Psychosocial Responses to Disaster and Exposures: Distress Reactions, Health Risk Behavior, and Mental Disorders

Fig. 8.1

Mental health responses to disasters and emergencies

Knowledge of psychosocial responses to disaster comes from extensive observation of community behaviors following natural and man-made disasters [4]. In addition, there is evidence from recent and historical nuclear accidents and the field of bioterrorism that enhance our understanding of how individuals and communities specifically respond to fears of exposure to chemical, biological, radiological, and nuclear material [5, 6]. Patterns of psychosocial response are influenced by community and cultural characteristics. The response of community leaders and technical experts to a disaster can influence the distress and behaviors of disaster communities, both positively and negatively.

Nuclear accidents have two characteristics that are of importance to understanding their unique psychosocial response. First, these incidents are heavily influenced by human factors. Second, nuclear accidents involve uncertain exposure to hazards not well understood by the general population. Very few people understand the risks posed by nuclear material and contamination. Usually anything nuclear or associated with radiation is seen as an ominous threat that generates responses out of proportion to actual danger. Credible and accurate risk communication is essential to disaster recovery. Community responses to past nuclear exposures, including World War II, Three Mile Island, Chernobyl, and Fukushima, demonstrate that psychosocial consequences were greater than the actual illnesses and injuries directly attributed to radiation or contamination. Understanding community response to nuclear accidents offers valuable information to assist governments, community leaders, and healthcare personnel.

8.2 Psychosocial Responses to Disasters

8.2.1 Distress Reactions, Health Risk Behaviors, and Mental Disorders

In the immediate aftermath of a disaster, distress reactions predominate. Individuals feel a sense of vulnerability and often engage in blaming, scapegoating, and expressions of anger at government and other leaders perceived as responsible. Demoralization and a loss of faith may also occur. Many individuals experience insomnia, irritability, and feelings of distractibility [7]. Some individuals present to healthcare settings with physical symptoms as a manifestation of psychological distress [8]. Symptoms such as headache, dizziness, nausea, fatigue, and weakness are common in the wake of a disaster even when an identifiable physical disorder cannot be found [9]. These are normal reactions to an extraordinary event. Planning for these distress reactions requires ensuring adequate resources to respond to individuals with distress symptoms in a timely and supportive manner and triage at emergency care settings to enable management of other physical and mental disorders.

In addition to distress responses, several health risk behaviors are known to increase following disasters. Increased use of alcohol, caffeine, and tobacco are common coping mechanisms and often represent self-medicating of distress symptoms [10]. Reduced use of social activities and self-imposed travel restrictions occur as well and may result in decreased access to social support networks and adverse economic impacts on the larger community [11]. Following disasters, intimate partner violence and overall levels of violence may increase as family distress and community concern about resources are increased [12].

Some individuals develop mental disorders following a disaster. The most widely studied of these disorders (but not the only one) is posttraumatic stress disorder (PTSD) [13]. Many studies suggest that approximately 10–20 % of those exposed to a traumatic event will develop PTSD, though many more individuals will experience milder symptoms, which can persist and become problematic over time [14]. The course of PTSD varies with some individuals recovering and some showing symptoms long after the initial incident (See Fig. 8.2). Posttraumatic stress disorder is not the only trauma-related disorder nor perhaps the most common [15]. People exposed to disaster are at increased risk for depression [16], generalized anxiety disorder, panic disorder, and increased substance use [17]. In some studies, suicide rates have also been shown to increase although this is not universal [18].

Fig. 8.2

Traumatic stress responses over time. Line 1 represents acute stress symptoms that resolve with time; 2 depicts ASD that also resolves; 3 is ASD that progresses to PTSD; and 4 shows delayed onset PTSD

8.2.2 Unique Aspects of Nuclear Exposures

Nuclear incidents can affect very large numbers of individuals and involve technological failures or be the result of man-made errors leading to exposures. They result in unique psychosocial responses related to the uncertainty of an invisible and mysterious chemical agent along with fears of permanent contamination (See Table 8.1). The inability to see and touch radiation and its depiction in books, movies, and other popular media as a frightening and inescapable force cause nuclear spills to produce adverse psychosocial responses that significantly exceed the actual health risks [6]. While many people have preconceptions about the impact of nuclear material, information and education are important aspects of population health management. In the aftermath of nuclear exposure, open and honest communication from government officials and leaders involved in managing the incident is critical in building trust and alleviating psychological distress [19].

