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The 42st National Conference of Child and Adolescent Neurology and Psychiatry and Allied Professions with international participation


PSYCHOPATHOLOGICAL DISORDERS OF CHILDREN AND ADOLESCENTS IN DISASTER

Autor: Constantin Lupu
Distribuie pe:

There are describe and exemplified psychopathological condition during and after natural and/or antropogenic disasters inflected on children and adolescents exposed to trese situations.

All these events must be coverd on medical and psychological emergencies, so it is required to be known by our experts who can take preventive and treatment measure in many cases of catastrophes and disasters.

I insisted on describing the symptomatology on the following psycho-pathological issues:

  • acute psychic states of shock during catastrophic events
  • psycho-pathological reaction after a catastrophic factor
  • state of population panic
  • chronic disorder after catastrophic stress.

At each of these presentations are refrences from personal experience and from Medico-Psychological Fird Aid mesuares.

 


 

Psycho-traumatic situations from disasters are feelings of acute distress the subject lives and faces a catastrophic event during which he was or might be seriously injured or is threatened with death.

These psychopathological experiences go through the same subjects who were direct witnesses to the tragic events and are involved as participants in them.

Catastrophic acute mental distress has the same conditions, in addition subject feels and lives feelings of sudden threat of life and / or a feelings of impending death. A disaster engages a large number of sufferers, giving it a character of suffering population.

Participation and the response of the subjects to catastrophic events translates complex psychological symptoms: anxiety and superacute anguish, blocking feelings and behavior and horror, acute panic. In children, these manifestations are expressed through agitation, somatic conversion and psychological suffering.(12)

After catastrophic experiences (earthquakes, floods, landslides, bombings, war aggression and destruction, etc.) suffering is installed: despair, anxiety, depression, the reliving of calamity (flash-backs) and subconfuzional states – conversion followed by amnesia.(16)

Descriptions of mental suffering in disasters can be divided into three distinct phases.

The first psychological aggression

Felt during the disaster, which is installed along with physical agent: moments and / or somatic and mental suffering during short period in earthquakes and more prolonged in flood, typhoon, invasion, tsunami, traffic accidents and aggressive states on subjects. After G. Perren-Klinger (1994) – during and immediately after the exposure to a brutal shock situation is classical for each person, adult or child, to undergo a personal reaction nonspecific or specific to the aggressive situation.(15)

Among non-specific reactions we include: feelings of block, maximum helplessness, fear and horror for the moments of the traumatic events, loss of personal security and self-confidence inside and in others, depression and deplore thrugh the loss of people, objects, plans and illusions.

Specific psychological reactions would be: hipersomatization suffering (headache, cardiac disorders, respiratory and blood pressure disorders, digestive disorders, reactivation gastritis, gastric and intestinal hypermotility, urinary disturbance, acute joint pain etc.). Specific psychological reactions are dominated by anxiety, phobic states, panic attacks, flash-back recollections, nightmares, emotional and somatic paraesthesia and anesthesia.

Knowing these sufferings we can guide the future doctor, psychologist and psychotherapist for individuals abused in various disaster recovery.

Distress is induced by conflictual situations, different psychotrauma aggression and acting on the mental and psychological communication and socio-economic information, with intensity and duration capable of producing acute, subacute or chronic mental changes. (19)

Of course that the psycho-pathological feelings and responses depending on the individual capacities of learning, understanding, processing and response of subjects, maturity or disruption of cognitive maturity, meaning the type of personality and type of vulnerability.(18)

The Japanese experience has shown that education and the training for psycho-somatic control in earthquakes and tsunami significantly reduces acute pain states in such disasters.

Psycho-somatic distress mechanisms are triggered by cortic-subcortical activation, and diencefalo- thalamic mechanisms and transmitted through mechanisms of neuro-vegetative neuro-endocrine axis, and finally are taken from the viscera and musculoskeletal apparatus.

