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Normal Reactions to an Abnormal Situation
It is important to help survivors recognize the normalcy
of most stress reactions to disaster. Mild to moderate
stress reactions in the emergency and early post-impact
phases of disaster are highly prevalent because survivors
(and their families, community members and rescue workers)
accurately recognize the grave danger in disaster (Young
et al., 1998). Although stress reactions may seem 'extreme',
and cause distress, they generally do not become chronic
problems. Most people recover fully from even moderate
stress reactions within 6 to 16 months (Baum & Fleming,
1993; Green et al., 1994; La Greca et al., 1996; Steinglass
& Gerrity, 1990). (From Disaster Mental Health Response
Handbook, NSW Health, 2000, p. 27.)
In fact, resilience is probably the most common observation
after all disasters. In addition, the effects of traumatic
events are not always bad. Although many survivors of
the 1974 tornado in Xenia, Ohio, experienced psychological
distress, the majority described positive outcomes: they
learned that they could handle crises effectively, and
felt that they were better off for having met this type
of challenge (Quarantelli, 1985). Disaster may also bring
a community closer together or reorient an individual
to new priorities, goals or values. This concept has been
referred to as 'posttraumatic growth' by some authors
(e.g., Calhoun, 2000), and is similar to the 'benefited
response' reported in the combat trauma literature (Ursano
et al., 1996). (From Disaster Mental Health Response Handbook,
p. 27.)
There are a number of possible reactions to a traumatic
situation that are considered within the norm for individuals
experiencing traumatic stress.
Common Traumatic Stress Reactions (modified from
Disaster Mental Health Response Handbook, p. 28)
Emotional Effects
•shock
•terror
•irritability
•blame
•anger
•guilt
•grief or sadness
•emotional numbing
•helplessness
•loss of pleasure derived from familiar activities
•difficulty feeling happy
•difficulty experiencing loving feelings
Cognitive Effects
•impaired concentration
•impaired decision making ability
•memory impairment
•disbelief
•confusion
•nightmares
•decreased self-esteem
•decreased self-efficacy
•self-blame
•intrusive thoughts/memories
•worry
•dissociation (e.g., tunnel vision, dreamlike or
"spacey" feeling)
Physical Effects
•fatigue, exhaustion
•insomnia
•cardiovascular strain
•startle response
•hyper-arousal
•increased physical pain
•reduced immune response
•headaches
•gastrointestinal upset
•decreased appetite
•decreased libido
•vulnerability to illness
Interpersonal Effects
•increased relational conflict
•social withdrawal
•reduced relational intimacy
•alienation
•impaired work performance
•impaired school performance
•decreased satisfaction
•distrust
•externalization of blame
•externalization of vulnerability
•feeling abandoned/rejected
•overprotectiveness
Although many of the above reactions seem negative, it
must be emphasized that people also show a number of positive
responses in the aftermath of disaster. These include
resilience and coping, altruism, e.g., helping save or
comfort others, relief and elation at surviving disaster,
sense of excitement and greater self-worth, changes in
the way they view the future, and feelings of "learning
about one's strengths" and "growing" from
the experience (Disaster Mental Health Response Handbook,
p. 28).
Problematic Stress Responses
The following responses are less common and indicate
that the individual will likely need assistance from a
medical or mental-health professional:
•Severe dissociation (feeling as if
the world is unreal, not feeling connected to one's own
body, losing one's sense of identity or taking on a new
identity, amnesia)
•Severe intrusive re-experiencing (flashbacks, terrifying
screen memories or nightmares, repetitive automatic reenactment)
•Extreme avoidance (agoraphobic-like social or vocational
withdrawal, compulsive avoidance)
•Severe hyper-arousal (panic episodes, terrifying
nightmares, difficulty controlling violent impulses, inability
to concentrate)
•Debilitating anxiety (ruminative worry, severe
phobias, unshakeable obsessions, paralyzing nervousness,
fear of losing control/going crazy)
•Severe depression (lack of pleasure in life, feelings
of worthlessness, self-blame, dependency, early wakenings)
•Problematic substance use (abuse or dependency,
self-medication)
•Psychotic symptoms (delusions, hallucinations,
bizarre thoughts or images)
Some people will be more affected by a traumatic event
for a longer period of time than others, depending on
the nature of the event and the nature of the individual
who experienced the event. One of the most debilitating
effects of traumatic stress is a condition known as Posttraumatic
Stress Disorder (PTSD). The current trauma literature
suggests that many factors are related to the increased
or decreased risk for PTSD. The likelihood of developing
PTSD and the severity and chronicity of symptoms experienced
is a function of many variables, the most important being
exposure to a traumatic event. It is therefore important
to bear in mind that, even among vulnerable individuals,
PTSD would not exist without exposure to a traumatic event.