Table 8.1

Unique psychosocial responses to nuclear exposure

Contamination fears

Chronic focus on bodily symptoms

Poor perception of self health

Long-term distress and worry

Mistrust in authority

World War II introduced the world to the extraordinary psychosocial effects of large-scale nuclear exposure that resulted from the use of atom bombs during war. Atomic bomb survivors in Japan experienced a chronic fear of long-term contamination, increased worry about their physical well-being, and an ongoing sense of harm and bodily deterioration despite extensive education about the science and medical impact of nuclear exposure [20]. Many years after the incident, these individuals continue to attribute new physical symptoms to nuclear exposure despite medical reassurance these symptoms were unrelated.

In more recent history, accidents at Three Mile Island, Chernobyl, and Fukushima have further demonstrated the widespread and long-lasting psychosocial effects that occur in the aftermath of a nuclear exposure. The accident at Three Mile Island was a partial nuclear meltdown that occurred in 1979 in one of the two Three Mile Island nuclear reactors in the United States. It was the worst accident in US commercial nuclear power plant history. Nearly 1 year later, incident responders had elevated levels of distress [21]. Following the restart of the reactor 6 years after the incident, local residents reported increased anxiety and worry, specifically due to fear of cancer and loss of trust in the authorities [22]. For nearly 10 years post-incident, Three Mile Island residents were found to have increased levels of distress and persistent elevation in blood pressure when compared to similar people who were living at greater distance from the incident [23].

Chernobyl, the site of a nuclear power plant explosion in 1986, was the most disastrous nuclear accident until the incident at Fukushima in 2011. The Chernobyl incident resulted in feelings of helplessness regarding long-term health as well as decreased fertility rates, the latter suggesting a more negative future outlook on life [19]. Research also revealed high levels of general psychological distress and persistent focus on physical symptoms, not unlike the experience of World War II survivors documented by Lifton [24]. Nearly a quarter century after the events at Chernobyl, those who served as first responders, cleanup workers, and mothers who had small children at the time of the incident continue to experience elevated levels of depression, anxiety, and posttraumatic stress and report themselves as having poor health [25]. The lack of trust held by citizens in government and authorities appears to have played a major role in the development of long-term health effects following Chernobyl, demonstrating the importance of the relationships between government and citizens in affecting population health [26].

The disaster at Fukushima in 2011 was a unique hybrid event that included a tsunami, earthquake, and subsequent nuclear exposure. In addition to an increase in depression, anxiety, and PTSD, increased rates of delirium and psychosis were reported in the early aftermath of the disaster, most notably in those who were displaced from their home [27]. In the 7 months following the event, suicide rates were reported as increased among females in disaster-stricken areas [28]. Similar to other historical nuclear disasters, increased anxiety and distress were associated with fears of exposure and contamination, suggesting the need for education of both citizens, and relief workers remain as critical aspects of managing a nuclear exposure [29].

Because of the unique psychological and medical challenges that result from a nuclear exposure, advance planning for these types of catastrophic events is important to aid governments, responders, and victims [30]. Effective planning and preparedness may represent our best hope for reducing adverse psychosocial consequences.

8.3 Psychosocial Stages of Disaster Response

Governments and organizations that plan for and respond to disaster events need an understanding of the emotional and behavioral responses to disaster events. Often, there are phases to this response (See Fig. 8.3). Individuals or communities do not progress through these phases at exactly the same time or the same order. However, an understanding of the psychosocial factors that predominate in each phase (See Table 8.2) is helpful for policy development, response planning, and the training and education of personnel that deliver services to disaster victims [3, 31].

Fig. 8.3

Phases of a disaster

Table 8.2

Psychological and behavioral symptoms during disaster phases

Pre-disaster	Vulnerability, worry, remorse
Impact	Fear, confusion, numbness, disbelief
Heroic	Flashbacks, hyperarousal, anger, irritability, physical symptoms
Honeymoon	Collaboration, hope, optimism, openness to mental healthcare
Disillusionment	Disappointment, resentment, fatigue
Reconstruction	Acceptance, finding meaning, posttraumatic growth

8.3.1 Phases of a Disaster

A pre-disaster phase begins when an event is anticipated or advanced warning is given. This phase is highlighted by feelings of vulnerability and worry about safety. Individuals who do not heed advanced warnings to take recommended actions, such as sheltering in place or evacuation, may also experience significant remorse and feelings of responsibility for subsequent injury to loved ones or damage to property.

