• Describe the different groups of people at risk for injury and traumatic response
to a suicide bombing.
• Discuss the common psychological sequelae to those exposed to the direct andindirect effects of a suicide bombing.
• Describe the expectations for recovery, change, and growth to those directly andindirectly exposed to a suicide bombing.
• List the recommended early psychological interventions for suicide bombing
victims, their family and friends.
• Explain the controversy regarding debriefing for recent victims of trauma.

CASE SUMMARY
You are a psychiatrist reporting to the Emergency Department (ED) of your county’s general hospital shortly after hearing of an explosion at a nearby government
office building. You are confronted with a room crowded with people identified by
ED physicians as “no admission, may need psych help.” You must develop a strategy
to assess the mental health needs of this group, initiate treatment as necessary, andensure appropriate follow-up where indicated.

CASE HISTORY
Early one morning as you drive to the county hospital for routine morning rounds
on your psychiatric inpatients, you are shocked to hear that an explosion has occurredin front of a government office building just six blocks from your hospital. While thenews reports indicate no evidence of a chemical or radiological threat, terrorism is suspected. Although your first instinct is to drive to the scene of the explosion, you recall
that the county’s disaster response plan calls for your presence at the hospital’s ED.

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As you approach the hospital, the continuous wail of sirens alerts you to the likelihood that significant numbers of seriously injured people are arriving for evaluationand treatment. The large number of cars entering the hospital parking lot suggeststhat other people are responding to the disaster, leading to a log-jam of cars in theparking structure. As you search for a parking spot radio news stations provide
updates — as many as 15 are feared dead, upwards of 60 are wounded. These casualties and other victims are transported to local hospitals and trauma centers.
COMMENT: This case illustrates the importance of knowing the details of one’s local emergency
preparedness plan. Physicians responding to a disaster should be aware of their assigned roles,
responsibilities, and duty locations. They should have participated in realistic training exercises prior
to an actual disaster.

When you arrive at the ED, a nurse wearing an Emergency Response Team Vest
is providing instructions: “Nurses — report to the labor pool, Room 1-B, ER Docsto triage — right outside. Surgeons to the surgery conference room. Mental
Health — report to Room 1-C. ICU personnel to the ICU Annex.”
You recognize Room 1-C as the ED’s conference room, a medium sized classroom
with seating and desk space for 30 people, but without medical supplies or examination rooms. As you head for Room 1-C, you glance at your watch and are surprisedthat it has already been 45 minutes since you learned of the explosion, closer to anhour and a half since it likely occurred.
Outside Room 1-C, a nurse informs you that the conference room has about “25
to 30 people in the room, but more are coming.” She tells you that the group includes
people who received only minor injuries from the blast and have already been treated,others who did not appear to be injured, but were brought or presented to the ED due
to their proximity to the blast, and still others that “the ER docs said seemed really
shaken up and needed psych.” The nurse explains that all patients not admitted tothe hospital will eventually be directed to Room 1-C for wound care and follow-up
instructions, but that many are still waiting to be seen by the ER physicians. She saysthat a chaplain and a psychologist “are in there talking to folks. Go in and ask them
how you can help.”
COMMENT: In most mass casualty situations, initial ED triage will identify patients in critical needof medical or surgical intervention and hospital admission. Minor injuries will be stabilized. Persons
not requiring hospital admission will be directed to waiting areas for follow-up assessments and discharge instructions, but this process may be delayed as life-saving interventions are implemented forothers. Such holding areas are likely to include patients who do not appear to warrant psychiatricadmission, but may require psychological assessment and supportive care.
You recall that the Diagnostic Statistical Manual of Mental Disorders (DSM-IVTR) differentiates between transient responses to minimal stressors (eg, adjustment
disorders) and more significant social, occupational, or interpersonal impairment following an event. Examples of these more significant impairments include acute stressdisorder (ASD), beginning within 2 days of the event and lasting up to 4 weeks, andposttraumatic stress disorder (PTSD), persisting more than 30 days after exposure or
occurring after a delay of months to years. You quickly become concerned about thewell-being of the family members of those killed in the explosion. You remember thatsignificant stressors may exacerbate pre-existing psychiatric disorders, that depression

3

or anxiety disorders (eg, panic disorder) may follow traumatic events, and that somatic complaints without clear medical explanation can occur in the aftermath of disaster.1 You begin to wonder about how members of the community will be functioning
months or years from now.

