• Community victims killed and seriously injured
• Bereaved family members, loved ones, close friends
• Community victims exposed to the incident and disaster scene, but not injured
• Bereaved extended family members and friends
• Residents in disaster zone whose homes were destroyed
• First responders, rescue and recovery workers
• Medical examiner’s office staff
• Service providers immediately involved with bereaved families, obtaining information for body identification and death notification
• Mental health and crime victim assistance providers
• Clergy, chaplains
• Emergency healthcare providers
• Government officials
• Members of media
• Groups that identify with target-victim group
• Businesses with financial impacts
• Community-at-large
POST-DISASTER REACTIONS
INDIVIDUAL REACTIONS AND CHARACTERISTICS
Clinicians have struggled with why disaster survivors, when exposed to identical trauma and tragedy, respond with considerable variability. Some individuals are able to incorporate the experience into their lives; others continue to feel devastated and overwhelmed, suffering lasting psychological problems that prevent them from moving on with their lives. In the immediate aftermath of a large-scale disaster, those individuals suffering direct exposure may typically be seen as most at-risk, but other individual characteristics influence how people respond and recover from disaster. Post-trauma reactions are expressed through different pathways: physical, behavioral, emotional, and cognitive (Table 15-2).
| EMOTIONAL EFFECTS | COGNITIVE EFFECTS |
|---|---|
• Shock • Anger and resentment • Anxiety and fear • Despair and hopelessness • Emotional numbing and apathy • Terror • Guilt • Grief and sadness • Irritability • Helplessness and loss of control • Feelings of insignificance • Loss of interest • Variability in mood (“mood swings”) | • Difficulty concentrating and thinking • Difficulty making decisions • Memory impairment and forgetfulness • Disbelief • Confusion • Distortion of sense of time • Decreased self-esteem • Decreased self-efficacy • Self-blame • Intrusive thoughts, memories, and flashbacks • Worry |
| PHYSICAL EFFECTS | BEHAVIORAL EFFECTS |
• Fatigue • Insomnia • Sleep disturbance • Agitation • Physical complaints • Headaches • Gastrointestinal problems • Decreased or increased appetite • Decreased or increased sex drive • Exaggerated startle response | • Crying spells • Outbursts and acts of aggression • Social withdrawal and avoidance • Relationship conflict • School and work impairment |
Possible post-disaster reactions include the following:
• A concern for basic survival
• Grief over loss of loved ones and loss of valued and meaningful possessions
• Fear and anxiety about personal safety and the physical safety of loved ones
• Sleep disturbances, often including nightmares and imagery from the disaster
• Concerns about relocation and the related isolation or crowded living conditions
• A need to talk about events and feelings associated with the disaster, often repeatedly
• A need to feel one is a part of the community and its recovery efforts
PSYCHOLOGICAL TRIAGE
Targeting interventions to those at greatest risk is both more efficient and more effective than attempting to provide mental health interventions to everyone who has been exposed. The following characteristics increase the likelihood of psychiatric morbidity and are ranked from most to least likely:
1. Threat to one’s life
2. Infliction of physical injuries
3. Exposure to the dead and mutilated
4. Witnessing unexpected and violent death
5. Learning of the unexpected and violent death of a loved one
6. Learning one has been exposed to chemical or biological toxins
7. Causing death or severe harm to another
8. Knowledge that the infliction of pain and suffering was deliberate (such as in the Oklahoma City bombing and the terrorist attacks of September 11, 2001)
PSYCHOLOGICAL FIRST AID
Psychological first aid (PFA) is currently considered as the intervention of choice in the immediate aftermath of a disaster. Although there is no evidence-based literature supporting the efficacy of this intervention at the time of this writing, many components of PFA are based in crisis intervention and stress management approaches.
The concept of psychological first aid is similar to that of medical first aid in that we are trying to sustain life, promote safety and survival, comfort and reassure, and provide protection to those who have experienced a traumatic event. PFA helps people get through the immediate phase of the disaster by building on their existing resources and helping develop a sense of empowerment and safety.
