Psychological aftermath of disaster… How do we respond?

Dr. Jozelle Miller

Health Psychologist

In the aftermath of a major disaster, psychological repair is just as paramount as are the social and economic efforts to restore infrastructure and normalcy. The persons who experienced or witnessed the disaster first hand (those who lost friends and loved ones), and those who responded in an attempt to rescue the living and later recover the dead, would have undoubtedly suffered the most. But notwithstanding that, even those watching the disaster unfold on television, radio or whatever social media, were unwittingly exposing themselves to what for many would be a severe stress.{{more}}

PSYCHOLOGICAL TRAUMA

There are many definitions of psychological trauma but most of them include some type of overwhelming, unanticipated danger from which one cannot escape and for which there appears to be no method of either decreasing the danger or the individual’s anxiety. Under these circumstances, intensity of the event causes a cognitive and physiological disregulation that renders the usual cognitive and behavioural responses to the stimuli experienced less effective than normal.

The disaster victim may almost instantaneously develop physical and mental symptoms, including a feeling that one’s heart is about to burst, difficulty in breathing (so that one feels smothered), muscles that feel like exploding and don’t seem to work right, feelings of terror and panic, a confused mental state which may lead to the actual shutting down of the ability to think, freezing and feelings of helplessness or being out of control. These responses are complex and include biological defenses against the threat, the activation of mechanisms related to past learning and adaptation in similar situations, response to social cues (i.e., one’s behaviour is shaped by whether or not there are others in the disaster with you and whether or not they are strangers or friends and relatives), reactions to immediate loss or separation from a loved one and the effects of the cognitive disarray that can occur from experiencing chaos all around one.

Key Clinical Questions:

1. Are there specific factors from a disaster that cause an increase in mental stress?

2. How do children respond to disasters?

3. What are abnormal reactions to disasters, when do they occur and how should they be treated?

4. What should a state wide behavioural health response include?

FACTORS THAT CAN AFFECT AN INDIVIDUAL’S RESPONSE TO A DISASTER:

• Event Factors

• Individual Factors

Event Factors:

Physical proximity to the disaster has been found to be a determining factor in crisis response to a disaster. Thus, although one can still be traumatized, watching an event unfold on television usually does not have the same psychological impact as being a victim of the disaster. Emotional proximity to an event is also a determining factor in that even if one is only an observer, the impact will differ depending on whether a loved one is known or presumed to be a disaster victim or one is watching the disaster impact strangers. One’s response is also affected by whether or not there are secondary events, such as a disruption of daily routines through the loss of shelter, work place, transportation, etc.

Whether or not a disaster occurs by natural causes, such as hurricane or flood, or is caused by an act of another person known or unknown, also has been reported to affect an individual’s response. “God’s Will” is more readily accepted then accidental or premeditated harm caused by another human being.

Individual Factors:

Many individual factors can affect the way a person responds to a disaster. These include such things as genetic vulnerabilities and capacities, prior history of a constant stress or exposure to past disasters, history or presence of a psychiatric disorder, being female, lower education and income, lower IQ, being divorced or widowed, health issues or psychopathology within the family, the presence or absence of family and social support structures and the age and developmental level of the individual. Thus, children represent a particularly vulnerable population.

CHILDREN’S RESPONSES TO A DISASTER

For most children, and especially younger children, what they feel and think about a disaster is primarily mediated by their adult caregivers. The caregiver’s emotional response is often as important as the actual event and shapes both the children’s immediate and subsequent handling of the experience. Typically, children’s initial responses revolve around questions and concerns about safety and security, with the focus on frightening things or thoughts.

Feelings of anger and thoughts of revenge are common. They often make an attempt to deal with these thoughts and feelings through continual play or talking about the event. Some of their symptoms are similar to those found in adults and some are special to the fact that they are children. Nightmares and inability to sleep are very common, as is decreased, or sometimes increased, appetite.

They often appear sad and can be much more withdrawn and quiet than normal. Some will show irritability, fussiness, or become argumentative. Regression in behaviour is common and a loss of recently achieved milestones can occur. Difficulty in paying attention, secondary to daydreaming or easy distractibility, can be seen and many times anxiety level is so high that they become extremely clingy and refuse to leave the presence of their parents.

Just because a child is quiet doesn’t mean that he/she is not thinking about the events that have occurred and trying to make sense of them in the light of his/her own experience and the parents’ reaction. As with adults, a child’s interpretation of his or her behaviour during or after a traumatic event can change their sense of self. Thus, they may feel increased physical prowess or weakness, see themselves as more passive or active. They may think of themselves as cowards or heroes and thus, experience a decrease or enhancement of their sense of self.