Table 1. Community Response to Traumatic Events
Immediate phase• strong emotions• disbelief• numbness• fear• confusion accompanied by symptoms of autonomic arousal and anxiety

Delayed phase• persistence of autonomic arousal• intrusive recollections• somatic symptoms• combinations of anger, mourning, apathy, and social withdrawal

Chronic phase• continued intrusive symptoms and arousal• disappointment• resentment• sadness for others• re-focusing on new challenges• rebuilding of lives

COMMENT: Studies have described the range of emotional response to disaster in the context ofa multi-phasic traumatic stress response (Table 1). Prospective studies suggest that symptomatic distress peaks in the days and weeks following traumatic exposure and then gradually declines over thecourse of the year after injury. In the National Comorbidity Survey, the prevalence of PTSD2 was 7.8%,
but it is estimated to be considerably higher in primary care-seeking populations and those exposed tomass-violence.3-5 Surveys of traumatically exposed populations suggest that natural recovery over the
first 3 to 6 months is the general rule. In those who develop PTSD, symptoms decrease most rapidly inthe first 12 months.2 However, one-third of people who develop PTSD experience chronic symptoms
that do not remit. Some exposed patients develop long-lasting personality changes, impaired affectmodulation, self-destructive behavior, shame, despair, hopelessness, impaired interpersonal functioning,or a loss of previously held supportive beliefs. Some remain relatively symptom-free and have little orno lasting impairment associated with trauma exposure. Still others report interpersonal growth experiences as a result of their traumatic exposure.

QUESTION 1
List 4 possible psychiatric sequelae in the immediate aftermath of a traumatic
event. (Write your answer in the space provided.)Reminder: You can find the Answer Key & Discussion on page 8.
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Table 2. Psychiatric Diagnoses Often Applicable to Injured Trauma
Survivors Treated in the Acute Care Medical Setting*,†Diagnosis

Symptomatic Criteria

Functional Criteria

Time Course

Posttraumaticstress disorder

A. Exposure to a traumatic event in which
the person experienced or witnesseda life-threatening event that was
associated with intense emotions(eg, physical injury)
B. The event is persistently re-experienced
C. Persistent avoidance of reminders of theevent
D. Persistent arousal symptoms

Symptoms are associated withclinically significant impairments
in social, occupational, or evenphysical function.

Diagnosis must be made atleast 1 month after the event.

Acute stressdisorderA. Exposure to a traumatic event in which
the person experienced or witnesseda life threatening event that was
associated with intense emotions(eg, physical injury)
B. Either while experiencing the eventor after, the person experiences 3
or more dissociative symptoms,eg, numbing, reduced awareness ofsurroundings, derealization, depersonalization, dissociative amnesia
C. The event is re-experienced
D. Avoidance of reminders of the event
E. Symptoms of arousal

Symptoms are associated withclinically significant impairments
in social, occupational, or evenphysical function.

Diagnosis can be madebetween 2 and 30 days
after the event.

Major depressive
episodeFive or more of the following‡:
depressed mood, diminished interest inpleasurable activities, weight loss or
gain, insomnia or hypersomnia, agitation or retardation, fatigue or energy
loss, feelings of worthlessness, poor
concentration, and suicidal ideation

Symptoms are associated withclinically significant impairment insocial, occupational, or evenphysical function.

Symptoms must be present for
2 weeks.

Traumatic griefDistressing thoughts and experiences
related to reunion, longing, andsearching for the deceased loved
one (non-DSM-IV).

The disturbance causes clinicallysignificant impairment in social,occupational, or other important
areas of functioning.

Duration of disturbance is atleast 2 months.