Once exposure to a disaster has already occurred, efforts must then be directed toward the reduction of psychological harm (Tables 15-3 and 15-4).
| FIRST AID | COMMENT |
|---|---|
| Remove individuals from ongoing trauma. | If patient is showing signs of acute stress disorder, encourage patient to rest and assist in connecting with available sources of social support. |
| Educate patients. | Individuals will be comforted by knowing that their reactions are normal after experiencing extreme stress. |
| Prevent retraumatization. | Limit number of persons with whom victims must interact in order to receive services, and also reduce amount of red tape required. |
| Prevent new victims. | Limit number of people exposed to sights, sounds, and smells of a disaster site, whenever possible. |
| Prevent “pathologizing” distress. | Avoid labeling normal reactions as pathological; this can prevent symptoms from being interpreted as a medical condition or disorder that requires treatment. |
| Allow silence. | Silence gives survivor time to reflect and become aware of feelings; “being with” survivor and his/her experience is very supportive. |
| Attend nonverbally. | Eye contact, head nodding, and caring facial expressions let survivors know you are in tune with them. |
| Actively listen. | Repeating portions of what person has said conveys interest, understanding, and empathy; paraphrasing also clarifies meaning and checks for misunderstandings. |
| Reflect feelings. | If survivor’s tone of voice or nonverbal gestures suggest anger, sadness, or fear, the worker may state, “You sound/appear angry, scared, etc.; does that fit for you?” This helps survivor to identify and articulate his/her emotions. |
| Allow expression of emotions. | Expression of intense emotions through tears or angry venting is an important part of healing; it often helps survivor work through feelings so that he/she can better engage in constructive problem solving; workers should stay relaxed, breathe, and let the survivor know that it is okay to feel these emotions. |
| DO SAY | DON’T SAY |
|---|---|
• These are normal reactions to a disaster. • It is understandable that you feel this way. • You are not going crazy. • It wasn’t your fault; you did the best you could. • Things may never be the same, but they will get better, and you will feel better. | • It could have been worse. • You can always get another pet/car/house. • It’s best if you just stay busy. • I know just how you feel. • You need to get on with your life. |
THE PUBLIC’S REACTION
People who have experienced terrorism or a natural disaster may have a wide range of reactions, but panic is not a common one; more often helpful and adaptive behaviors prevail. Fear should not be misunderstood or mislabeled as panic; it is a normal and often appropriate response to very frightening circumstances. However, the possibility of mass hysteria/panic still exists. Mass hysteria/panic has been referred to as a condition when individuals are consumed by such an enormous fear that their actions are conducted solely in self-interest and, as such, their actions lead to loss of social organization, loss of social roles, and overall chaos. Providing clear and concise information as well as specific tasks may lessen panic and increase the sense of control.
ENVIRONMENTAL EFFECTS
• Civil unrest
• Hoaxes
• Mass suicide
NURSING IMPLICATIONS
• Treating patients with medically unexplained physical symptoms; this may not differ from routine emergency care in that the etiology of symptoms is often unknown.
• Prepare to treat fractures and head injuries that may result from a mass exodus or public panic.
PSYCHOLOGICAL CONDITIONS
ACUTE STRESS DISORDER (ASD)
Acute stress disorder is the disorder most likely to be encountered by the disaster response team.
• Signs and symptoms: anxiety; dissociation
• Onset: within 1 month of trauma
• Duration: minimum of 2 days
If symptoms persist longer than 4 weeks’ post-trauma, a diagnosis of post-traumatic stress disorder (PTSD) should be considered. For the diagnosis of PTSD to be made, the person should have been exposed to a traumatic event in which both of the following were present:
1. 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.
2. The person’s response involved intense fear, helplessness, or horror.
Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:
1. A subjective sense of numbing, detachment, or absence of emotional responsiveness
2. A reduction in awareness of his or her surroundings (e.g., “being in a daze”)
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