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Post-traumatic Stress Disorder
Managing the After-effects of Disaster Trauma –
The Essentials of Early Intervention
a report by
T r o n d H e i r , A j m a l H u s s a i n and L a r s W e i s æ t h
Norwegian Centre for Violence and Traumatic Stress Studies, University of Oslo
Although disaster traumas differ widely, they usually have some
must shift towards public health. This calls for secondary preventative
common characteristics in terms of risk of developing psycho-
psychiatry applied on a mass scale.
pathology. Bereavement, threat to life and integrity, witnessing death
and horror, suffering an emotional storm or psychic numbing, physical
The World Health Organization (WHO) has defined disasters as a public
injuries, property loss and social disruption have all been found to
health priority in large parts of the world. The smallest and poorest
affect mental health after a variety of disasters.1 Stress reactions after
countries are affected most severely by natural disasters, and the
a disaster may include the diagnosis of post-traumatic stress disorder
poorest and most disadvantaged members of a disaster-affected
(PTSD), depression and anxiety disorders, as well as other psychiatric
community are likely to experience the most serious consequences.
conditions such as prolonged grief reactions, somatisation and
Poverty is both a cause and an effect of disaster.3
substance abuse. A stressful disaster exposure may exacerbate pre2
existing psychiatric conditions, trigger a latent disorder or cause
The UN recognised the increasing impact of disasters on the world’s
psychic vulnerability to later stressful events.
population and environment by declaring the 1990s ‘the international
decade for natural disaster reduction’. One must question the
During a disaster there will be a discrepancy between urgent needs
effectiveness of this declaration: while the likelihood of dying in a
and immediately available medical resources. This lack of resources
disaster was indeed reduced during the 1990s, the number of persons
results in reduced possibilities for high-quality individual psychiatric
affected and the costs have increased profoundly.4 After the South-
care. Normally, the mental health professional focuses on the
East Asian tsunami in December 2004 in particular, the need to
individual and his or her family; however, after a disaster the focus
systematically reduce the impact of disasters has been gaining
recognition and commitment among governments worldwide.5
Trond Heir is a Specialist in Psychiatry and a Senior Researcher
at the Norwegian Centre for Violence and Traumatic Stress
Studies, University of Oslo. Before specialising in psychiatry,
he was employed in primary healthcare services and military
medicine. His research interests have included physical activity
and sport science, physical fitness and mental health in
military service personnel, psychotraumatology and disaster
medicine. He is currently conducting research on survivors of
the 2004 tsunami.
E: [email protected]
Ajmal Hussain is a Research Fellow at the Norwegian Centre
for Violence and Traumatic Stress Studies. He graduated
from the Medical Faculty of the University of Oslo in 2001.
After residencies in internal medicine, surgery and district
practice, he specialised in psychiatry. As part of his PhD
project, since 2006 he has been following up survivors of
the 2004 tsunami.
Disaster Psychiatry
According to the WHO’s programme of work, the master plan for
dealing with the health aspects of disasters should include a mental
health component. The WHO has described a model for a stepwise
development towards self-sufficiency, beginning with international
reliance and moving towards national to local reliance.3 However,
16 years later developing countries are dependent on international
disaster expertise in mental health.
More than any other type of help-giving, disaster interventions need to
be highly organised and co-ordinated, and they should be conducted
in a collaborative atmosphere. Cross-disciplinary mental health
workers are expected to work closely with professions to which they
are not accustomed. Good basic training in general psychiatry is
necessary, but not sufficient. Psychiatrists must apply their knowledge
Lars Weisæth is a Specialist in Psychiatry and Research
Director of the Norwegian Centre for Violence and
Traumatic Stress Studies, and a Professor of
Psychotraumatology at the University of Oslo. He is a
qualified supervisor in psychotherapy and a member of the
Norwegian Psychoanalytic Association. Professor Weisæth
was Chief Psychiatrist of the Joint Armed Forces Medical
Services from 1984 to 2004, and is a past Board Member of
the International and European Societies for Traumatic
Stress Studies. Since 1975 he has been studying responses during and after danger situations
in civilian and military settings among survivors, bereaved families and rescue personnel, and
was a member of the World Health Organization’s psychiatric teams sent to Kuwait in 1991
and to Croatia and Serbia in 1991–1992. Professor Weisæth is Co-Editor of Ursano et al.’s
Textbook of Disaster Psychiatry, published by Cambridge University Press in 2007.
and skills in situations that differ dramatically from their traditional
daily work, which focuses on diagnosis and treatment. Often
interventions are offered to people who have not asked for them or
actively sought help.
