Effects of Traumatic Stress after Mass Violence, Terror or Disaster
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
Cognitive 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
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
Interpersonal 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
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
individuals 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:
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.
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Traumatic stress: The effects of overwhelming experience on
mind, body, and society (pp. 441-462). New York: Guilford
Press.