The impact phase occurs immediately after an acute event and consists of strong emotions, including feelings of disbelief, numbness, fear, and confusion. During this time, if the scope of a disaster broadens, the psychological effects typically increase. The impact phase may be brief, such as an earthquake. It can also be very long as in a slow-rising flood or an undetected radiological leak. Duration will affect both the response and the impact. In addition, the response of a population is affected by the culture and history of communities. Incorporating cultural understanding of communities and their values, leadership, and support systems is an important element of effective planning and response efforts.

Next is the heroic phase. This phase often lasts days to weeks in situations involving a short event period, but may be extended in disasters that occur over a longer period of time. Injury of loved ones or separation of family members can increase anxiety and worry and decrease the energy available for immediate problem solving. This phase is frequently accompanied by the initial appearance of assistance from outside communities, government agencies, or other countries. Disaster victims begin to adapt to the new environment and outsiders appear in the disaster community. Convergence begins during this phase, as people come into the disaster zone looking for family, friends, and even pets from which they have been separated. There is also a gathering of displaced individuals who have fled their homes. Intrusive symptoms (distressing recollections of explosions, fire, building collapse, and others, in the form of flashbacks or nightmares) emerge during this phase. Hyperarousal is also common, where individuals constantly feel tense and irritable. Physical symptoms, such as fatigue, dizziness, headaches, and nausea, along with anger, irritability, and social withdrawal, may also emerge. During this phase, personnel providing mental health interventions recognize the normal range of emotions and behaviors and respond to disaster victims with empathy, caring, and support for basic elements of living.

The honeymoon phase often follows. This coincides with more extensive availability of government and volunteer assistance and community bonding as a result of sharing the catastrophic experience as well as the giving and receiving of assistance. Survivors are often more hopeful during this phase and experience an optimism that the help they will receive will make them whole again and restore their lives to “normal.” Governments can use this time to build positive relationships with affected communities by ensuring basic needs are met for food, water, and shelter and that resources are distributed equitably. In addition, clear and effective communication about what type of aid will be provided assists with setting expectations and helping reduce uncertainty. Providing disaster response workers with items necessary to live and work safely and effectively can reduce the diversion of resources intended for victims. Disaster workers who are specifically aiding with psychosocial issues are most likely to be perceived as helpful during this phase, be readily accepted by community members, and develop a foundation from which to provide assistance in the difficult phases ahead.

Commonly, a disillusionment phase follows this honeymoon. Disillusionment is marked by feelings of disappointment and resentment, as disaster assistance agencies and volunteer groups begin to withdraw from the community. The magnitude of individual and collective loss may be realized. Hopes for aid and restoration of the pre-disaster emotional and physical environment may not be fully met. Individual and community economic losses may add to an already stressed population. The sense of community is weakened as individuals focus on their personal needs or the extent to which these needs are still unmet. Resentment may surface as survivors receive unequal compensation for what they perceive to be equal or similar damage and issues of social justice emerge. In addition, neighboring communities less impacted by the disaster often return to life as usual, which can discourage and alienate those who were more severely impacted. During this phase, survivors may become physically exhausted due to the enormity of multiple demands, including financial pressures, family discord, bureaucratic hassles, and a lack of free time for recreation or self care. Long-term displacement and loss of familiar home and surroundings can be a particularly challenging stressor. Health problems and exacerbation of preexisting conditions emerge due to ongoing stress and fatigue. Governments can anticipate difficulties as disaster assistance begins to diminish and provide survivors with anticipatory guidance in advance. Unity among formal and informal community leaders in anticipating and communicating upcoming changes or transitions is helpful. The disaster “anniversary” experience may occur during this phase and can be a critical opportunity for leaders to support disaster victims. This can be done through memorializing and creating meaning from the devastating events that have occurred. Failure to effectively address a disaster anniversary experience can further demoralize survivors, enhance feelings of frustration, and exacerbate underlying psychosocial distress.