Symptoms of PTSD
Posttraumatic Stress Disorder (PTSD) is a mental disorder
resulting from exposure to an extreme, traumatic stressor.
PTSD has a number of unique defining features and diagnostic
criteria, as published in the American Psychiatric Association's
Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV, 1994). These criteria include:
•Exposure to a traumatic stressor
•Re-experiencing symptoms
•Avoidance and numbing symptoms
•Symptoms of increased arousal
•Duration of at least one month
•Significant distress or impairment of functioning
Exposure to a traumatic stressor (Criterion
A)
To be diagnosed with PTSD, the person must have been
exposed to a traumatic event in which both of the following
were present:
the person experienced, witnessed, or was confronted
with an event or events that involved actual or threatened
death or serious injury or a threat to the physical integrity
of self or others; and
the person's response to the trauma involved intense
fear, helplessness, or horror. (In children, this may
be expressed by disorganized or agitated behavior.)
Stressful events of daily life that do not meet these
conditions include divorce and financial crises, which
may lead to adjustment problems but are not sufficient
to satisfy the criterion for a traumatic event (i.e.,
Criterion A) for PTSD.
Qualifying stressors must induce an intense emotional
response. According to DSM-IV, a qualifying stressor must
not only be threatening, but it must also induce a response
involving intense fear, helplessness, or horror. Some
severely traumatized individuals may dissociate during
a stressor or have a blunted response due to defensive
avoidance and numbing. Often, the intense emotional response
to the stressor may not occur until considerable time
has elapsed after the incident has terminated.
Re-experiencing symptoms
One set of PTSD symptoms involves persistent and distressing
re-experiencing of the traumatic event in one or more
ways. With these symptoms, the trauma comes back to the
PTSD sufferer through memories, dreams, or distress in
response to reminders of the trauma. An extreme example
of this is flashbacks, where individuals feel as if they
are reliving the traumatic experience. This is a severe,
less common re-experiencing symptom. PTSD is distinguished
from normal remembering of past events by the fact that
re-experiencing memories of the trauma(s) are unwanted,
occur involuntarily, elicit distressing emotions, and
disrupt the individual‰s functioning and quality
of life.
Avoidance and numbing symptoms
Another set of PTSD symptoms involves the numbing of
general responsiveness and the persistent avoidance of
stimuli associated with the trauma. These symptoms involve
avoiding reminders of the trauma. Reminders can be internal
cues, such as thoughts or feelings about the trauma, and
external stimuli in the environment that spark unpleasant
memories and feelings. To this limited extent, PTSD is
not unlike a phobia, where the individual goes to considerable
length to avoid stimuli that provoke emotional distress.
PTSD symptoms also involve general symptoms of impairment,
such as pervasive emotional numbness, feeling out of sync
with others, and not expecting future goals to be met.
Symptoms of increased arousal
Symptoms of increased arousal include difficulty falling
or staying asleep, irritability or outbursts of anger,
difficulty concentrating, hyper-vigilant watchfulness,
and an exaggerated startle response. Individuals suffering
from PTSD experience heightened physiological activation,
which may occur in a general way even while at rest. More
typically, this activation is evident as excessive reactions
to specific stressors that are directly or symbolically
reminiscent of the trauma. This set of symptoms is often
linked to reliving the traumatic event. For example, sleep
disturbance may be caused by nightmares, intrusive memories
may interfere with concentration, and excessive watchfulness
may reflect concerns about preventing the occurrence of
a traumatic event similar to the previous trauma.
Required duration of symptoms
For a diagnosis of PTSD to be made, the symptoms must
endure for at least one month.
PTSD symptoms must be clinically significant
PTSD symptoms must cause clinically significant distress
or impairment in social, occupational, or other important
areas of functioning. Some individuals may experience
a great deal of subjective discomfort and suffering owing
to their PTSD symptoms without displaying conspicuous
impairment in their day-to-day functioning. Other individuals
show clear impairment in one or more spheres of functioning,
such as social relating, work efficiency, or ability to
engage in and enjoy recreational or leisure activities.
