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For your Final Paper, you will apply concepts, principles, and theories presented
in the course as they relate to a specific type of disaster, crisis, or trauma of your
choice. Your paper should be 10–12 pages (not including references, title page,
or abstract), double-spaced, with proper APA formatting. Your paper must
include all of the following elements:
• A minimum of 10 references (in addition to any course readings that you
may wish to reference)
• A description of the type of disaster, crisis, or trauma you selected
• An explanation of the crisis intervention approach you would use to
respond to the disaster, crisis, or trauma
• An analysis of ethical, legal, and multicultural considerations related to the
disaster, crisis, or trauma
• An assessment of the potential impact of the disaster, crisis, or trauma
including the following areas:
o Affect
o Behavior
o Cognition
o Development
o Ecosystems
• An explanation of the global impact of the disaster, crisis or trauma
• A description of the crisis intervention strategies and skills (including
Psychological First Aid) you would use and an explanation of how you
would use each
• An explanation of the potential long-term psychological effects (e.g.,
transcrisis state, PTSD) of the disaster, crisis, or trauma
• A description of potential risk and resilience factors and an explanation of
how each might impact recovery
• An analysis of trends and/or future research related to the disaster, crisis,
or trauma
Although the Final Paper is not to be submitted until Day 7 of Week 10, you
should become familiar with the paper requirements and have them in mind as
you proceed through the course.
Be sure to protect the identity of any real persons used in your paper. No
identifying information should be used.
The Final Paper will be evaluated according to the Final Project Rubric. The Final
Paper is worth 39% of your final grade.
© 2014 Laureate Education, Inc. This should reflect scholarly writing.
disaster_related_physical_and_mental_health_.pdf

lessons_learned_about_psychosocial_responses_to_disaster_and_mass_trauma_an_international_perspective.pdf

ethical_issues_in_trauma_related_reserch.pdf

ptsd_dsm_5.pdf

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Disaster-Related Physical and Mental Health:
A Role for the Family Physician
JOHN R. FREEDY, M.D., Ph.D., and WILLIAM M. SIMPSON, JR., M.D.
Medical University of South Carolina, Charleston, South Carolina
Natural disasters, technologic disasters, and mass violence impact millions of persons each year. The use of primary health
care services typically increases for 12 or more months following major disasters. A conceptual framework for assisting disaster victims involves understanding the individual and environmental risk factors that influence post-disaster
physical and mental health. Victims of disaster will typically present to family physicians with acute physical health
problems such as gastroenteritis or viral syndromes. Chronic problems
often require medications and ongoing primary care. Some victims
may be at risk of acute or chronic mental health problems such as
post-traumatic stress disorder, depression, or alcohol abuse. Risk factors for post-disaster mental health problems include previous mental
health problems and high levels of exposure to disaster-related stresses
(e.g., fear of death or serious injury, exposure to serious injury or death,
separation from family, prolonged displacement). An action plan should
involve adequate preparation for a disaster. Family physicians should
educate themselves about disaster-related physical and mental health
threats; cooperate with local and national organizations; and make sure
clinics and offices are adequately supplied with medications and suture
and casting material as appropriate. Physicians also should plan for the
care and safety of their own families. (Am Fam Physician 2007;75:841-6.
Copyright © 2007 American Academy of Family Physicians.)
For a recent commentary
on this topic, please
see Swain GR, Burns K.
Emergency response:
physician training and
obligations. Am Fam
Physician 2007;75:401-5
(http://www.aafp.org/
afp/20070201/curbside.
html).
T
he American Red Cross defines a
disaster as involving 100 or more
persons, 10 or more deaths, or an
appeal for assistance.1 Qualifying
events include natural disasters (e.g., hurricanes, earthquakes, floods, tornadoes), technologic disasters (e.g., nuclear or industrial
accidents), and mass violence (e.g., terrorist
attacks, shooting sprees). The annual worldwide impact of disasters is substantial, with an
average of more than 500 incidents impacting 80 million persons, displacing 5 million
from their homes, seriously injuring 74,000,
and killing 50,000.2 Although most largescale disasters occur in developing countries,
events such as Hurricane Katrina in 2005 and
the September 11 terrorist attacks in 2001
are reminders that the United States is not
immune to large-scale disasters.3
Years of research and applied practice
have produced a consensus about the vulnerability of the U.S. population to disasters.
