Disasters and Mental Health

PREFACE

The mental health consequences of disasters have been the subject of a rapidly growing research literature in the last few decades. Moreover, they have aroused an increasing public interest, due to the dramatic impact and the wide media coverage of many recent disastrous events—from earthquakes to hurricanes, from technological disasters to terrorist attacks and war bombings.

The World Psychiatric Association has had for a long time a great interest and commitment in this area, especially through the work of the Section on Military and Disaster Psychiatry and the Program on Disasters and Mental Health. Several sessions on this topic have taken place in past World Congresses of Psychiatry, and other scientific meetings organized by the Association have dealt exclusively with disaster psychiatry.

Several research and practical issues remain open in this area. Among them, those of the boundary between "normal" and "pathological" responses to disasters; of the early predictors of subsequent significant mental disorders; of the range of psychological and psychosocial problems that mental health services should be prepared to address; of the efficacy of the psychological interventions which are currently available; of the nature and weight of risk and protective factors in the general population; of the feasibility, effectiveness and cost-effectiveness of the preventive programs which have been proposed at the international and national level. Moreover, wherever disasters strike, policy and service organization issues that plague the mental health field worldwide receive even more prominence: the detection and management of mental health problems are assigned less priority than care for physical problems; trained personnel is lacking; community resources for mental health care are poor; a vast proportion of people in need hesitate to ask for or accept mental health care.

However, it is clear that the field is progressing rapidly from the scientific viewpoint (with a refinement of early diagnostic concepts and treatment strategies, and a deeper understanding of resilience factors at the individual and community level) and that in a (slowly) growing number of countries concrete steps have been taken concerning training of personnel, education of the population, and the development of a network of services prepared to deal with psychological emergencies.

This volume aims to portray this evolutionary phase, by providing an overview of current knowledge and controversies about the mental health consequences of disasters and their management, and by offering a selection of first-hand accounts of experiences in several regions of the world. We were impressed by the liveliness of some of the reports, and particularly touched by some of the chapters dealing with the mental health consequences of armed conflicts, especially on children and adolescents. The authors of these chapters have accepted our advice to be as objective as possible in their descriptions. However, despite the intentions of the authors and the editors, some traces of their unavoidable emotional involvement may have been left in their chapters.

Neither the research overview nor the selection of experiences presented in this volume should be seen as being comprehensive. We hope, however, that the book will throw more light on the issue of mental health consequences of disasters, stimulate acquisition of more knowledge through research, enhance our sensitivity, and contribute to a more effective prevention and management of the behavioural effects of disasters. Disasters have been happening since time immemorial and will continue to happen. We must be prepared to face them and deal with their consequences.

Juan Jose Lopez-Ibor
George Christodoulou
Mario Maj
Norman Sartorius
Ahmed Okasha

CHAPTER 6

Organization of Mental Health Services for Disaster Victims

Louis Crocq, Marc-Antoine Crocq, Alain Chiapello and Carole Damiani

Necker Hospital, Paris, France
Rouffach Hospital, Rouffach, France
French Red Cross Society, Paris, France
INAVEM (Institut National d’Aide aux Victimes), Paris, France


INTRODUCTION

In the past, the care of disaster victims was limited to rescuing them, tending their wounds, offering shelter and material assistance, helping them to relocate and resume their previous occupation. In the last three decades, increasing attention has also been given to the victims’ psychological suffering, and to the psychosocial and moral burden of the individual and the community. Thus, programs for medical, psychological, and psychosocial intervention have been devised in various countries. They are implemented at different stages of the disaster and its aftermath. The guiding principles are: (a) to take into account psychological distress; (b) to manage the psychosocial impact on the individual and society; and (c) to prevent the development of late sequelae that would handicap individual or group functioning. Various initiatives have been proposed by governments, non-governmental organizations (NGOs), international associations, and private groups. Some of these initiatives have been quite successful. However, there is a need to integrate these various initiatives into a coherent whole. At a certain level, rescue and rehabilitation need to be coordinated by government authorities.

THE IMPACT OF DISASTERS ON INDIVIDUAL AND
COLLECTIVE MENTAL HEALTH

In 1988, the World Health Organization estimated that natural disasters had afflicted 26 million persons between 1900 and 1988. In that number, 10 million had been made homeless. A 1992 report by the International Federation of the Red Cross and Red Crescent Societies identified 7,766 disasters that had occurred in the world between 1967 and 1991, killing 7 million and affecting 3 trillion individuals [1]. Natural disasters predominantly afflict poor populations – 68 out of 109 natural disasters that occurred in the world between 1960 and 1987 concerned developing countries, and only 41 affluent countries. Furthermore, the casualty rate is higher when disasters happen in poor countries, as compared with richer countries, because of factors such as overcrowding in areas that are prone to natural (e.g., floodland) or industrial disasters (e.g., chemical plants).