Symptoms of Acute Stress Disorder (ASD)
For some trauma survivors, acute stress reactions are
severe enough to meet DSM-IV criteria for Acute Stress
Disorder (ASD). A growing body of evidence suggests that
there are specific stress symptoms that may occur almost
immediately following a traumatic event that may predict
the development of PTSD (see review by Koopman, Classen,
Cardena & Spiegel, 1995). The observation of acute
stress reactions in these and other studies of natural
and human-caused disasters led to the formation of the
Acute Stress Disorder (ASD) diagnosis in the Diagnostic
and Statistical Manual, Fourth Edition. Acute Stress Disorder
is conceptually similar to PTSD and shares many of the
same symptoms. Diagnostic criteria include dissociative
(emotional numbness, feeling "unreal" or disconnected
from emotions or the environment), intrusive, avoidance,
and arousal symptoms. To meet a diagnosis of ASD, symptoms
must occur between 2 days and 4 weeks after a traumatic
experience.After 4 weeks, a PTSD diagnosis should be considered
(Bryant & Harvey, 1997).
Who develops Acute Stress Disorder and Posttraumatic
Stress Disorder?
The percentage of those exposed to traumatic stressors
who then develop Posttraumatic Stress Disorder (PTSD)
can vary depending on the nature of the trauma. At the
time of a traumatic event, many people feel overwhelmed
with fear; others feel numb or disconnected. Most trauma
survivors will be upset for several weeks following an
event but will recover to a variable degree without treatment.
The percentage of trauma victims that will continue to
have problems and develop Posttraumatic Stress Disorder
will depend on many factors, including the severity of
trauma exposure.
In research on disasters, prevalence rates have
been:
Natural disaster 4-5%
Bombing 34%
Plane crash into hotel 29%
Mass shooting 28%
The following types of exposure place survivors
at high risk for a range of postdisaster problems:
Exposure to mass destruction or death
Toxic contamination
Sudden or violent death of a loved one
Loss of home or community
The rates of Acute Stress Disorder (as cited
in Bryant, 2000) following traumatic incidents vary, with
higher rates reported for human-caused trauma.
Typhoon 7%
Industrial accident 6%
Mass shooting 33%
Violent assault 19%
MVA 14%
Assault, burn, indust. 13%
Given that an individual must be exposed to a traumatic
event in order to develop PTSD, other risk factors that
have been shown to contribute to the development of PTSD
include magnitude, duration, and type of traumatic exposure.
Variables such as earlier age when exposed to the trauma
and a lower level of education are also associated with
increased risk for developing PTSD. Additional factors
related to vulnerability for developing PTSD include:
severity of initial reaction; peri-traumatic dissociation
(i.e., feeling numb and having a sense of unreality during
and shortly following a trauma); early conduct problems;
childhood adversity; family history of psychiatric disorder;
poor social support after a trauma; and personality traits
such as hypersensitivity, pessimism, and negative reactions
to stressors. Women are more likely to develop PTSD than
men, independent of exposure type and level of stressor,
and a history of depression in women increases the vulnerability
for developing PTSD (Kessler, Sonnega, Bromet, Hughes,
& Nelson, 1995; Breslau, 1990; Kulka et al., 1990).
While exposure to a traumatic event may result in an increased
vulnerability to subsequent traumas, several studies have
also reported that exposure to trauma can have a ‹stress
inoculation effect and can strengthen an individuals protective
factors. This is because the individual has gained experience
in successfully mastering traumatic events (Ursano, Grieger,
& McCarroll, 1996).