Similar to other disaster workers, mental health professionals should
be pre-selected and pre-trained. It is important to have clinical
experience with trauma-related psychiatric disorders and to be familiar
with principles of early intervention. Ideally, mental health workers
should have taken part in large-scale disaster exercises. A recently
published textbook on disaster psychiatry provides an updated
knowledge base of the field.6
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Managing the After-effects of Disaster Trauma – The Essentials of Early Intervention
A Proposed Five-step Model
Sense of Safety
There is no evidence-based consensus with regard to effective
Adverse stress reactions tend to persist under conditions of ongoing
interventions for use in the immediate, early and mid-term post-
threat.18,19 It is essential to bring disaster victims to a safe place that is
disaster phases.7 For example, two recent assessments of the effect of
free of threats to life and exposure to witnessing horrors. For example,
early interventions after potentially traumatic events of large and small
in a study of Norwegians who survived the South-East Asian tsunami
magnitude confirm that the available evidence is weak or lacking.8,9
of 2004, we noted an accumulated risk of stress complaints six months
For many years ‘acute stress debriefing’ was the intervention of choice
post-disaster when a victim was both exposed to personal danger and
for disaster survivors. However, research about its efficacy has failed to
witnessed horrors such as deceased victims or abandoned children.20
show any positive outcome.
10,11
The recent work by Hobfoll et al.12 tries to achieve consensus in a field
that has been plagued by controversy. In this work, an expert panel of
mental health professionals from a broad range of disciplines draws
attention to some central elements or principles of intervention,
ranging from prevention to support to therapeutic interventions. The
authors make it clear that their recommendations are evidence-
There is no evidence-based consensus
with regard to effective interventions
for use in the immediate, early and
mid-term post-disaster phases.
informed rather than evidence-based. Their five intervention principles
are to promote a sense of safety, calming, a sense of self- and
collective efficacy, connectedness and hope. These interventional
Some disaster situations allow for an escape only to relative safety,
principles have been criticised as being too ambitious in their provision
such as in a war zone or the after-shocks of an earthquake. Even a
of detailed public health intervention. The critics state that for many
relative sense of safety can buffer the risk of developing PTSD.21,22
practical circumstances there seems to be a gap between what is
Failure to feel safe may be caused by untreated physical injuries,
desirable and what is feasible.13 In our opinion, although practical
uncertainty about loved ones and feeling responsible for the search
work has to be adapted to available resources as well as to local
and rescue of other victims at the expense of personal safety.
context and culture, we think that the five intervention principles serve
as general aims for intervention strategies.14
Priority should be given to reuniting family members and providing
information about missing next of kin because the safety of loved ones
Components of the five intervention principles are relevant to the entire
is just as important, or even more important, than the safety of
disaster population. Everyone can benefit from certain aspects of these
oneself.12 When such ongoing stressors are resolved, most survivors
principles. Indeed, most post-traumatic stress reactions are normal – and
experience an immediate sense of relief, a sort of ‘let-go’ reaction,
sometimes adaptive – during the early aftermath of disaster, and these
with trembling, tearfulness and an understanding that the real danger
reactions will often gradually disappear.6 There is a risk that early
has passed. This cathartic reaction, which can be facilitated by
interventions unintentionally disrupt the normal recovery and processing
intervention, has been shown to predict a positive prognosis.23
More than any other type of helpgiving, disaster interventions need to
be highly organised and co-ordinated,
and they should be conducted in a
collaborative atmosphere.
In many disaster situations it is important to have a family focus.
Particularly with children, perceived safety is associated with the
assurance of continued contact with parents or other familiar caregivers. In the past, well-intended measures such as the evacuation of
children to safety have inflicted separation trauma.24 It is also
important for adults to be around someone they trust. Sense of safety
can be either promoted or undermined by group processes.25
Reliable information is important, ideally from an authority, in order
of events. During the early aftermath, ‘watchful waiting’ may be the
to neutralise rumours. Media may sometimes enhance anxiety and
recommended strategy.