Adjustment
disorderA. Development of emotional or
behavioral symptoms in response toan identifiable stressor. Symptoms
can include depression, anxiety,conduct disturbance, or otheremotional disturbance.
B. The symptoms or behaviors areclinically significant as evidenced
by marked distress.

Emotional or behavioral symptoms
are associated with marked
impairment in social, role, oreven physical function.

Onset of stressor occurs within 3 months after the traumatic injury. Symptoms do
not persist longer than 6months once stressor has
terminated.

* Adapted from DSM-IV and Zatzick D.6† Posttraumatic symptoms may be present that are insufficient to meet criteria for the above diagnoses. In such cases,
DSM IV-TRV Code Diagnoses would be indicated, as would continued monitoring for the development of further
psychiatric disorder(s). Other mood and anxiety disorders may occur, or be exacerbated by traumatic exposures.
‡ At least one of the five symptoms must be either depressed mood or diminished interest in pleasurable activities.

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As you enter Room 1-C, a chaplain appears to be addressing a group of about 9
patients whose chairs are arranged in a circle, partitioned off from the rest of the roomby an office divider. Approximately 20 patients are sitting at 2 conference tables andappear to be filling out paperwork. Many look somewhat dazed, some are crying. You
recognize a psychologist from the inpatient unit who is interviewing one individual ata time in another corner of the room. Not certain of where you fit in to this situation, you approach the psychologist when he is between patients. He explains thenurses are assessing each patient to insure that they are stable, everyone is filling out
insurance paperwork, and the chaplain made an announcement that anyone whowanted to participate in a group, and discuss how they are feeling should join him,
and they’ve been going for about 20 minutes. “I’m just seeing if anyone is suicidal,
homicidal, or psychotic. What else should we be doing?”
COMMENT: Treatment in the immediate aftermath of trauma should aim to reduce current distress. Ideally, it should prevent future disorders. Small controlled trials support the efficacy of cognitive
behavioral approaches, but in the first hours or even days after an event people may not be able tolisten attentively or absorb new information in a manner that promotes recovery. Data from controlled
studies of medication interventions are lacking. Recent pilots of propanolol and imipramine suggest
these may be beneficial in reducing posttraumatic symptoms in specific populations in small controlled
trials. While benzodiazepines reduce immediate anxiety and improve sleep, they may also increase thelikelihood of subsequent development of PTSD symptoms.
Supportive interventions and psycho-education appear to be helpful as early interventions. When
access to expert care is limited, rapid dissemination of educational fact sheets may reassure many with
sub-syndromal manifestations, provide guidance for self-help, and outline additional means for obtaining assistance. Such materials describe expected physiological and emotional responses to traumatic
events, stress reduction techniques, the utility of remaining mentally active, concentrating on self-caretasks, effects of decreasing or continued exposure, and referral recommendations for seeking consultation if symptoms persist. Because symptoms develop over time and patients may be reluctant to seek
mental health assistance, efforts should also focus on identifying persons at risk and mechanisms thatfacilitate follow-up assessment. Examples of these educational fact sheets can be found at:
http://www.usuhs.mil/psy/disasteresources.shtml.

QUESTION 2
List interventions that are generally recommended in the acute aftermath of adisaster for victims who do not require immediate medical or surgical intervention. (Write your answer in the space provided.)

6

COMMENT: Recommendations for Psycho-Social Intervention
1. Brief exposure assessment. Screening evaluation for severe symptoms (agitation, disorientation,
dissociation)
2. Address basic needs, (eg, might identify patient who will not be able to pick up food stamps since
government office building has been destroyed)
3. Provide psycho-educational materials regarding the range of expected responses to traumatic
exposures (including ASD, PTSD) and points of contact should worrisome symptoms develop.
4. Record contact information and permission to follow-up with exposed persons, so that status may
be monitored over time.
5. Sedative-Hypnotic medications for acutely agitated individuals may reduce immediate agitation
and anxiety and promote sleep, but do not prevent development of PTSD.