Several factors present in the acute-phase recovery environment
of a disaster have been found to aggravate stress reactions
and therefore increase survivors' risk of developing negative
outcomes (Emergency Management Australia, 1999). (From
Disaster Mental Health Response Handbook, p. 36). These
include:
•Lack of emotional and social support
•Presence of other stressors such as fatigue, cold,
hunger, fear, uncertainty, loss, dislocation, and other
psychologically stressful experiences
•Difficulties at the scene
•Lack of information about the nature and reasons
for the event
•Lack of, or interference with, self-determination
and self-management
•Treatment [given] in an authoritarian or impersonal
manner
•Lack of follow-up support in the weeks following
the exposure
Protective factors that may mitigate negative effects
include:
•Social support
•Higher income and education
•Successful mastery of past disasters and traumatic
events
•Limitation or reduction of exposure to any of the
aggravating factors listed above
•Provision of information about expectations and
availability of recovery services
•Care, concern and understanding on the part of
the recovery services personnel
•Provision of regular and appropriate information
concerning the emergency and reasons for action
Finally, community-related mediators that may help alleviate
distress are rapid disaster relief and a positive community
response that does not single out certain survivors as
victims (Solomon et al., 1993).
Studies show that while there is no singular pattern
of psychological consequences to disasters, typically
the very early responses following disaster impact will
be similar for both natural and human-made disasters (Burkle,
1996). However, the persistence of responses may differentiate
the two. The effects of natural disasters seem no longer
detectable in comparison to control populations after
about two years, whereas several studies have shown that
the effects of human-made events may be much more prolonged
(Green & Lindy, 1994) (From Disaster Mental Health
Response Handbook, p. 44). The degree of death, destruction,
horror, inescapability, shock, loss and dislocation will
still be influencing factors in determining pathological
outcomes for both types of disasters, but these may be
more marked in many human-made disasters. Furthermore,
the element of human contribution to the disaster, particularly
human malevolence, is likely to add to the complexities
and difficulties of psychological adjustment, thus leading
to more adverse mental health effects (From Disaster Mental
Health Response Handbook, p. 45).
Associated Disorders
In addition to PTSD and ASD, individuals who have experienced
trauma are at heightened risk for developing other psychiatric
disorders, including:
•Depression
•Substance abuse
•Panic Disorder
•Obsessive-Compulsive Disorder
•Sexual dysfunction
•Eating disorders
Bereavement and bereavement complications
(From Disaster Mental Health Response Handbook, pp.
41-43).
In situations of traumatic or catastrophic loss the bereaved
person may demonstrate both traumatic stress reaction
phenomena and bereavement phenomena, with either predominating
or appearing intermittently (Raphael, 1997). Although
a discussion of loss usually focuses upon death, loss
that results from postdisaster experience may thus include
(Cohen, 1998):
•Loss by death of loved one, family, or friend
•Property destruction
•Sudden unemployment
•Impaired physical, social, or psychological capacities
and processes
It is generally agreed that there may be an initial
and usually brief period of shock, numbness and disbelief,
and to a degree, denial. While this period may be more
prolonged if there is the additional impact of psychological
trauma (see below), it is usually brief. This initial
period usually gives way to intense separation distress
or anxiety. The bereaved person is highly aroused, seeking
for or scanning the environment for the lost person on
higher alert. There may be searching behaviors, particularly
if it is not certain that the person is dead, or the body
has not been identified. In a disaster setting the bereaved
person may place himself or herself at further risk through
agitated searching behaviors. There is also likely to
be a sense of anger, protest and abandonment anger that
may be recognized as irrational by the bereaved person
but nevertheless amounts to anger towards the deceased
for not being there and for being among those who died.
Anger is also directed towards those who may be seen as
having caused or been associated with the death, who are
alive when the deceased is not.
These reactions progressively abate and give way to a
mourning dimension where the bereaved person is focused
more on the psychological bonds with the dead person,
the memories of the relationship, painful reminders of
the absence of the person, and progressively accepting
the death, although with ongoing feelings of sadness or
loss. These latter reactions are more likely to appear
during the recovery phase with progressive attenuation
as the bereaved person adapts to life without the person
who has died. These complex emotions of anxiety, protest,
distress, sadness and anger are usually referred to as
grief. The acute distress phase usually settles in the
early few weeks or months after the loss, but emotions
and preoccupations may occur over the first year or years
that follow.
Normal bereavement shows both attenuation of psychological
distress and progressive functional adaptation during
the first few months. Complications may include adverse
mental health outcomes such as impact on immune function
(Bartrop et al., 1977), development of depressive or anxiety
disorders, and adverse social or health effects (Byrne
& Raphael, 1994; Middleton et al., 1998). In addition,
it has been shown that about 9% of a normal community
sample of bereaved people may develop 'chronic grief.