This is the approach favoured by the UK’s
uncertainty by conveying information in a dramatic way. Many studies
National Institute for Health and Clinical Excellence.15 For those who do
have demonstrated that viewing television coverage of traumatic
not improve, subsequent targeting is necessary. While the triage of
events has been associated with later psychological distress among
physical injuries must be immediate, mass psychiatric screening has a
both children and adults.26–28 It is important to tell parents to restrict
longer time-frame; that is, a larger window of opportunity. Screening can
children’s television viewing because children have less capacity to
be accomplished by identifying high-risk disaster exposures and
understand the immediacy of threats. 29,30 For example, some
vulnerable individuals/families/communities, or by measuring post-
Norwegian children who experienced the 2004 tsunami believed that
disaster stress responses, all of which predict long-term psychopathology.
there had been several tsunamis because of repetitive presentations
Questionnaire screening followed by clinical interviews will help to
on television.
13
identify high-risk cases.16,17
Calming
In the following, we briefly review the five intervention principles
The psycho-physiological and neurobiological reactions that are activated
listed above, as well as some evidence for an additional principle:
by extreme stress – the fight, flight or freeze reactions – are deeply
controlled exposure.
embedded in the brain and not easily switched off. The accompanying
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emotions of anger, anxiety, psychic numbing, despair, etc. impair a
In order to reach the many affected in post-disaster situations, the
person’s sense of control and effectiveness. The myths of the
mental health professional has to work through others.50 This can be
helplessness of the disaster survivor and of the omnipotence of the
achieved by mobilising human networks such as families, neighbours,
disaster worker are likely to underestimate the capacity of the survivor to
friends and work-mates to provide social support. A ‘honeymoon
accomplish purposeful and relevant activities that are effective in
phase’, which frequently occurs after a disaster, creates an altruistic
regulating effects. Such activities will also empower the disaster victim.31
community characterised by out-reach and social support.
Calming techniques need to be employed in panic prevention and
treatment. A properly executed medical examination is an excellent
Mental health professionals must consider several factors when trying
psychological first aid. Psycho-education that emphasises the normative
to foster connectedness. Avoidant behaviour, personality styles and
and adaptive function of stress reactions is recommended.
effective coping strategies should be taken into account when
connecting with others. The ‘art’ of intervention involves balancing the
Medication is often used for symptomatic relief during the acute
need for contact with respect for avoidance, which is part of the post-
phase of a disaster. Facilitation of sleep is important because sleep
traumatic stress response.
deprivation reduces stress tolerance. The use of benzodiazepines in
the management of disaster stress reactions is controversial. They
Hope
initially have an calming effect, but they are shown to not decrease the
A disaster event creates strong feelings of helplessness and
risk of later PTSD.32,33 Interesting attempts have been made to use
powerlessness in victims as well as in many disaster workers. It is
propranolol34 and hydrocortisone35 in the acute phase to prevent post-
essential that helplessness is not transformed into hopelessness. This
traumatic stress reactions, but no conclusions can yet be drawn on the
risk is likely to be greatest among those who have suffered severe or
preventative effect of medical intervention.
multiple losses. Post-traumatic stress reactions after a disaster often
undergo a gradual reduction. Knowledge about this natural
Self-efficacy
attenuation can be used to foster hope. Quick and effective disaster
Psychologically traumatised people are hypersensitive to situations they
rescue, relief and reconstruction counter pessimism and catastrophising
cannot personally control. Providing a sense of control, whether real or
while also raising hope. Housing, employment and insurance
perceived, is important. Here, some theoretical concepts are useful, such
reimbursements help people to restore their lives and re-establish
as establishment of positive response, result and recovery expectancies.36
hope.12 Early CBT interventions counteract negative thoughts and
This can be achieved through encouraging support from a care provider,
install positive, action-orientated expectations about the future.