Regardless of the degree of material destruction, disasters are first and foremost characterized by the intensity of human trauma. The psychosocial aspect of disasters is underlined in our definition of a disaster by a combination of five criteria: (a) the occurrence of a negative event that brings distress to the people and the community (a revolution that frees a country from a tyrant is not considered a disaster, even when it causes thousands of casualties); (b) the causation of material destruction that significantly alters human environment (an avalanche in an uninhabited mountain valley is not a disaster, contrary to an avalanche in a populated valley); (c) a great number of victims, dead, injured, homeless, who suffer significant somatic injuries and psychological suffering; (d) the overwhelming disruption of local means of rescue and protection; and (e) the interruption of services that are normally offered by society (i.e., sheltering; producing, distributing, and consuming energy, water, food; health services; transportation; communication; public order; and even . . . burying the dead). It should be remembered that victims have been threatened not only in their individual ego, but also in their collective ego, or sense of belonging to a community. Their individual misfortune is also a collective misfortune. Gerrity and Steinglass [2] developed similar hypotheses about the familial group, on the basis of Reiss’s ‘‘family paradigm’’ [3]. The family elaborates a set of beliefs about the environment. Its response to a disaster will be determined by its cognitive and emotional perception of the traumatic event and its relationship with the family’s history.

The term ‘‘victim’’ is somewhat unclear. In the broadest meaning of the term, a victim is anyone who has been affected by the disaster in his/her physical or mental health, properties, or social life. Victims are usually classified into five groups on the basis of their distance to the disaster [4]: (a) primary victims (dead, wounded, uninjured survivors), who have been directly exposed to the disaster; (b) secondary victims, who have not been directly affected, but who mourn a close relative who is part of the primary victims; (c) third-level victims, such as rescuers, health personnel, who intervened on the scene and have often witnessed traumatizing events; (d) fourth-level victims, such as government or media workers, who may have suffered emotionally when taking decisions or witnessing scenes; (e) fifth-level victims, in the general public, who were not physically present at the scene but suffered by proxy when exposed to the media coverage.

MENTAL CONDITION AND HEALTH CARE NEEDS OF
DISASTER VICTIMS

The mental state of victims should be considered at the three different stages of disaster and aftermath: (a) the immediate reaction (usually, from a few hours to less than a day); (b) the post-immediate phase, that begins on the second day and lasts from a couple of days to a couple of months; (c) the delayed and long-lasting sequelae, that may be transitory (from 2 to 6 months) or become chronic (longer than 6 months).

Immediate Phase

About 75% of victims show no mental disorder, but only short-lived neurovegetative and psychological symptoms that are transitory (a few hours) and are part of the normal adaptive stress reaction. A short period of physical and psychological exhaustion may follow, because stress depletes energy. From a psychological viewpoint, this adaptive stress reaction is characterized by an adaptive focusing of attention on the danger situation, by the recruitment of mental capacities, and by the facilitation of action. Adaptive stress leads to decision-taking, acting on a decision, and adaptive fight-or-flight reactions. However, adaptive stress is an exceptional response that has a high cost in energy and discomfort. Therefore, individuals who exhibited this adaptive response may still need psychological help afterwards.

A smaller proportion (25%) of victims may present with abnormal and maladaptive stress reactions, which may follow one of four patterns [5,6]: stupor, agitation, panic flight, automatic reaction. These maladaptive stress reactions always comprise elements of peri-traumatic dissociation [7], including confusion, derealization, fright, impression of absence of relief, and abulia. In ICD-10, such reactions are termed ‘‘acute stress reaction’’. DSM-IV proposes no diagnosis for this acute stress reaction, since the criteria of ‘‘acute stress disorder’’ require that the disturbance lasts for a minimum of 2 days, which exceeds the duration of the immediate stress reaction. Individuals who responded with maladaptive stress should be viewed as ‘‘psychological casualties’’; they have lost their capacity for autonomy and should be given psychological help.

Post-immediate Period

Either the mental state returns to normal in a few days (neuro-vegetative and psychological symptoms subside, the individual is no longer entirely preoccupied by the event and can resume his previous activities), or a psychotraumatic syndrome appears, characterized by the re-experience of the event, avoidance of stimuli reminiscent of the trauma, hyperreactivity, and constant preoccupation with the trauma. Psychotraumatic symptoms may appear only after weeks, or months. This is the so-called ‘‘latency period’’, which had been identified in traumatic neurosis by Charcot and Janet, and called period of incubation, contemplation, meditation or rumination. The duration of this period is variable: each individual needs a different amount of time to organize new defense mechanisms. Furthermore, if the individual is still hospitalized, he may wait till he recovers his autonomy to start coping with the trauma. ICD-10 and DSM-IV propose the diagnostic term ‘‘post-traumatic stress disorder’’ (PTSD) (acute type, since the duration is short) for this syndrome. In addition, DSM-IV offers the category ‘‘acute stress disorder’’ for the cases with dissociative symptoms (appearing in the immediate phase) and psychotraumatic symptoms such as re-experiencing (appearing within 4 weeks of the trauma). Individuals who presented with a maladaptive acute stress reaction are more at risk to present with acute PTSD afterwards. However, this course is not unavoidable, and there are cases of maladaptive stress reaction that recover without consequences, whereas individuals who initially responded adaptively to the trauma may later develop severe PTSD.