After Enăchescu C. (1973), the neocortex formationes that processes the distress agencies are: prefrontal neocortex in actions guidance, the praxys and some affective behavior and determines postrolandic neocortex functions and motor dysfunction; postrolandic integrates sensory neocortex functions, rinecephalon (hippocampus, cingulate gyrus and temporal amygdala) for affective emotional stimuli – and part of school behavior – professional conduct.(6)

As we know, the frontal lobes process emotional manifestations, especially anxiety and associated areas of the frontal lobes summarize and compare different information from all the brain sectors.

After Von Eiffel and Steinmuller, biological basis of distress from disasters are links of the cortex with limbic and temporal bands of the hypothalamus.(5)

According to the corticoviscerale theory(Pavlov, Bîcov) psychological shock situations are recorded and cortical and processed, then they “induce a subcortical storm” that trigger the neurohormonal and neurovegetative mechanisms.

Addressing recent changes triggered by acute and chronic psychiatric conditions somatic and psychological aggression, enter into the equation the onset and the communication activities assigned to the conjugated neurons-neuroglia that produce positive or negative formulas.

Quantum telepathy and thought transmission by transmitting positive or negative feelings in children is more prominent with loved mother and relatives nearby.

This vision by quantum theory of brain function explains the speed of installation and physiological and / or psychopathological states psihotraumatice negative feelings. In addition, quantum communication waves approach explains the functions of emotional contagion states such as anxiety, depression, anxiety (and joy).

That is another psychotherapeutic argument in disasters where intervention is our recommendation of sedatives and anxiolytics, plus counseling of the adults not to submit anxiety, sadness and despair to the children.

Returning to the analysis of psychopathological experiences acute reaction to a catastrophic psychotrauma, we described two phases of these situations:

1. Acute mental stress state during catastrophic events. This phase lasts for the period of the catastrophic agent, so a few seconds to a few minutes (often up to 1-3 hours).

During catastrophic events and in the immediately following period of the brutal and unexpected aggression, the subject travel a particular psychopathological condition that consists of symptoms and sensory loss or consciousness modification, dissociative type, signaled by Predescu et al. the earthquake of 1977:feelings of calmness with detachment and lack of emotional reactivity in those moments, followed by a brief reduction or loss of consciousness and presence in the environment (derealisation feeling of living in a fog appearance in nebulous) impression of imminent death, reliving flash-back of important periods of life, or imaginary review of dissociative amnesia close people with anxiety over catastrophic event sequences during the process.

For the victims, this shock is experienced as intense brutal environmental change (destruction in seconds: fire, destroyed buildings), loss of time/space landmarks and often loss of soil stability underfoot.

According to DSM III and IV, in these momentsit is created the illusion of centrality in which the subject feels he is in the center of the disaster and the feeling of extreme vulnerability, without the aid in proximity.

L.Crocq (1992) emphasizes that these experiences happen with the collapse of invulnerability narcissistic belief that lived before the disaster.

There are reasons that don’t allow the recognition from the beginning of this phase, through the feeling that everything that happens in moments of acute shock as they travel experience apparently normal subjects many around him.

2. Response after a catastrophic factor

Following acute psychiatric state of shock it is the acute reaction described as a transient disorder occurring asˮ a person who has no other mental disorder shown and expressed as minutes from the traumatic experience, disappearing usually within hours or days (CIM F43.0).

At this stage the aggressive event is constantly relived through images, thoughts, dreams, illusions recollections-illusions, recurrent episodes containing anxiogenic flash-back or feelings of reliving the catastrophe.

These are intense reliving in children and adolescents and motivated by the mental peculiarities. After exposure to catastrophic events and remembering psychotraumatized situations, most children and young people benefit from evacuation thoughts, feelings and disaster film, others avoid remembering conversations and activities that evoke disaster.

This could be a component of defense mechanisms that are part of the psyche at a childhood and adolescence age.