NB: The behavioural changes and responses of children are dependent on the child’s stage of development.

TREATMENT OF THE CHILD WHO HAS BEEN TRAUMATIZED BY EXPERIENCING OR WITNESSING A DISASTER –

The stage of development in the child will, in most cases, determine the treatment. Thus, treatment of child trauma survivors must facilitate developmentally appropriate expression of feelings (for example, through drawing or playing) should focus on age-relevant categories or themes (for example, safe, unsafe) and should not expose the child to more information than its developmental level will allow it to handle.

One of the primary immediate objectives of any child, victim or witness of a traumatic event is to reunite the child with important adults and family members. In addition, it is important to remember that interventions for children should also include caretakers, because if the adult has so many problems that they cannot attend to their child, then the outcomes are poor. Adults tend to underestimate the impact on children of a disaster or alternatively they may displace their own feelings onto the child.

ADULT RESPONSES TO DISASTER

• Acute Reactions

• Pathological or Mal-adaptive Reactions

Acute Reactions

Worthy of note is that each survivor of a disaster is unique and their personal history, as well as their psychological strengths or deficits, has a direct influence on their response to a given disaster. Additionally their beliefs, values, family and community resources available will shape the meaning of their experience and then play a role in the process of recovery. Important as well, is an understanding of the cultural differences of each community or group of persons, as this will be significant in understanding why a survivor shows a particular pattern of stress responses.

Most important to remember is the fact that the great majority of survivors will not have lasting consequences related to their experience, despite the fact that they may present with a variety of symptoms which, if they had not been subjected to a traumatic event, would be considered pathological.

• Despair

• Guilt

• Irritability

• Nightmares

• Hyper-arousal

• Somatic/physical complaints (e.g. headaches, unsettled stomach)

• Difficulty concentrating (with or without memory impairment)

• Feelings of alienation

• Social withdrawal

• Feelings of disassociation in which one feels like one is in a dream-like state and appears “spacey” to persons around.

In these acute cases, the focus should not be on diagnosing disease, but rather on health, as the majority of people will experience these symptoms as transient and they should be considered as normal responses to abnormal events.

Pathological Reactions

Acute Stress Disorder

This disorder can appear immediately after a disaster or up to four weeks after a traumatic event; but, in order to be diagnosed, must have duration of at least two days and maximum of four weeks. The criteria for diagnosis include three of five dissociative symptoms (i.e., the individual feels detached, dazed, experiences de-realization or depersonalization or amnesia).

These individuals also experience recurrent unwanted memories, while either awake or asleep, and often experience physiological or psychological distress when confronted with reminders of the trauma they have experienced. Because the distress can be so severe when reminded, they often avoid such stimuli. Hyper-arousal is also common and can be manifested by anxiousness, irritability, insomnia, poor concentration, hyper-reactivity or hyper-vigilance. In acute stress disorder these symptoms are so severe that there is significant psychosocial impairment. Individuals with this disorder are at a higher risk of developing Post Traumatic Stress Disorder (PTSD).

Summary:

The majority of individuals experiencing a severe disaster will develop some symptoms in the immediate aftermath, which, although abnormal in any other setting, are normal under the circumstances. These symptoms will resolve, in the great majority of cases, over a period of time.

A small percentage will develop acute traumatic distress disorder, pathological grief, depression and/or post traumatic stress disorder. Although there are some risk factors that increase the probability of developing post traumatic stress disorder or depression, it is impossible to predict whether or not a given individual will develop one or more of these disorders.

In addition, there is no clear evidence that any particular intervention in the immediate aftermath of a disaster will prevent their development. In times of crisis and disaster, to regain normalcy we need all HANDS ON DECK… every person will be required to get involved to provide support and help to each other.

References:

www.ncptsd.org – National Center for Posttraumatic Stress Disorder

Lonigan CJ, et al: Risk factors for the development of post-traumatic symptomatology, Journal of the American Academy of Child & Adolescent Psychiatry, (1994), 33(1): 94-106.

Disaster Mental Health Response Handbook, Ed: Centre for Mental Health, NSW Health and NSW Institute of Psychiatry, (2000), 1-170. State Health Publication No: (CMH)00145, ISBN: 07347 32139.

First MB, et al: Acute Stress Disorder. In: Frances A, Pincus HA (Eds): Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association: Washington, DC, (1994), 429.

Fullerton CS, et al: Debriefing Following Trauma, Psychiatric Quarterly, (2000), 71(3): 259-276.

Litz B, et al: Early Intervention for Trauma: Current Status and Future Directions, Clinical Psychology: Science and Practice (2003), in press.

Prepared by:

Dr Jozelle Miller

Health Psychologist

Milton Cato Memorial Hospital

06-01-14