' This is a form of abnormal grief where the initial acute
distress continues with other manifestations for six months
or more, and often for many years. 'Traumatic grief' and
complicated grief disorder are similar forms (Raphael
& Minkov, 1999).
Risk factors for complications of bereavement have been
identified by a number of researchers (Parkes & Weiss,
1983; Raphael, 1977; Raphael & Minkov, 1999; Vachon
et al., 1980). These include:
•Perceived lack of social support
•Other concurrent crises or stressors
•High levels of ambivalence in relation to the deceased
•An extremely dependent relationship
•Circumstances of death which are unexpected, untimely,
sudden or shocking
Personality vulnerabilities and a past history of losses
may also contribute. Thus it is clear that many circumstances
of disaster deaths may be likely to lead to higher risk
of bereavement complications. It has also been shown that
inability to see the body of the dead person may further
contribute to risk of adverse outcomes (Singh & Raphael,
1981), perhaps disrupting opportunities for farewell (Schut
et al., 1991). In this context the concept of traumatic
bereavement is highly relevant.
Studies of traumatic bereavement have identified traumatic
circumstances of the death as a risk factor for adverse
mental health outcome (Raphael, 1977; Parkes & Weiss,
1983). Lundin's (1984) studies of sudden and unexpected
bereavement found increased morbidity compared with those
where bereavement was expected. Unexpected loss resulted
in more pronounced psychiatric symptoms, especially anxiety,
which was more difficult to resolve. The phenomena identified
at long-term follow-up included high levels of numbing
and avoidance and could be interpreted as reflecting traumatic
stress effects. Lehman et al. (1987) studied bereavement
after motor vehicle accidents, likely to involve traumatic
and unexpected losses, especially when the bereaved had
been an occupant of the vehicle and thus involved in and
potentially traumatized by the accident. Even 4 to 7 years
later, spouses showed significantly higher levels of phobic
anxiety, general anxiety, somatization, interpersonal
sensitivity, obsessive-compulsive symptoms and poorer
well-being. For more than 90% of participants, memories,
thoughts or mental pictures of the deceased intruded into
the mind frequently, and for more than half of these they
were 'hurt or pained' by these memories. These phenomena
did not appear to be the sad, nostalgic memories of someone
who has recovered from a loss, but were more like the
intrusive re-experiencing of posttraumatic memories.
Copies of the Disaster Mental Health Response
Handbook are available from:
The NSW Institute of Psychiatry
Telephone: (02) 9840 3833
Fax: (02) 9840 3838
Email: inspsy@magna.com.au
Website: www.nswiop.nsw.edu.au
References
(Any references cited in the text and not given here
are from the Disaster Mental Health Response Handbook.)
Breslau, Naomi. (1990). Stressors: Continuous and discontinuous.
Journal of Applied Social Psychology, 20(20),
1666-1673.
Bryant, R.A. (2000). Acute Stress Disorder. PTSD
Research Quarterly, 11(2), 1-7.
Bryant, R.A. & Harvey, A.G. (1997). Acute Stress
Disorder: A critical review of diagnostic issues. Clinical
Psychology Review, 17, 757-773.
Kessler, R.C., Sonnega, A., Bromet, E.J., Hughes, M.,
& Nelson, C.B. (1995). Posttraumatic Stress Disorder
in the National Comorbidity Survey. Archives of General
Psychiatry, 52(12), 1048-1060.
Koopman, C., Classen, C.C., Cardena, E., & Spiegel,
D. (1995). When disaster strikes, Acute Stress Disorder
may follow. Journal of Traumatic Stress, 8(1),
29-46.
Kulka, R.A., Schlenger, W.E., Fairbank, J.A., Hough,
R.L., Jordan, B.K., Marmar, C.R., et al. (1990). Trauma
and the Vietnam War generation: Report of findings from
the National Vietnam Veterans Readjustment Study.
New York: Brunner/Mazel.
NSW Institute of Psychiatry and Centre for Mental Health.
(2000). Disaster Mental Health Response Handbook.
North Sydney: NSW Health.
Ursano, R.J., Grieger, T.A., & McCarroll, J.E. (1996).
Prevention of posttraumatic stress: Consultation, training,
and early treatment. In B. A. Van der Kolk, A.C. McFarlane,
& L. Weisaeth (Eds.), Traumatic stress: The effects
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(pp. 441-462). New York: Guilford Press.
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