In our interventions we take into account the fact that the victims have disturbances in their system of understanding and of social relations, so apparently they are unresponsive to the moral support that is offered from outside. So people involved in the First medical-psychological Aid (PAMP) must continue their efforts to achieve a post-disaster relief to sufferers.(19)

Status panic population

After ICD 10 F43.0, acute condition after disaster can be accomplished by moving from individual psyche (disorientation, feeling of impending death with tanatofobie, loss of decision, desperately seeking protection or a pattern of behavior)to the state of collective psyche, meaning that group or collective panic.(7)

This situation is felt simultaneously by all individuals of a community exposed to catastrophic superacute experience and mentalities and behaviors characterized by regressing to a level archaic and gregarious.

Events occurring in the state of panic population occur brutal, are dominated by anxiety, run, agitation and violence, aggression and even suicide. Sudden onset to a small group quickly spreads through contagion, imitation and gregarisme after the models initiators called „germ panic”.

In children, by Girard et al (1966) and Osada (1982), there is a dislocation of the individual consciousness extremely anxious background with altered perception, maximum suggestibility, emotional setback in infant attachment (requests for care as an infant) and anxiety separation. In pupils appear social retraction, run, stereotypes and oppositional and and in youth groups, attractiones to obscure behavior, violence and aggression, so that panic is dangerous for the subject and for others.

Mental contagion is one of the most constant symptoms of panic population, which we actually recorded in children and young patricipants to the Revolution of 1989 in Timisoara and repeated earthquakes Banloc area since 1991. (12)

There are states of acute short psychotic disorder that we found in young mild or moderate mental deficiency.

PTSD – Post Traumatic Stress Disorder

It is consisted of different psychopathological or prolonged response, with or without injury, which occurs in less than 6 months (from several weeks to several months) after exposure factor and can have catastrophic evolution subacute and chronic if symptoms continue beyond three months. The diagnosis is established if ideation and imaginary experiences from the psihotraumatic event resurface and return by invading flash-back memories through dreams and nightmares, lacunar amnesia sustainable context and emotional lability, anhedonia, social indifference and detachment, sleep disturbances.

Within PTSD dominates anxiety, may occur depression and suicidal ideation. There are associations with comorbid panic attacks, phobias, multiple forms of suffering psychosomatic. These disorders varies according to history of each child or adolescent, mostly being neurotic states.

In conclusion, we can say that disasters can induce acute and chronic psychopathological states, some of which may be more persistent, such as anxiety and seismofobia.

It is known and insists that a well-run coping strategy can greatly reduce the negative effects of disasters psychopathological states.

First Aid medical and psychological Earthquakes (PAMP)

The experience of the Centre for Neurology and Psychiatry Children and Adolescents in Timisoara

Between 12 July and 4 December 1991 in Timis County were two destructive earthquakes in this period were 202 aftershocks. Banloc earthquake zone is ranked as the second seismic zone of Romania, after Vrancea curvature of the Carpathian Mountains.

Mental sufferings and children’s behavioral in catastrophic situations began to be studied after the years 1950- 1960. There are very few materials that examines the repercussions catastrophic situations among human victims, and less about the suffering of children.

First aid measures in case of earthquake start with emegencies for injureds, seriously somatic injured and prevent side effects as physical pain, cold, heat, hypoxia and epidemics that may occur after disasters. For a long time human population that was not physically victimized in disasters was considered unaffected by any suffering, so they did not require a specific intervention. However, the alert situations hiperanxiety, sadness, consciousness disorders, blockage of thinking, sleep disorders and especially psycho-somatic determined studies followed by protective measures and medical and psychological first aid.

Our experience in the area of earthquakes in Banat, since 1991 and in the next 5 years, formed several landmarks in the first aid relations addressed to thesuffering population.