as well as self-regulation of thoughts, emotions and behaviour.37 In a
study of people who maintained mental health during and after
It is important not to pathologise grief. Grief is not an illness and
disastrous events, Antonovsky38 introduced the notion of ‘the sense of
should not be treated as such. Initially, prolonged grief cannot be
social coherence’ as a crucial factor for resilience. This notion consists
easily differentiated from normal grief: the two conditions manifest
of the combined effect of comprehensibility (i.e. true understanding of
similarly.51 The differentiation between acute depression and intense
what is happening to me), manageability (i.e. the ability to act and
grief, on the other hand, is important. Grief is characterised by
influence the situation) and the personal meaningfulness of the stressful
intense yearning for the deceased and pangs of sadness elicited by the
event. In contrast, a disaster experience that reactivates a latent identity
realisation of one’s loss.52 In contrast, depression is characterised by a
dominated by helplessness, powerlessness, pre-determined bad luck or
stable depressed mood, a lack of positive expectations, negative
the belief that the world is an evil place puts the person at high risk of
thoughts directed against one’s self and lowered self-esteem.
developing prolonged stress reactions.39 In contrast to individual trauma,
disasters offer a collective experience. Collective efficacy, or the belief
Controlled Re-exposure
that one’s group can achieve a positive outcome, has been shown to be
All effective psychosocial treatments of PTSD have one thing in
beneficial.40 People find strength in numbers.
common: in vitro or in vivo exposure. Exposure is important to
desensitise the nervous system, and it may be indicated for victims who
For a long time, strategies that enhance resilience have been advocated
avoid necessary life situations associated with the trauma. Early
by the military to reverse incapacitating stress reactions in combat-
attempts should be made to regain control over important life activities;
stressed soldiers.
Such stress management programmes include
survivors should be encouraged to ‘get back on the horse’. For those
recovery through activity and the positive expectancy of recovery.14 The
who are plagued by traumatic stress symptoms for many weeks or
efficacy of cognitive–behavioural therapy (CBT) in preventing
months after a disaster, a more systematic exposure therapy is useful.
prolonged PTSD is evidence-based.15,42–44 CBT promotes active coping,
For example, in one of our studies of Norwegian tsunami survivors, we
individual skills and self-help, elements that are critical for maintaining
evaluated the effect of returning to the disaster area under the
or restoring self-efficacy.
guidance of a psychiatric team.53 Participants were motivated survivors
41
who were still suffering from significant post-traumatic stress
problems. Considerable improvements in anxiety symptoms were
Connectedness
45,46
Fostering connection quickly after mass trauma is critical for recovery.
reported and observed in both adults and children. No apparent cases
Research evidence has demonstrated the importance of social support
of re-traumatisation occurred. Many stated that the visit to the disaster
such as sharing a group identity, having emotional contact, getting
area had given them a better perspective of events. This contributed to
practical help, receiving information and receiving social guidance and
the drawing together of discontinuous and fragmented images into a
limits. Social support serves as a buffer to stress, and is related to better
more comprehensible whole picture: that is, the mental processing of
emotional wellbeing and recovery following mass trauma.47–49
overwhelming impressions.
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Managing the After-effects of Disaster Trauma – The Essentials of Early Intervention
The above corresponds with both psychodynamic and cognitive theories
approximately 2–3,000 Norwegian tourists who were affected by
about how therapeutic processes take place. In the psychodynamic
the disaster. In a survey of all of the 1,500 RGPs who were responsible
approach, the therapeutic effect may be dependent on the patient
for victims, Hjemdal54 found that the concerns of RGPs about actively
reaching a coherent narrative of his or her experience. In cognitive theory,
calling their patients were not confirmed by the positive responses of
re-experiencing helps to correct distorted beliefs about one’s self and what
their patients to being contacted. This finding supports the usefulness
occurred, and helps to desensitise the conditioned fear response.
of the participation of RGPs in the psychiatric response to disasters.
Intervention by Whom?
For the mental health professional, disaster psychiatry is an interesting
In European countries with national health systems, it is possible to use
and demanding challenge. Knowledge in psychiatry is essential for
primary care physicians to systematically respond to psychiatric needs
the management of the disaster trauma. When it comes to
after a disaster. This is in accordance with WHO’s recommendation.3
implementation, however, some interventions may be more effective
For example, following the 2004 tsunami, Norwegian regular
when applied by other types of disaster worker. Future challenges
general practitioners (RGPs) were given the main responsibility for
include better co-operation between professions within the field of
the psychiatric evaluation, treatment and sometimes referral of the
disaster management. ■
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