You remember from the last disaster drill that the educational handouts are located in the Behavioral Health disaster preparedness box. Along with these handouts
are phone numbers for the outpatient behavioral health clinic and other support
agencies. You ask a member of the disaster response team to get the box of handouts.
When he returns with the box you ask the nurse who appears to be in charge ofactivities in Room 1-C to begin distributing these materials along with otherdischarge instructions.

QUESTION 3
List populations considered to be at greater risk for the development of psychiatric disorders in the aftermath of a terrorist bombing. (Write your answer inthe space provided.)

A nurse asks you to identify people who may be at greater risk of developing
complications of psychiatric disorder in response to this event and to note this riskon their hospital record. You assess their current mental health status and ability tounderstand discharge instructions/follow-up recommendations that will be provided
to them soon by the nursing staff. Additionally, you assure them that their immediateconcerns about food, shelter, as well as questions about the status of their loved ones
will be addressed.
The chaplain announces that he is ready to speak with another group. You areconcerned that the chaplain is conducting single-session critical incident debriefingintervention in an effort to prevent the development of PTSD or ASD. The literature suggests that such interventions do not prevent these illnesses and may be harmful to some people by increasing their exposure to trauma. You ask the chaplain about
the nature of his discussions with patient groups and he informs you that he has been
reminding patients to seek strength in their own spirituality if this has been helpful inthe past, and on request has led some in prayer. The chaplain states that he has never7THE DEBRIEFING
DEBATE
Psychological debriefing is a staged,
semi-structured intervention that
addresses both facts and emotions
related to a particular traumatic
event. Although it was developed as
an intervention to prevent the negative emotional sequelae including
ASD and PTSD, well-controlled studies of debriefing as a single session
individual or group intervention havenot demonstrated efficacy. Althoughsome participants have reported thatthey experience debriefings as helpful,7 there is no evidence at present
that establishes debriefing as aneffective prevention strategy.8,9 In
some settings it has been shown toincrease symptoms.10,11

been trained in Critical Event Debriefing or Critical Incident Stress Debriefing and asks
if you should begin conducting such a group with the people in the room. Instead, you
inform him of your concerns about these sessions. Since it is clear many in the room
are looking to the chaplain for guidance, you encourage him to continue to educate
groups on the importance of using support sources, such as religion, that have worked
for them during difficult times in the past. You ask him to identify people who areconcerned about their loved ones, and you help them establish liaisons with others
who may know more about the health and safety status of their family members.

QUESTION 4
Which of the following statements is incorrect about the single-session groupinterventions in the period immediately following a traumatic event?
a. Most well-controlled studies of single session individual or group debriefings
in the immediate aftermath of traumatic events have demonstrated efficacy at
preventing the development of PTSD.
b. Some studies suggest that psychological debriefings may, in some instances,be harmfulc. There is limited evidence that debriefings may be helpful to some individuals
under specific circumstances.
d. Psychological debriefing is a staged, semi-structured intervention that
addresses both facts and feelings related to a trauma.
Patients who have received their educational materials are being discharged andmore patients continue to arrive in Room 1-C. Realizing that the psychiatric and psychological burden of this event will not become clear for weeks or months you return
to your desk to assist in the screening process. Although natural recovery over the next
3 to 6 months is the general rule, you are reassured by the fact that your hospital disasterplan includes having other clinicians in the intensive care units, surgical suites, recovery
rooms, and the visitor center identifying individuals at increased risk for developing posttraumatic sequelae over time so that follow-up may be provided as necessary.