Postseismic distress managementi it is good to be well known to those skilled in the medical and psychological networks for children and adolescents. On the basis of measures that can be taken are the preventive ones: building earthquake, earthquake education for population- to be informed, prepared and trained for rational reactions and behaviors in earthquake, also defense measures and first aid intervention with staff and trained volunteers.

Our country is affiliated to the International Programme launched by the UN in 1991, to reduce the effects of natural disasters: IDNDR. National Program for antiseismic education of the population of Romania launched in 1992-1993 a set of materials entitled “to protect us in case of earthquake”. Psychosocial and educationa prevention plays a major role in the protection and minimizing the disasters consequences of disasters minimizing

A protective factor for psychological distress for states is postseismic stress is stress coping which fosters learning opportunity combined with genetic resistance to distress. After the earthquake, medical, psychological and therapeutic interventions vary according to the stage where specialists can reach the victims.

Medical-Psychological First Aid (PAMP) is required immediately after the earthquake and post-earthquake lag phase and during acute reactions in post-seismic distress. Specifically, the earthquakes in Banat, we were present with the team finding the same day of the earthquake, after four hours of the disaster. We found that there is restnessles in the population that suffered serious material losses and multiple states of panic group in schools and kindergartens. The first measure against anxiety was tackled with respect to the pain of children in the earthquake zone. The next day I was presented with the first brigade of Red Cross and pediatric neuropsychiatric specialists, psychologists, sociologists, personal environment with which we began to consult and implement key measures of our intervention:

A. Along with prime medical help for victims of physical injuries (wounds, fractures, crushing injuries body) began to distribute sedative and anxiolytic which applied in post-earthquake situation. It was obvious to spot that a measure of prime order was the conduct of medical treatment, psycho-pathological consequences being detectable such as Syndrome of disaster, which,after Duffy (1988), is the immediate psycho-pathological reactions in the first hours after the disaster, to more than 75% of the population.

At the same time, our psychologists have tested adults and children to quantify post-seismic anxiety.On the third day after the first earthquake I edited a newsletter distributed in large circulation in the 12 municipalities that suffered the highest intensity earthquake: Banloc, Livezile, Dolat, Ofseniţa, Soca, Partos, Ciacova, Obad, Gilead, Macedonia, Petroman, Voiteni and Deta.

In this newsletter I assured people that their situation is known as the whole country wants to help. This model I appreciated as a first step to calm people’s psycho-therapeutic calamity and loss of homes destroyed in the earthquake Annexes and scared for their future

The fourth day of the first shipment from the German Red Cross to support the population, with vaccines, drugs, especially anxiolytics: we used for the first time 600 boxes Xanax-Alprazolam (which had not reached in our pharmacies). The population immediately understud the anxiolytic medication benefit and purpose, so sedatives were required by many families, including children and adolescents. Depending on the disorders detected by our brigades (tachycardia, hypertension, abdominal pain, difficulty breathing, joint and muscle pain etc.), we requested from the Danish Red Cross and Romanian Red Cross group support other drugs: Propranolol, Extraveral, sleeping pills, hypotensives, antispasmodic, anti-inflammatory.

The next day we returned with other medical brigades in these localities- from Timişoara we always came from with two buses with medical personnel who frequent treated fever in children due to capacity immunological decreasing, digestive disorders, headaches etc.

The Romanian Red Cross president arrived from Bucharest, bringing funds and antibiotics, vaccines, sedatives, tents with large capacity and material features specific interventions in disaster CRR.

Important to note is the strategy then, to take into account the protection of the brigade support staff I worked with colleagues in Timişoara and medical personnel in the affected localities: Each participant was instructed about possible psychopathological states of earthquakes and worked only outside buildings (courts, parks, open spaces) as prevention in case of possible aftershocks of earthquakes. One day, being in Ofseniţa, surprised us such a reply, strong enough, a state of shock felt particularly knee joints and viscera. A colleague who felt these unknown disturbance suddenly started running down the street to depart the building.

