Disaster Plans Should Include Those with Mental Illness

Disaster Plans Should Include Those with Mental IllnessWhen disaster strikes — whether a deadly supercell tornado, a flood, or man-made catastrophe — it is not just those with physical injuries and trauma-related disorders who suffer. Johns Hopkins University researchers say more attention should be devoted to triaging and managing those identified as having mental disorders. In a commentary appearing in the June issue of the journal Biosecurity and Bioterrorism, Peter Rabins, M.D., M.P.H., said, “Disasters limit the availability of resources, and these groups are especially vulnerable because they cannot advocate for themselves. “But little attention has been given to the ethical challenges that arise when resources are limited, to the importance of identifying these ethical issues ahead of time, and for establishing mechanisms to address these moral dilemmas.” The researchers said disaster-response planning has generally overlooked the special needs of people who suffer from pre-existing and serious mental conditions. Disaster survivors can include those diagnosed with conditions such as schizophrenia, dementia, addictions and bipolar disorder. In the article, Rabins and Nancy Kass, Sc.D., said many of the mentally ill are dependent on caretakers and aren’t fully capable of making sound decisions on their own. Emergency planners are ethically obligated to ensure that immediate and adequate mental health services are provided alongside more traditional triage. “Disaster-response managers and those on the front line are well aware that survivors may succumb to PTSD and other mental disorders,” said Rabins. “But sudden devastation also puts people with both lifelong and acquired intellectual disabilities in grave danger as well.” One study the authors cited found that 22 percent of Hurricane Katrina survivors who had pre-existing mental disorders faced limited or terminated treatment after the disaster. Beyond patients with dementia and others who are mentally impaired, the authors say that this vulnerable group includes those who suffer from chronic pain and may be dependent on opiates, as well as substance abusers who receive treatment in the form of powerful sedatives classified as benzodiazepines. Withdrawal from these medications can be life threatening, the authors noted. As a first step, the authors recommend that disaster-response planners proactively identify and anticipate what needs might arise by meeting with clinicians and public health officials. Those discussions would then guide comprehensive advance planning. As licensed professionals are often unavailable (because of demand) immediately after a disaster, planners should consider training emergency medical technicians (EMTs) and other first-responders to identify those with pre-existing mental conditions and recognize those in need of prompt attention. The training should include volunteers from the community, such as religious leaders and trained civilians, to distribute basic materials and temporary services to at-risk individuals. In an effort to reduce adverse outcomes, the researchers advise that secondary prevention measures may take priority. This action could be in the form of EMTs distributing sedatives to manage short-term anxiety-related symptoms. But the authors say that policies would need to be developed to expand the list of those authorized to prescribe such drugs, as they are at present strictly regulated by federal law. The authors note that sedatives were distributed in New York City immediately after the Sept. 11, 2001, terrorist attacks. They also recommend that planners focus on ethical challenges likely to arise when assisting the mentally disabled during and after a disaster. These challenges may be partially addressed by adopting a “crisis standard of care” consistent with guidelines from the Institute of Medicine. Special attention should be given to assisted-living and long-term care facilities that house many residents with significant cognitive impairment, such as dementia. If these people are forced to evacuate, they may not fully comprehend the crisis and may be at risk for extreme emotional distress. Hence, disaster-preparedness training for first-responders should also include information about how to interact with such individuals in a way that respects their dignity, the authors said. Source: Johns Hopkins Medical Institutions

Obsessive Fears Arise in Response to Compulsions in OCD

Obsessive Fears Arise in Response to Compulsions in OCDThe chicken-and-egg question regarding obsessive-compulsive disorder (OCD), for the most part, is usually answered by identifying obsessive fears as driving the behaviors such as repetitive hand-washing. A new study effectively reverses the order, finding that the repetitive behaviors themselves (the compulsions) might be the precursors to the disorder, and that obsessions may simply be the brain’s way of justifying these behaviors. New research suggests performance of repetitive behaviors may lead to obsessive-compulsive disorder (OCD). This interpretation goes against popular beliefs that behaviors  found that in the case of OCD the behaviors themselves (the compulsions) might be the precursors to the disorder, and that obsessions may simply be the brain’s way of justifying these behaviors. The study, conducted at the University of Cambridge and the University of Amsterdam, provides important insight into how the debilitating repetitive behavior of OCD develops and could lead to more effective treatments and preventative measures for the disorder. Funded by the Wellcome Trust and published in the American Journal of Psychiatry, the study tested 20 patients suffering from the disorder and 20 control subjects (without OCD) on a task which looked at the tendency to develop habit-like behavior. Subjects were required to learn simple associations between stimuli, behaviors and outcomes in order to win points on a task. The team, led by Claire Gillan and Trevor Robbins at the University of Cambridge MRC/Wellcome Trust Behavioral and Clinical Neuroscience Institute and Sanne de Wit at the University of Amsterdam, found that patients suffering from the disorder had a tendency to continue to respond regardless of whether or not their behavior produced a desirable outcome. In other words, this behavior was habitual. The discovery that compulsive behavior – the irresistible urge to perform a task – can be observed in the laboratory, in the absence of any related obsessions, suggests that compulsions may be the critical feature of OCD. This finding is consistent with the recognition that cognitive behavioral therapy (CBT) is one of the most effective treatment for OCD. In this therapy, patients are challenged to stop compulsive responding, and learn that the feared consequence does not occur, whether or not the behavior is performed. The effectiveness of this treatment is compatible with the idea that compulsions, and not obsessions, are critical in OCD. Once the compulsion is stopped, the obsession tends to fade away. “It has long been established that humans have a tendency to ‘fill in the gaps’ when it comes to behavior that cannot otherwise be logically explained,” said Claire Gillan, a Ph.D. student at the University of Cambridge. “In the case of OCD, the overwhelming urge to senselessly repeat a behavior might be enough to instill a very real obsessive fear in order to explain it.” Source: University of Cambridge
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