PTSD: National Center for PTSD
Helping Survivors in the Wake of Disaster
Helping Survivors in the Wake of Disaster
The Impact of Disasters on Affected Individuals
Disaster survivors exhibit a wide variety of reactions and patterns of change over time. A significant proportion of those exposed to disasters will experience immediate intense reactions, which decline over time (e.g., 1-4). The proportion of survivors who develop chronic long term problems is generally less than 10%, and rarely exceeds 30% (5-7). For instance, in one review of the literature (8):
- 50% of the disaster studies indicated moderate effects in their cohorts, (increased or prolonged stress but little enduring psychopathology).
- 24% of studies showed severe effects.
- 17% of studies indicated very severe effects (25% - 50% + prevalence of clinically significant distress or psychological disorder).
- Reactions were most likely to be apparent in the year following the disaster, with 70% of the samples showing improvement past that time.
The majority of disaster survivors will not typically require the attention of mental health professionals. While there have been few longitudinal studies, in one multi-site trial following survivors of both natural disasters and a terrorist attack over time (1): Approximately 10% had few symptoms of distress both immediately following the disaster, and for months afterwards.
- Approximately two-thirds had initial mental health problems or psychological distress, but showed resilience or recovery in the following months.
- Approximately one-fourth showed chronic dysfunction.
What are some common, expectable stress reactions following disasters?
Most individuals involved in disasters experience stress reactions. These reactions may last for several days or even a few weeks or months, and may include:
- Emotional reactions: shock; fear; anxiety grief; anger; guilt; shame; feeling helpless or hopeless; feeling numb; feeling empty; diminished ability to feel interest, pleasure, or love, perceived stress, demoralization
- Cognitive reactions: confusion, disorientation, indecisiveness, worry, shortened attention span, difficulty concentrating, memory loss, unwanted memories, self-blame
- Physical reactions: tension, fatigue, edginess, insomnia, bodily aches or pain, startling easily, racing heartbeat, nausea, change in appetite, change in sex drive, physical health problems and/or somatic concerns, poor sleep quality, increased activation of the autonomic nervous system and hypothalamic-pituitary-adrenal (HPA) axis
- Interpersonal reactions: distrust, conflict, withdrawal, work problems, school problems, irritability, loss of intimacy, being over-controlling, feeling rejected or abandoned
What are more severe reactions to a disaster?
Prolonged distress and impairment in functioning lasting more than a few months are the hallmarks of potential need for more behavioral health interventions (8). Of those individuals exhibiting more severe reactions following disasters, the effects most commonly observed are:
- Acute stress disorder
- Posttraumatic stress disorder (with intrusion and arousal symptoms more often prevalent and avoidance symptoms less common)
- Severe anxiety (debilitating worry, extreme helplessness, compulsions, or obsessions)
- Severe depression (loss of the ability to feel hope, pleasure, or interest; feeling worthless)
- Increases in the use of alcohol or drugs
- Physiological indicators of stress such as physical pain
- Complicated grief, which presents as a combination of grief and PTSD symptoms, causing greater psychological distress and for a longer period of time than when death is due to natural causes
What do we know about risk factors?
Many factors influence the impact of a disaster on affected individuals. While methodological challenges in disaster research make it difficult to definitively assign weights to these factors, the risk factors that have consistently and most strongly influenced the likelihood of serious or lasting psychological problems following disasters and mass violence are (8-12):
- Severity of exposure to the event (especially injury, threat to life, and extreme loss)
- Post-event stresses and adversities
For instance, in one review of literature, in the first year after a disaster, prevalence of PTSD depended on exposure to the disaster (13):
- Between 5% and 10% in the general population
- Between 10% and 20% among rescue workers
- Between 30% and 40% among direct victims
Other risk factors that have emerged from empirical literature include (e.g., 5,8,14-17):
- Female gender
- Ethnic minority group membership
- Age in the middle years of 40 to 60 or over sixty five (if sick, economically disadvantaged, or frail)
- Poverty or low socioeconomic status
- Presence of children in the home
- Little previous experience in coping with disasters
- Psychiatric history
- In children, reactions of parents, separation from primary caregiver, and exposure to media
A number of post-event risk factors hold particular relevance for intervention, such as: Absence of social support (e.g., 18,19).