B. After or concurrent medical intervention psychological help (PAP) insals. Knowing that natural catastrophic events trained human presence is necessary for psychological aid, we offered our presence through newsletters, through consultations, advice and explanations for professionals through training of local Red Cross volunteers, through many conversations and important insurance purpose of calming and prevention of posttraumatic stress disorder (PTSD). With all these measures, we urgently intervene in the winter of 1991 in December 4, when there was still a destructive earthquake in Voiteni. Arriving on the same day in this town, I found many homes destroyed in a cold day o-5 C and many people were on the streets and risked to the effects of cold (freezing, frost, infections).

Some “treated with self-medication” (alcohol) wich they offered the children also. I asked as a major emergency a heated coach train and in the honor of CFR Timisoara Department, 28 CFR Timişoara coachesarrived just prepared for a warmer night. So to the onset of darkness, at 17 h, we managed, with the mayor”s help we managed to lead with the heated train thefamilies whose homes were destroyed by the earthquake (eventhough many did not accept to separate from their fallen houses and their wealth).

We found that, in common cases, parents and relatives may not be useful inPAP interventions, so the protector and psychotherapist role should be taken by a trained (caregiver) trained. Psychotherapeutic intervention is difficult to catastrophic syndrome children because you have to cover the three requirements that can be implemented in at least 2-3 days and the current in 7-8 days: the first is that of achieving catharsis for victims by listening to reports suffered by children and accept their feelings narrative account rendered detail.

The second psychotherapeutic approach is to offer support in this situation and ensure that the situation’s record (their) of victims is known that many people are with them and will support the next. Child victims ask insistently to be sure that they will not be separated from family and will not be evicted from their locality. This separation anxiety relief must be repeated several times and the situation asks hospitalization or epidemiological securityof returning to thefamily have to be supported by all the adults around them.

The third PAP stage is set depending on the return to a more approchable state activity, eich it is often achieved with the sedative andanxiolytic medication help. This step means small family group meetings or school classes and consists of psychotherapy group sessions. They will start with problems and games- poems, songs but also general discussions about the measures and methods of self-defense as game, in case of repeated earthquakes. It is important for children to know to place themselves under benches, tables and more important to use protective triangle around large furniture. Avoid runing up the stairs or positions of the door frame.

In terms of disasters, repeated earthquakes, as Banloc area where there have been 202 aftershocks, emotional control capacity decreases, children and adolescents living sneaky feelings anxiaty and depression disturb their existence.

On this background through contagion and other psychiatric symptoms easily inoculate . In these situations mystical, tanatological, suicidal and migration to other quiet areas ideation dominate.

Children and adolescents with mental or motor disabilities support very difficult the catastrophe syndrome, showing extensive mental states as paroxysms of anxiety and panic attacks, distressing lack of inhibition with intense emotional tension and often noisy. Those assets are exposed to injuries (fractures, tears in muscle or visceral, head trauma, etc.).

In the OMS materials H.Katsching, T. Konieczna and JE Cooper (1993) describe in 17 European countries the existence of the specialized psychiatric emergency services in crisis interventions, accidents, disasters (earthquakes, floods, fires, etc.) with two segments: prehospital and intraclinic.

It appears that the management of disasters and psychotrauma distress from disasters and can be endorsed by the design of the two control methods:

  • by reducing the sources of suffering
  • by controlling the physiological and emotional reactions by learning techniques notto react to each agent by anxiety and hostility
  • by controlling behavioral reactions so not to initiate inappropriate behaviors (run, anxiety, passivity, aggression etc.)
  • by supremacy controlling of states, meaning to obtainin patterns that do not react by unrealistic negative thoughts.

These requirements can be achieved through games, stories, short puppet shows and dance music etc.

In children and youth in development the reversibility in psycho-pathological phenomena is not detectable, but we can get a good compensation of mental disorders, which in evolution may withdraw or in time.

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