ANSWER KEY & DISCUSSIONQUESTION 1
List 4 possible psychiatric sequelae in the immediate aftermath of a traumatic
event.
POSSIBLE ANSWERS INCLUDE:• No Axis I Diagnosis (V codes)• Adjustment Disorders• Acute Stress Disorder (later, PTSD)• Panic Disorder, Generalized Anxiety Disorder, and Phobias• Mood Disorders• Disorders secondary to general medical conditions (including delirium)• Multiple somatic symptoms, fatigue, insomnia (Somatization Disorder)• Exacerbation of pre-morbid mood, affective, or thought disorders.
• Factitious Disorder or malingering

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Although natural recovery over 3 to 6 months in the aftermath of traumatic exposure is the general rule,depressive disorders and anxiety disorders including, but not limited to, ASD or PTSD, may result. Head injury
suffered as a result of blast or missile may also precipitate mood or anxiety disorder as well as altered mental status. Somatic symptoms not fully explained by physical injury or illness may increase following disasteror trauma. When additional attention or compensation is provided to disaster victims, people may consciously or unconsciously feign or exaggerate symptoms. Table 2 provides an overview of psychiatric diagnoses
often applicable to trauma survivors.

QUESTION 2
List interventions that are generally recommended in the acute aftermath of adisaster for victims who do not require immediate medical or surgical intervention.
POSSIBLE ANSWERS INCLUDE:• Brief initial assessment to identify degree of exposure. Screening evaluation for severe symptoms(agitation, disorientation, dissociation)• Supportive interventions to address basic needs, (eg, might identify patient who will not be able topick up food stamps since government office building has been destroyed)• Provide psycho-educational materials to patients, families, and staff• Record contact information and permission to follow-up, so that status may be monitored over time
• Sedative-hypnotic medications for acute agitated individuals may reduce immediate agitation andanxiety and promote sleep, but do not prevent development of PTSDQUESTION 3
List populations considered to be at greater risk for the development of psychiatricdisorders in the aftermath of a terrorist bombing.
POSSIBLE ANSWERS INCLUDE:• elderly• children• those with impairing physical injuries• those with pre-morbid psychiatric conditions• family members of those significantly injured or killed
Since healthy coping includes reliance on others for support, those with limited psycho-social support orpoor access to medical care, such as the elderly, are at risk for developing psychiatric disorders in the aftermath of disaster. The loss or debilitating injury of a parent may be particularly difficult for children, shattering basic assumptions about the world as a safe and just place. The incidence of anxiety disorders (including
ASD/PTSD) and depression in persons with serious physical injuries also increases, in part, as a patient confronts barriers imposed on normal activity (eg, work, recreation, exercise) by these injuries. Highly stressful
situations can exacerbate many pre-morbid psychiatric conditions including mood, anxiety, and psychotic
disorders, and the loss or injury of loved ones.

QUESTION 4
Which of the following statements is incorrect about the single-session group interventions in the period immediately following a traumatic event?
ANSWER: The correct answer is a. Randomized controlled studies and meta-analyses have not demonstrated efficacy of debriefing in preventing PTSD.
In one study,10 randomly selected victims who received debriefings 24-48 hours after motor vehicle crashes
demonstrated either similar or worsened symptomatic outcomes compared with controls at 4 months.
While debriefing does not appear to prevent the development of PTSD, participants often acknowledge
that they feel the debriefing is helpful in some manner. Open trials have demonstrated improvement in
self-efficacy and reduced anxiety in the short term.7
9REFERENCES
1. Benedek DM, Ursano RJ. Military and disaster psychiatry. In: Smelser NJ, Baltes PB, eds.
International Encyclopedia of the Social and Behavioral Sciences. Oxford, UK: Elsevier Press;
2001:9850-9857.
2. Kessler RC, Sonnega A, Bromet, E, Hughes M, Nelson CB. Posttraumatic Stress Disorderin the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52:1048-1060.
3. Stein MB, Mcquaid JR, Pedrelli P, Lenox R, McCahill ME. Posttraumatic Stress Disorderin the primary care medical setting. Gen Hosp Psychiatry. 2000;22:261-269.
4. Schlenger WE, Caddell JM, Ebert L, et al. Psychological reactions to terrorist attacks:
findings from the National Study of Americans’ Reactions to September 11. JAMA.
2002;288:581-588.
5. Weine SM, Becker DF, McGlashan TH, et al. Psychiatric consequences of ‘ethnic
cleansing’: clinical assessments and trauma testimonies of newly resettled Bosnian
refugees. Am J Psychiatry. 1995;152:536-542.
6. Zatzick D. Posttraumatic stress, functional impairment, and service utilization after
injury: a public health approach. Semin Clin Neuropsychiatry. 2003;8: 149-157.
7. Shalev AY, Peri T, Rogel-Fuchs Y, Ursano RJ, Marlowe D. Historical group debriefing
after combat exposure. Mil Med. 1998;163:494-498.
8. van Emmerik A, Kamphuis JH, Hulsbosch AM, Emmelkamp PM. Single session debriefing after psychological trauma: a meta-analysis. Lancet. 2002;360:766-771.
9. Rose S, Bisson J. Brief early psychological interventions following trauma: a systematic
review of the literature. J Trauma Stress. 1998;11:697-710.
10. Hobbs M, Mayou R, Harrison B, Worlock P. A randomized controlled trial of psychological debriefing for victims of road traffic accidents. BMJ. 1996;313:1438-1439.
11. Rose S, Bisson J, Wessely S. Psychological debriefing for preventing post traumatic stressdisorder (PTSD). Cochrane Database Syst Rev. 2001;3:CD000560.

