Psychiatric Impacts of Disasters and Trauma
"Research has shown that about 40% of Americans
will be exposed to a traumatic event in their lifetimes..."
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An article in the March 28, 2002 issue of the New England Journal of Medicine found that
about 37% of New Yorkers who lived near the World Trade Center are suffering from post
traumatic stress disorder (PTSD) or depression, and about 17% of New Yorkers are suffering
from one of these disorders.
This issue discusses the short-term and long-term effects of trauma on the general
population. Although most persons exposed to a disaster will have mild, transitory symptoms,
some individuals will develop psychiatric disorders. The extent of psychiatric injury
depends on a number of factors, including:
- the type, size and severity of disaster (the larger and more severe, the more likely
there will be a psychiatric disorder resulting);
- whether a person has previously had a psychiatric disorder (the more severe the
disaster, the less important this factor becomes);
- whether the person was physically injured and how severely (the greater the injury,
the more likely a psychiatric illness will also arise, especially if there was a head
injury);
- death of or severe injury to loved ones, especially if the person witnessed it or if
the loved one lost is a child;
- the severity and duration of community disruption;
- whether it is natural or human caused (human caused, including airplane crashes,
terrorist acts and industrial accidents are usually more traumatic);
- the person's exposure to the dead or mutilated;
- secondary stressors, such as negotiations with insurance companies for reimbursement,
or unemployment secondary to destroyed businesses; &
- family and support systems available.
Those at greatest risk include rescue workers, hospital personnel, the persons injured,
children, heroes, and those who must handle the personal effects of the deceased. Heroes
suffer because they are idealized and expected to bring hope and courage to others, &
not allowed to express their own anger, sadness, worry, and fear.
Research has shown that about 40% of Americans will be exposed to a traumatic event in
their lifetimes, and that 6 to 7% of the U.S. population is exposed to a disaster or trauma
each year, ranging from motor vehicle accidents and crime to hurricanes and earthquakes.
Human Response to Disaster
Psychological responses to disaster frequently have a predictable structure and time course.
For most persons, psychiatric symptoms are transitory. For some, however, the effects linger
long after its occurrence. For example, a small earth tremor can rekindle the horror of an
earthquake. As we have witnessed, traumas can have positive effects, such as causing persons
to reprioritize their lives in a healthy way. For others, numerous psychiatric and other
illnesses can result, the most likely of which are:
- Organic mental disorders secondary to head injury, toxic exposure, illness, and
dehydration
- Acute stress disorder (ASD)
- Post traumatic stress disorder (PTSD)
- Depression
- Anxiety disorders
- Substance abuse
Many persons will also have to cope with anger and grief, other painful normal responses
to an abnormal event, which, if left unaddressed, can lead to family violence.
Phases of Response
Researchers have identified four general phases of human response to disasters:
- Immediately following a disaster, there are strong emotions, disbelief, numbness,
fear, and confusion. People tend to cooperate, and heroic deeds are seen. These
reactions are "normal responses to an abnormal event."
- From a week to several months after the disaster, assistance flows in from outside the
community, and the cleanup/rebuilding process begins. This is often accompanied by an
increase in visits to physicians for complaints of somatic symptoms such as fatigue,
dizziness, headaches, and nausea. Irritability, apathy, and social withdrawal are signs
that recovery may be at risk.
- Up to a year after the event, people often experience disappointment and resentment
when expectations of aid and restoration are not met. The strong sense of community may
weaken.
- Reconstruction, which may last for years, as survivors gradually rebuild their lives.
Acute Stress Disorder (ASD) & Post Traumatic Stress Disorder (PTSD)
ASD
and PTSD are similar. ASD symptoms usually begin within 4 weeks of a traumatic event and
last between 2 days and 4 weeks. It involves symptoms that are greater than the normal
response. PTSD generally appears more than 4 weeks after the event and may persist for
years. Typical symptoms include:
- intrusive thoughts (flashbacks that evoke painful emotions and often make the person
feel he/she is reliving the trauma, nightmares);
- avoidance (inability to feel emotions or develop close emotional ties, and avoiding
situations that remind the person of the original trauma);
- hyperarousal (feeling constantly threatened by the trauma, resulting in irritability,
explosiveness, insomnia).
Persons with PTSD are at increased risk of suicide and substance abuse.
Depression & Other Disorders
Major depression and substance abuse are frequently found, either independently or jointly
with PTSD. Some indications that a person is depressed include persistent feelings of
sadness or anxiety or loss of interest or pleasure in usual activities in addition to five
or more of the following:
- changes in appetite,
- insomnia, fatigue,
- restlessness or irritability,
- feelings of worthlessness or inappropriate guilt,
- difficulty thinking, concentrating, or making decisions, and
- thoughts of death or suicide or attempts at suicide
Over time, if resources remain limited and employment and financial resources are scarce,
family violence can arise.
Post disaster chronic sleep disturbances are common clinical problems that may require
treatment. Sleep difficulties can be due to anxiety related to recurrent disaster events
(e.g., aftershocks) or to underlying psychiatric disease such as depression or PTSD.
All of these problems are likely to place significant stress on primary care, emergency,
and mental health systems and providers for months after the disaster.
Treatment
Most of these psychiatric disorders will require treatment with some combination of
medication and psychotherapy.
Biological treatments that specifically alter the anxiety response include several of the
selective serotonin reuptake inhibitors such as Prozac, Zoloft and Paxil. Tranquilizers and
sleeping agents may be used for short periods, generally not more than 2 weeks, if
necessary.
Psychotherapies that penetrate rapidly to the feeling level and take into account the
biology are often highly effective. Patients also usually respond well to education
concerning the link between their emotional responses and the biological changes in their
brains.
Sources: Ursano, et. al., Psychiatric Dimensions of Disaster: Patient Care,
Community Consultation, and Preventive Medicine, and sources cited therein; New England
Journal of Medicine, Vol. 346, No. 13, March 28, 2002.
Useful websites: American
Psychiatric Association,
Disaster mental health services
program of the U.S. Department of Health and Human Services,
National Center for PTSD, a consortium of
Veterans' Administration centers across the nation,
Federal Emergency Management Agency
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