Delayed and Chronic Period

Cases of acute stress and post-traumatic stress that occur during the postimmediate phase may resolve – spontaneously, or with treatment – fairly rapidly (in less than 3 months). However, they may also persist, and even become chronic. The typical clinical picture of PTSD may then become manifest during the delayed and chronic period, with its key features of: (a) exposition to a traumatic event, evoking a response of intense fear or helplessness; (b) persistent re-experience of the traumatic event (in intrusive recollections, dreams, flashback episodes, etc.); (c) avoidance of stimuli associated with the trauma and numbing of general responsiveness; and (d) symptoms of increased arousal.

It is worth noting that the above criteria (c) and (d) together reproduce the personality changes that were described in the former European diagnostic category termed ‘‘traumatic neurosis’’. According to Fenichel, this personality change was characterized by the blocking of such functions of the ego as: (a) filtering of the environment; (b) presence; (c) relationship with others. Briefly, the victim no longer has the same relationship with others and the world since the traumatic event. He has developed a new way of perceiving, thinking, loving, wanting, and acting. In addition to PTSD, ICD-10 provides another diagnostic category entitled ‘‘enduring personality change after catastrophic experience’’ (F62.0), defined by criteria such as a mistrustful attitude toward the world, social withdrawal, feelings of emptiness or of being threatened, and estrangement.

Traumatic neurosis, as it was described in Europe, associated several non-specific symptoms, such as physical, psychological, and sexual asthenia; anxiety; hysterical, phobic, or obsessive overlay symptoms; somatic complaints (notably in children); psychosomatic complaints; conduct disorders, addiction, suicide attempts. Many patients still present with these symptoms, which are considered ‘‘comorbid’’ in DSM-IV and ICD-10, like the pseudo-depression that is linked to psychological numbing. These non-specific symptoms may be prominent in the clinical picture, and lead to errors in diagnosis and treatment. In clinical practice, many patients do not meet all the DSM criteria for PTSD, or the ICD criteria for ‘‘enduring personality change after catastrophic experience’’. There are many atypical cases of varying onset, duration and severity, with a diverse degree of handicap. All disaster victims who still present with symptoms at this stage should be offered psychological or psychiatric care until recovery.

Numerous surveys have shown that a substantial proportion of disaster victims still present with PTSD symptoms several years after the traumatic event. Green and Lindy [8] observed a PTSD prevalence of 44% two years after the 1972 Buffalo Creek flood disaster, and of 14% after 14 years. Bromet and Dew [9] mention a 22% rate of psychological sequelae (including 11% PTSD) after a hurricane in Honduras. In a survey of 43 terrorist attack victims, Bouthillon-Heitzmann et al. [10] reported a 79% PTSD rate 3 years after the event; one-third of subjects showed clear psychosomatic disorders.

MENTAL STATE OF THE AFFLICTED COMMUNITY

A disaster strikes a whole community, causing types of collective behavior which cannot be reduced to the mere sum of instances of individual behavior. Collective behavior is influenced by a community’s psychology, by the crowd’s state of mind, and is characterized by its own specific features. After a disaster, collective behavior may be either adaptive or maladaptive.

Adaptive collective behavior is often rehearsed and expected. Instances of adaptive collective behavior during the immediate phase are remaining at one’s post, orderly evacuation, helping others. Adaptive collective behavior is characterized by three features: (a) group structure is preserved; (b) leadership is maintained or reestablished; (c) mutual help is organized. During the post-immediate and long-term phases, adaptive collective behavior is manifested by normal mourning, regaining autonomy, reconstruction and resuming normal professional and social activities.

Maladaptive collective behavior during the immediate phase may show as: (a) collective stupor (the population remains reactionless or evacuates the impact zone in a long centrifugal exodus); (b) collective panic (headlong flight, scrambling for safety); or (c) exodus. These three types of collective behavior are characterized by: (a) the loosening of group structure; (b) the collapse of leadership; and (c) the lack of solidarity. Additionally, it is possible to observe, during the post-immediate period, the spread of rumors, and violence outbursts (riots, hooliganism, and search for scapegoats). The delayed and chronic phase may give rise to a paranoid collective mentality (hostility toward the world and demanding redress), and a dependent mentality, with feelings of being entitled to assistance, and the inability to recover autonomy.

The leaders who are responsible for organizing rescue operations must be aware of these behavior patterns, and their predisposing factors. Raphael et al. [11] identified some pathogenic factors in the social context of disaster: (a) the extent of material destruction, (b) the disturbance of the normal channels of psychosocial support, (c) a history of previous collective trauma, (d) the pre-existing state of the community (e.g., migration), and (e) the separation of families. Additional negative factors are the composition of the population (proportion of elderly, children, women), its lack of structure and preparedness, its mental state on the eve of the disaster (the "expectant attention", described by Le Bon, facilitates panic), rumors fostering feelings of panic or abandonment, and the presence of specific individuals who overtly spread alarmist views and will "contaminate" others. After a disaster, individual interventions should be complemented by collective measures aimed at restoring collective psychological health.