SUGGESTED READING
1. Ursano RJ, McCaughey BG, Fullerton CS, eds. Individual and Community Responses toTrauma and Disaster: The Structure of Human Chaos. New York, NY: Cambridge
University Press; 1994.
2. Vlahov D, Galea S, Resnick H, et al. Increased use of cigarettes, alcohol, and marijuanaamong Manhattan, New York, residents after the September 11th terrorist attacks.
Am J Epidemiol. 2002;155: 988-996.
3. Shuster MA, Stein BD, Jaycox LH, et al. A national survey of stress reactions after the
September 11, 2001, terrorist attack. N Engl J Med. 2001;345:1507-1512.

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EVALUATION FORMTERRORISM AND DISASTER: WHAT CLINICIANS NEED TO KNOW
Emergency Mental Health After a Suicide Bombing
Participant Information
Name/Degree

Practice setting: ❏ Hospital/In-patient ❏ Outpatient/Clinic ❏ Other

Address

Email

City

Clinical Specialty

State

Zip

Signature

Telephone

Date

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Case Study Evaluation
Please rate this case study according to the following scale: 1=Very Poor 2=Poor 3=Fair 4=Good 5=Very Good 6=Excellent
1. Accredited CME activities must be “free of commercial bias for or against any product.” In this regard,
how would you rate this activity? If you perceived any bias, please provide specific comments below.

1 2 3 4 5 6oooooo__________________________________________________________________________

oooooo2. How well did the case study satisfy your purpose for reading it?

oooooo

3. To what extent were the stated objectives of the case study achieved?

oooooo4. In general, was the case study well organized and presented?
5. To what extent has this CME activity improved your preparedness to recognize and care for victims of aterrorism attack or other public health disaster?
6. What was your overall rating of this case study?

oooooooooooo7. I would recommend this case study to a colleague.

o Yes

8. Based upon your review of this case, what specific action(s) could you take to enhance disaster
preparedness in your workplace?

Please estimate the probability
that you will act on this item
(0-100% where 100% = certainty)o No

A. ________________________________________________________________________

A. ___________

B. ________________________________________________________________________

B. ___________

C. ________________________________________________________________________

C. ___________o Please check this box if you prefer not to be contacted for follow-up about the impact of this activity on your clinical practice.
11