Accepted facts include: (1) disasters are
common events that affect millions of persons annually; (2) with more persons living
in disaster-prone areas and increased technologic complexity, it is expected that the
risk and impact of disasters will increase in
future years; and (3) disasters are associated
with a variety of adverse physical and mental
health effects that can range from mild and
transient to severe and chronic.4
Family physicians are well suited to address
the physical and mental health needs of
disaster victims. Disaster exposure increases
primary health care use for 12 months or
more after the event.5 More importantly, the
acute and chronic physical and mental health
issues that most commonly occur after a
disaster are within the scope of practice for
family physicians and other board-certified
primary care physicians.3,4,6-8
Risk Factor Model
Table 1 presents a risk factor model for postdisaster adjustment.4 Research supporting
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American
Family Physician
841
Disaster-Related Health
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Clinical recommendation
Disaster victims with high levels of disaster
exposure should be monitored for the
possible emergence of post-traumatic stress
disorder, depression, or alcohol abuse.
Mental health screening measures should be
used to efficiently and accurately identify
adults who may be experiencing mental
health problems following a disaster.
Evidence
rating
References
C
4, 13, 15
disaster result in an inability to cope effectively after the disaster.
In general, ethnic minority status and
lower
income have been associated with
C
27-32
poorer post-disaster physical and mental
well-being.9 Although being married appears
to help men, a married woman may experience poorer post-disaster adjustment if her
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limitedmarital status results in her giving out more
quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual
social support than she receives.4-7
practice, expert opinion, or case series. For information about the SORT evidence
rating system, see page 789 or http://www.aafp.org/afpsort.xml.
Pre-disaster life events also may have an
impact on post-disaster physical and mental
health. Exposure to traumatic events has
this model is briefly summarized to orient family physi- been associated with a range of mental health problems
cians to these risk factors. When clinically evaluating (e.g., post-traumatic stress disorder [PTSD]) that can
persons after a disaster, family physicians should con- impact post-disaster response.10 Less intensely stresssider these individual and environmental risk factors to ful life events (e.g., financial or marital problems)
assess potential impact on patients’ physical and mental existing one year before disaster exposure have been
health.
associated with increased physical and psychological
A person’s response to a disaster is determined by symptom reports.9,10
demographic and socioeconomic factors, as well as the
In terms of mental health, a history of pre-disaster
person’s pre-disaster mental health and the extent of symptoms can predict the presence of post-disaster
his or her social support before, during, and after the symptoms. Also, persons with pre-disaster mental health
event. Regarding demographic factors, children typically histories are more likely to display post-disaster mental
display emotional distress when family conflict occurs; health problems including PTSD.8
middle-age adults experience psychological and physical
Predictors of effective coping can help triage lessproblems when a disaster makes it impossible to meet needy patients. Coping refers to cognitive and behavresponsibilities4,6-8 ; and older adults most often display ioral abilities to solve problems, manage emotions, or
post-disaster physical and mental health problems when disengage from difficult problems or emotions.11 In
limits on income, health, or social support before the general, successful coping is characterized by flexibility,
creative thinking, willingness to try new
things, action orientation, working cooperaTable 1
tively with others, and the ability to tolerate
Risk Factor Model for Post-Disaster Adjustment*
frustration or other strong emotions.6,7,12
The impact of pre-disaster social supThe rights holder did not grant the American Academy of Family
port on post-disaster well-being is complex.
Physicians the right to sublicense this material to a third party. For the
Generally, victims’ post-disaster adjustment
missing item, see the original print version of this publication.
can be improved if they perceive that they
are supported, if they receive more support
than they give, or if they are embedded in a
healthy social network.6,7
Within a disaster, exposure has objective
(e.g., serious injury, death) and perceived
(e.g., sensing threat to life) elements. High
levels of disaster exposure increase the risk
of developing PTSD or other severe mental health problems following the disasAdapted with permission from Freedy JR, Resnick HS, Kilpatrick DG. Conceptual frameter.4 Family physicians must be comfortable
work for evaluating disaster impact: implication for clinical intervention. In: Austin LS.
in tactfully, directly, and privately asking
Responding to Disaster: A Guide for Mental Health Professionals. 1st ed. Washington,
D.C.: American Psychiatric Press, 1992:6.
patients about exposure to within-disaster
mental health risk factors.
842 American Family Physician
www.aafp.org/afp
Volume 75, Number 6

March 15, 2007
Disaster-Related Health
Common Post-Disaster Health Outcomes
The probability of a particular post-disaster physical
or mental health condition varies according to the
time since the disaster onset. It is helpful to divide
the post-disaster time frame into acute (less than one
month), intermediate (one to 12 months), or long-term
(i.e., chronic; longer than 12 months) phases.