- Higher levels of life stress and ongoing adversity (19,20)
- Lack of or loss of both practical and social resources (21-24)
- Negative coping strategies, such as self-blame (25)
- Negative appraisals, including appraisals about the event, personal role in the event, reactions, and potential future risk (12,25,26)
What do we know about resilience factors?
A number of unique predictors of a resilience following disasters have emerged, including (5,22,27,28):
- Social and emotional resources
- Personality traits such as low negative affectivity and capacity for positive emotions
- Optimistic attributional style
- Perceived coping self-efficacy
- Range of demographic and biological factors such as male gender, older age, and greater education
How do risk and resilience factors inform disaster response?
From the literature on risk and resilience factors, we know that:
- Many individuals will have recurring stress reactions that fluctuate in severity, even years later.
- Acute distress reactions should not necessarily be regarded as pathological responses or even as precursors of subsequent disorder.
- Most individuals are likely to need social support and provision of resources, rather than clinical treatment.
- Some individuals, especially those with the highest exposure to traumatic and loss stressors, may require more intensive intervention.
What are best practices for assisting disaster survivors?
Interventions should address not only risk factors and acute distress reactions, but also foster provision of resources and other protective factors. Searching for a single solution to fostering resilient recovery might not be responsive to the way risk and resilient patterns vary across situations and timelines (29). Additionally, because resilient individuals appear capable of coping effectively on their own, it has been suggested that global interventions for everyone might undermine some individual's natural coping abilities (30).
A multifaceted approach is recommended, with a number of different interventions that are sensitive to the cultural and event context, as well as to differential exposure levels and unique reactions of affected individuals. Experts have recommended that five empirically-supported intervention principles be used in situations of both disaster and ongoing mass violence. These principles are: (a) promoting a sense of safety, (b) promoting calming, (c) promoting a sense of self- and community-efficacy, (d) promoting connectedness, and (e) instilling hope (22).
A number of studies and reviews have concluded that psychological debriefing cannot be endorsed, particularly for use with disaster survivors (31-35). Interventions for those in distress in the early aftermath, such as Psychological First Aid (PFA), should focus on reducing ongoing adversity, promoting safety, attending to practical needs, enhancing coping, stabilizing survivors, and connecting survivors with additional resources, to help mitigate the consequences of traumatic events. PFA models aim to reduce distress, foster short- and long-term adaptive functioning, and link distressed or at-risk survivors with additional services. PFA is designed to be tailored to the specific needs of each disaster survivor (22,36).
While some individuals will require more intensive interventions, and some level of screening for predictors of continued distress is recommended, besides symptom severity at 1-2 weeks post-trauma, there is no algorithm to predict persisting distress (32). Trying to create a simple conceptual framework of risk factors might obscure the important nuances and complexities of a disaster's consequences (37).
Outreach to other service providers and systems (including spiritual leaders, school personnel, first responders, public health and health professionals, employee assistance programs, and volunteers) is recommended to support the integration of mental health principles into all phases of disaster management and response and to counter the many barriers to care that may present themselves after disasters (i.e.,33,38-40).
Early clinical intervention should be offered, as it yields success in those who complete treatment, and results in markedly greater overall population impact (41-44). However, the decision to implement early versus intermediate clinical intervention should be determined not by the length of time after an event, but rather by the extent to which a sense of threat persists for survivors, and the extent to which survivors have sufficient resources to engage in the intervention (36). Additionally, monitoring and follow up of those offered early intervention may be necessary, as longitudinal follow up of individuals offered early interventions has shown that they may still suffer from PTSD and other symptoms years later (45).
Cognitive behavioral interventions delivered to disaster survivors and first responders have yielded significantly greater reductions in PTSD, depression, and anxiety compared to control conditions. There has been acknowledgement that CBT requires resources and motivation on the part of survivors, and may not be appropriate for all survivors at all times. (e.g., 46-50). Because of this, more flexible CBT models exist tailored to the post-disaster setting and have yielded positive results (e.g., CBT-PD, 51; STAIR/MPE, 52; the Screen and Treat Approach, 18,53; a brief CBT disaster intervention, 54; Problem Management Plus, 55; Skills for Psychological Recovery (SPR), 56; an internet-based screening and education intervention, 57).
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