QUESTIONS FOR CONTINUING EDUCATION CREDIT
1. The psychiatric differential diagnosis for patients presenting for care in the aftermath of a terrorist event
such as a suicide bombing includes:a. Adjustment Disorderb. Grief reactions
c. Panic Disorderd. No Axis I Diagnosis
e. All of the above
2. Which of the following statements is true about treatment of persons exposed to traumatic events?
a. Well-controlled trials have established the efficacy of SSRI’s in preventing the development of PTSD
when administered shortly after exposure.
b. Preliminary evidence suggests cognitive behavioral approaches may be helpful in the aftermath of trauma.
c. Psychological debriefings reduce posttraumatic sequelae when delivered by appropriately trained individuals.
d. Mental status examination findings such as agitation and fear in the hours immediately after the event are
accurate predictors of future development of PTSD.
3. What are important design considerations in creating educational materials provided to ambulatory victims ofterrorist attacks prior to discharge from medical observation?
a. Advising patients of predictable responses to traumatic events since hyper-suggestibility will lead tosymptom development
b. Guidance on self-help and stress management techniquesc. Should be limited to specific and simple wound-care instructions since trauma exposed persons will not
be able to synthesize new informationd. Are of limited utility as most symptoms will require ongoing medical evaluation and medication management
4. Which of the following statements about psychological debriefings is true?
a. They have been shown to prevent development of PTSD only when patients initially experience them as
unpleasant or painful.
b. They have demonstrated efficacy in reducing posttraumatic symptomatology, but only as a group intervention.
c. They may result in secondary traumatization for some patients as they hear others recount their experiences.
d. They should be considered as a first-line intervention strategy in the immediate aftermath of a terrorist attack.
5. What considerations should you keep in mind for mass casualty situation patients not requiring intensive
care or immediate surgical intervention?
a. These patients are at very limited risk for the development of symptoms requiring mental health intervention.
b. They are more likely than acutely physically injured persons to develop Acute Stress Disorder or otheranxiety disorders.
c. These patients should be instructed in new coping strategies while in the ER since previously effective coping
mechanisms are most likely to be overwhelmed by their recent experience.
d. Patients should be encouraged to utilize their own natural support systems and reminded that exercise andremaining mentally active may be helpful in reducing distress.

12errorism
Tand isaster
D
Rush University Medical Center
faculty, in collaboration with facultyfrom the Uniformed Services
University of the Health Sciences(USUHS) authored a case series
to provide continuing medical
education (CME) for terrorism
preparedness and other publichealth emergencies.
A series of 14 case studies was developed to provide innovative learning
opportunities for health professionals
to problem-solve issues related toterrorism or other public healthemergencies. Due to the complicated and volatile nature of a terrorist
event, the case studies were designed
to expand outside the clinicianpatient interaction and involve:• deploying outside resources• notifying appropriate officials• coordinating a response team• dealing with media andconcerned public• initiating emergency/disaster plans
Each case provides the CME user
with decision-making challenges
within his or her discipline, alongwith scenarios that address broader
interdisciplinary issues. This interdisciplinary approach is particularly
important in disaster preparedness,when health professionals will likely
be called on to work outside their
day-to-day experiences.

WHAT
CLINICIANS
NEED TO
KNOW

Authored by experts in the field,
each self-paced case includes athorough case history, questions totest your knowledge, a resource listof additional readings and relevant
websites. One-hour CME andCEU credit is available for eachcase, following the successful completion of the CME questions
included with each case. The CME
and CEU credit is available free ofcharge through March 2007.

INTERDISCIPLINARY
The interdisciplinary cases address
basic medical management,general
disaster planning, communicatingwith the media and concerned
public, and psychosocial casemanagement.
• Inhalational Anthrax• Pulmonary Toxicants• SARS• Smallpox• Viral Encephalitis

The cases in the series include:
MEDICINE
The medicine cases address recognitionof the agent, diagnosis, treatment, andmedical case management.
• Pneumonic Plague• Radiation Attack• Sarin• Smallpox• Staphylococcal Enterotoxin B• Viral Hemorrhagic Fevers
PSYCHIATRY
The psychiatry cases address issuesof disaster psychiatry.
• Emergency Mental Health
After a Suicide Bombing• Psychiatric Sequelae in a
Survivor of 9/11
• Psychosocial Managementof a Radiation Attack

For more information or to order
your free copy of any of the casesin this series, please contact:
Office of Continuing
Medical Education
Rush University Medical Center
Suite 433 AAF
Chicago, Illinois 60612
Telephone: (312) 942-7119
Facsimile: (312) 942-2000
E-mail: cme_info@rush.edu