Another way to view the post-disaster time frame
is in terms of the potential to experience a series of
chronic low-level stresses that may overwhelm coping
resources.4,8,13-16 Family physicians can be key agents
in lessening post-disaster physical and mental health
reactions. Key points include providing information,
remaining empathic, encouraging victims to seek and
accept assistance, advocating self-determination to the
extent feasible, reminding persons of how they may have
successfully coped with previous troubles, and repeatedly checking on disaster victims for up to 12 months
(or longer for more severely devastating events).17
Physical and mental health effects of disasters often
coexist. In some instances, physical problems may
increase the probability of mental health problems. For
example, a disaster may exacerbate a chronic health
condition such as diabetes or congestive heart failure
(CHF), with worsening physical health contributing
to the development or exacerbation of depression. The
reverse direction of causality is possible, with mental
health problems resulting in poorer health maintenance efforts and deterioration in chronic health
problems.
physical health outcomes
Table 24-9,18-26 presents common post-disaster health
problems. Physical problems fall into four categories:
(1) acute injuries; (2) acute problems; (3) chronic problems; and (4) medically unexplained physical symptoms.
More than one half of acute post-disaster health
issues are illnesses (e.g., self-limited viral syndromes,
gastroenteritis).20-24 Approximately one fourth of acute
post-disaster health complaints are injuries (e.g., cuts,
abrasions, sprains, fractures). Other acute post-disaster
health issues include routine items such as medication
refills, wound checks, and splinting.19
It is common for disaster victims to require assistance
in the management of chronic health problems (e.g., diabetes, hypertension, CHF). Simple provision of medication and medical supplies may be sufficient. Depending
on the degree to which the disaster has impacted community infrastructure, such assistance may be required
as part of the intermediate or even long-term phase of
post-disaster adjustment.
March 15, 2007

Volume 75, Number 6
Somatic complaints without organic cause, sometimes
described as medically unexplained physical symptoms,
are common following a disaster. These unexplained
symptoms also are associated with mental health problems such as depression, PTSD, and other anxiety disorders.26 Family physicians should increasingly consider a
mental health explanation for vague, unexplained physical symptoms as time since the disaster increases.
mental health outcomes
Most patients with post-disaster mental health problems
had similar problems before the disaster occurred. In
such cases, the role of the family physician includes the
provision of medication refills, supportive counseling,
and appropriate referrals when indicated and feasible.
Table 2
Common Post-Disaster Health Problems
Mental health
Acute responses18
Examples: Cognitive dysfunction or distortion; dysfunctional
interpersonal behaviors; emotional lability; nonorganic
physical symptoms
Chronic problems 4,6-8
Examples: Alcohol abuse or dependence; depression;
interpersonal violence; PTSD or other anxiety disorders;
schizophrenia or other severe chronic disorders
New-onset mental health problems6-8
Examples: Acute stress disorder possibly evolving to
PTSD; alcohol abuse or dependence; depression;
interpersonal violence
Physical health
Acute injuries19
Examples: Cuts or abrasions; fractures; motor vehicle
crashes; occasional self-inflicted wounds; sprains or strains
Acute problems20-24
Examples: Gastroenteritis or dehydration; head lice;
pulmonary problems; rashes; rodent-borne illness; selflimited viral syndrome; toxic exposures; vector-borne illness
Chronic problems5,9,20,25
Examples: Congestive heart failure; diabetes; hypertension;
pulmonary problems (e.g., chronic obstructive pulmonary
disease, acute bronchitis, asthma)
Medically unexplained physical symptoms26
Examples: Fatigue; gastrointestinal complaints; headaches;
other generally vague somatic complaints without clear
organic etiology
PTSD = post-traumatic stress disorder.
Information from references 4 through 9, and 18 through 26.
www.aafp.org/afp
American Family Physician 843
Disaster-Related Health
Table 3
Sample Questions to Assess Within-Disaster
Risk Factor Exposure*
Acute post-disaster psychological distress includes
emotional lability; negative emotions; cognitive dysfunction and distortions (e.g., reduced concentration, confusion, unwanted thoughts or memories);
physical symptoms (e.g., headaches, tension, fatigue,
gastrointestinal upset, appetite changes); and behaviors that negatively affect interpersonal relationships
(e.g., irritability, distrust, withdrawal, being overly controlling). For most persons, acute psychological distress
will resolve within weeks to several months, but it can
persist for up to one year. Distress tends to resolve as
victims are able to reliably meet their basic needs.18
More severe new-onset mental health problems can
occur, with the presentation ranging from obvious to
subtle. The most common post-disaster mental health
problems appear to be depression, PTSD, and other
anxiety disorders.8 Increases in alcohol or drug abuse
and domestic or interpersonal violence also have been
noted.6,7 Family physicians should consider screening
for common mental health problems among vulnerable
populations, such as persons with a history of mental
health issues, perceived life threat, serious injury, or
exposure to death.