The final phase often seen is that of reconstruction which may last for years. Survivors attempt to rebuild their lives and social and occupational identities by returning to old jobs or finding new work. They will also rebuild homes and resume or establish new social ties and emotional support systems. For some survivors, this phase is marked by an acceptance of new circumstances, including the changes and losses that have occurred. Individuals who are able to find meaning may experience posttraumatic growth, ultimately emerging from the disaster event with an increased sense of personal strength.

Individuals may progress through these phases at variable rates. Persons involved in planning and delivering care to victims of disasters may observe that individuals show emotional symptoms over different timelines in response to the same event. Moreover, depending on the severity of the trauma, available resources, coping skills, as well as subsequent disasters or other types of setbacks, individuals may develop persistent symptoms requiring prolonged treatment. Anger may be directed at caregivers and community leaders if these important factors are not sufficiently accounted for in medical and psychosocial response plans.

8.4 Managing Individuals and Populations Concerned About Nuclear Exposure

Because of the unique nature of a nuclear exposure, it is important for healthcare personnel to understand how radiation impacts the human body, basic facets of triage, early medical interventions, and the psychosocial aspects of how individuals respond to nuclear events.

8.4.1 Medical Aspects of Nuclear Exposure

A nuclear event can result in external as well as internal exposure to radioactive material. Material on clothing can be removed by undressing or showering with water. Radioactive material that has entered the body is much harder to remove [32]. Unlike chemical and biological exposure, a radiation event is not immediately life-threatening unless there are other injuries (such as trauma or burns) or the dose received is in a range that is always fatal [33]. In most situations, a person injured or contaminated by radiation poses no significant risk to healthcare personnel. An exception would be if a radiation source was planted and concealed on a patient and the treatment provider has sufficient contact to receive a large dose [32].

Early radiation signs and symptoms can be nonspecific and often resemble those of a viral illness, usually starting within 72 h of an acute exposure. These signs and symptoms include fever, headache, nausea, vomiting, diarrhea, abdominal pain, loss of appetite, fatigue, weakness, rapid heart rate, swelling of glands in the face, and reddening of the skin. Many of these are nonspecific and resemble those accompanying common viral illnesses. As a result, small-scale or unknown radiation exposures often result in patients being misdiagnosed with a viral illness or other self-limiting illness [32, 33]. In a large-scale nuclear incident, healthcare personnel should maintain a much lower threshold for initiating a full evaluation for possible radiation injury. In addition, some of the signs and symptoms of early radiation exposure may be confused with those that accompany distress reactions and mental disorders.

All radiation exposure is thought to increase the lifetime risk of cancer with no set point at which cancer begins. This “linear, no threshold” theory drives the occupational exposure standard of keeping radiation exposure “as low as reasonably achievable” (or ALARA). Whether “linear, no threshold” is valid is the subject of much debate. Some areas of the world have very high background radiation levels with no increase in the cancer incidence [32].

8.4.2 Assessment of Those Presenting with Concerns for Nuclear Exposure

Individuals typically experience varying levels of radiation exposure and at different periods of time after a nuclear incident. Some will have received no exposure. Others may have received a dose of radiation that is only associated with late effects such as cancer risk or cataract development. If there has been a high-dose exposure, acute illness or death can follow after only a few days to weeks. These individuals may also have adverse psychosocial responses in addition to signs and symptoms of radiation exposure [3].

Triage of large groups of people may be necessary [34]. This starts with broadly delivered, repeated, and updated public health messages from a trusted and credible source or officials about who should seek care. The objective is to categorize exposure or contamination risk so that individuals can take appropriate action. The message should state the geographic boundaries within which individuals could be at risk of radiation injury. Individuals beyond such boundaries can be informed to avoid seeking medical attention for radiation concerns alone, unless other medical emergencies occur. Those contaminated or very close to the event will need a medical assessment of radiation dose received, since early treatment of radiation injury enhances long-term survival unless the dose was very high [33]. When thorough evaluation reveals no evidence of exposure, individuals should be promptly informed of this fact to help decrease worry and anxiety [35].

Competent and confident medical response, triage, and assessment will likely decrease the incidence and severity of adverse psychosocial effects [29]. When individuals express concerns about radiation exposure, it is important to assure them that their concerns are being taken seriously. When people do not feel their concerns are being taken seriously, they may exaggerate symptoms or return frequently for evaluations, placing increased demands on already limited healthcare resources.

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