This is the second in a three-part series on post traumatic stress disorder following disasters. Part One, PTSD in Emergency Workers, can be found here.
General Public at Risk
Over 2/3 of the general population will experience some significant traumatic event in their lifetime, and 1/5 of Americans will undergo such an event in any year. One review of the literature found that the prevalence of PTSD in direct victims can range from 30-40%, in rescue workers 10-20%, and 5-10% in the general population.
Per the American Psychiatric Association DSM-V Criteria,
PTSD is defined as a Trauma/Stress Related disorder with a trigger which resulted in exposure to actual or threatened death, serious injury or sexual violation from one ore more of the following scenarios:
- directly experiences the traumatic event;
- witnesses the traumatic event in person;
- learns that the traumatic event occurred to a close family member or close friend (with the actual or threatened death being either violent or accidental); or
- experiences first-hand repeated or extreme exposure to aversive details of the traumatic event (not through media, pictures, television or movies unless work-related)
The disturbance must also cause clinically significant distress or impairment in the individual’s social interactions, capacity to work or other important areas of functioning. It is not the physiological result of another medical condition, medication, drugs or alcohol.
Symptoms of PTSD
In a guide to psychiatrists responding to disaster events, the Psychiatric Times details some common characteristics of disaster victims. After a disaster, the most common symptoms are sleeplessness, anxiety, depression, and constant and overwhelming bereavement. PTSD, major depressive disorder and substance abuse are more common in communities in which a traumatic event has occurred. After a disaster event, individuals may exhibit ‘distress behaviors’ including increased smoking, chronic irritability and even overwork. The authors note that disasters can deepen established frictions within a community which fall along cultural, economic or political lines, and exacerbate feelings of marginalization within certain segments of the population.
Mitigating Mental Health Traumas after Disasters
Mental Health Preparedness is a vital component of emergency preparedness, and procedures to mitigate the emotional and behavioral toll of disasters should be a part of every disaster response plan. On its Public Health Emergency website, the Department of Health and Human Services notes that disaster behavioral health response should serve to:
- provide psycho-education and information on physical and emotional hazards
- engage in supportive listening
- screen individuals at greater risk for long-term adverse reactions
- ensure referral to appropriate medical, psychological, or tangible services
The Department of Veterans Affairs has published an excellent resource: Disaster Mental Health Services – A Guidebook for Clinicians and Administrators. The following information is taken from the recommendations outlined by the Guidebook. The Guidebook outlines the need for a division of labor between clinicians and administrators.
Public Health Leaders & Administrators, on the other hand, should be prepared for the following tasks:
- Emergency and Early Post-Impact Phase Tasks:
- Coordinate response/liaison with other responding agencies (FEMA, Red Cross, County Office of Emergency Services, etc.)
- Coordinate Immediate Mental Health Response (mobilize team, activate mutual aid, establish disaster mental health crisis line, etc)
- Conduct needs assessment and/or gather information (impact on survivors, number of fatalities/injured, damage to property, impact on high-risk groups such as the elders or economically disadvantaged, etc)
- Coordinate information to media for public dissemination
- Coordinate services with other responding agencies to provide mental health services to emergencies responders
- Coordinate, allocate staff resources
- Coordinate documentation of services
- Restoration Phase Tasks
- Coordinate response/liaison with other responding agencies
- Conduct needs assessment and/or gather information
- Establish crisis counseling program
- Coordinate outreach and clinical services
Mental Health Response Teams
There are two types of mental health response teams:
- Standing Teams that are established before or shortly after a disaster event
- Ad Hoc Teams that are formed at disaster sites
Any response team must identify a team leader, the direct service providers, secretarial support and a program analyst/researcher. Preferably responders should hold mental health clinical licenses, be available to serve without much notice, be able to tolerate difficult working conditions and to establish rapport with a wide variety of individuals, training/experience in debriefing methods, ability to give presentations to survivors, helpers, community groups, and be organizational savvy and politically sensitive. Each team must also develop Standard Operating Procedures (SOP’s) that outline fiscal, mobilization, field procedures, demobilization, education, and program evaluation protocols.
In a paper published in 2005 entitled Psychological Preparedness for Disaster, Pearl S. Guterman further outlines the importance of mental health preparedness and proposes a model to incorporate mental health into disaster planning.
In the pre-event stage, she recommends that individuals receive training in psychological first aid (PFA) and implementation of psychological immunization.
PFA is offered through the National Child Traumatic Stress Network and the National Center for PTSD. A Field Operations Guide can be found here. Additionally, online training in PFA can be found at this link. In a study published in 2012, PFA was found to offer “an acceptable intervention option to be provided by volunteers without professional mental health training for people who have experienced a traumatic event. PFA is a vital fist step in ensuring basic care, comfort, and support,” though official treatment should be coordinated through certified mental health providers.
Psychological immunization can be provided through Stress Inoculation Training (SIT), first outlined by Meichenbaum in 1996, which integrates cognitive and affective coping factors with cognitive behavior modification and which has been employed to help individuals in the aftermath of stressful events and on a preventative basis to ”inoculate’ against future stressors. Preventative SIT was evaluated during the 1996-1997 cyclone season (in particular to the storm Justin) in Cairns, Queensland, Australia and found to be effective in improving coping and adaptive responding within the population.
During the event stage, Guterman suggests that responders be involved in triage, implementing PFA, and distributing appropriate information. Finally, in the post-disaster phase, responders should continue to implement PFA, screen psychological symptoms, treat for acute and long-term effects of trauma, assist in restoring normalcy and in therapy or counseling.
In a paper published in Disaster Medicine, Meredith et al describes a preparedness framework providing detailed actions to be taken in response to variety of different psychological triggers after a disaster event. The authors posit it is more efficacious to focus on the triggers that drive emotional, cognitive and behavioral responses rather than on the disaster event itself.
Resources for Disaster Survivors
A variety of resources are readily available online both for preparedness and post-event response.
The Veterans Affairs Administration provides these tips for self-care after disasters. The Substance Abuse and Mental Health Services Administration coordinates the Disaster Distress Helpline (1-800-985-5990) which offers free and confidential crisis counseling and support 24/7. This CDC webpage also links to a multitude of different resources for coping with a disaster or traumatic event.
Remember, it is normal to feel a variety of different emotions in response to a traumatic event. Individuals may feel shock and disbelief, fear, sadness, helpless, guilt, anger, shame or relief. Additionally, many may experience physical symptoms including trembling/shaking, pounding heart, rapid breathing, lump in the throat, stomach tightening or churning, dizziness/faintness, cold sweats or racing thoughts. It is important to be proactive about the situation. Step that one can take include:
- Re-establishing a routine
- Connecting with others
- Challenging sense of helplessness
- Minimizing media exposure
- Acknowledging and accepting feelings
- Making stress reduction a priority
If you experience any of the following warning signs, you may benefit from the help of a mental health professional:
- No improvement after 6 weeks
- Trouble functioning at home and work
- Experiencing terrifying memories, nightmares or flashbacks
- Increasing difficulty connecting and relating to others
- Experiencing suicidal thoughts or feelings
- Avoiding certain situations that remind you of the disaster or traumatic event
Every disaster response plan must include procedures to mitigate against the effects that traumatic events can have on the mental health of those affected. Take time now to ensure such plans are in place and that you know how to recognize the signs and symptoms of psychological stress following a disaster event.
Report written by Vidya Eswaran