A two-stage mental health screening process is recommended. If a disaster victim is thought to be at high risk
because of mental health history or within-disaster experiences, that person should be asked directly about exposure to toxic stressors (Table 34,6,7). If initial screening
suggests heightened mental health risk, the person should
be asked further symptom-based screening questions.
The authors recommend using the following screening
questionnaires: a two-item patient health questionnaire
for depression (PHQ-2; 96 percent sensitivity; Table 4)27;
a four-item primary care PTSD screen (PC-PTSD [this
test can be viewed at http://www.ncptsd.va.gov/ncmain/
assessment/ptsd_screening.jsp]; 78 percent sensitivity)28 ;
and the four-item CAGE questionnaire for alcohol abuse
(75 to 97 percent sensitivity).29-32 Relatively high sensitivity rates suggest that very few people with post-disaster
mental health problems will be missed by screening
(i.e., low false-negative rate). Positive screening results
should be followed up with additional diagnostic interviews and intervention as appropriate.25,33-35
Disaster Preparation
The authors propose a four-step disaster preparation
plan so that when disasters happen, family physicians
are able to turn their collective knowledge and skills into
compassionate and competent action. This plan includes
education, linking up with other organizations, logistical
preparation, and personal preparation.
844 American Family Physician
Certain experiences during disasters are thought to increase
the risk of developing anxiety, depression, or other similar
problems. To best help you, may I ask a few questions
about how you were affected by the disaster?
During or immediately following the disaster:
• Did you ever fear that you might be seriously injured
or killed?
• Were you or was anyone close to you seriously injured?
• Do you know anyone who died?
• Were you separated from anyone in your immediate
family?
• Was your home seriously damaged or destroyed?
note:
Positive responses should prompt further exploration.
*—Degree of within-disaster exposure directly determines risk of
developing post-traumatic stress disorder, depression, or other severe
mental health problems.
Table 4
Patient Health Questionnaire (PHQ-2)
for Depression Screening*†
How often over the past two weeks have you experienced
either of the following problems:
1. Having little interest or pleasure in doing things?
2. Feeling down, depressed, or hopeless?
*—“Yes” versus ”no” response format, with yes = 1 and no = 0. A score
of 1 is a positive screening result with a sensitivity of 96 percent.
†—Four-point response format, with 0 = not at all; 1 = several days;
2 = more than one half of the days; 3 = nearly every day. A score of 3
or more is a positive screening result with a sensitivity of 83 percent.
Information from reference 27.
education
Family physicians should educate themselves thoroughly
about disaster-related physical and mental health threats.
There are many articles and books available.6-8,33-36 Many
Web sites also provide information about disaster-related
resources and service opportunities (Table 5).
All physicians should know about threats that may
impact a community, including bioterrorism, terrorism,
and mass casualty events. Physicians within certain geographic regions also should educate themselves regarding natural disaster events particular to their area.
linking
Many opportunities exist to proactively apply professional knowledge and skills by becoming involved in
existing disaster preparedness efforts. Because the scope
of many disasters exceeds local health care capacity, it is
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March 15, 2007
Disaster-Related Health
Table 5
Internet Resources for Disaster Services and Disaster-Related Health Materials
Organization
Web address
Comment
American Academy of
Family Physicians (AAFP)
http://www.aafp.org
American Medical
Association (AMA)
http://www.ama-assn.org
American Red Cross
http://www.redcross.org
Centers for Disease Control
and Prevention
http://www.cdc.gov
National Center for Posttraumatic Stress Disorder
United Way of America and
Alliance for Information
and Referral Systems
http://www.ncptsd.va.gov
Type “disaster response” into the search function to obtain a
listing of AAFP-related resources, which include fact-based
articles, training courses, and service opportunities
Type “disaster response” into the search function to obtain a
listing of AMA-related resources, which include training courses,
information about the health impact of disaster, summaries of
current AMA disaster activities, and other Web site links
“Disaster services” link provides full access to Red Cross disaster
activities, which include related news stories and tips on
preparedness and coping with disasters
“Emergency preparedness and response” link provides health
information on a full range of disasters; useful handouts include
helping families cope with the stress of relocation, tips for
talking about disasters, and s …
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