In the aftermath of Hurricane Sandy, opinions -- some reliable, some misleading -- about the storm's potential mental health impact have proliferated. When media channels act responsibly, they engage experienced experts as spokespeople; when that does not happen, wrong information adds to the public's anxiety and can foster inappropriate clinical interventions and waste resources.
In the latter category, perhaps the greatest myths I have heard are:
- Post-traumatic stress disorder (PTSD) can appear in the immediate wake of a disaster.
- Watching television can cause PTSD.
- The highly common psychic distress in the wake of a disaster is a mental illness.
Here are some facts:
Psychic distress after a disaster, which can be highly prevalent and last up to a month, generally is a normal reaction to an abnormal situation. This is known as an "acute stress disorder" (ASD).
Many people experience ASD after exposure to a traumatic event in which they felt intense fear, helplessness or horror. A person who experiences it is deeply shaken and cannot stop thinking about the event; he or she may have difficulty sleeping, and may be jumpy or irritable or cry easily. Taking care of everyday business is hard, and socializing is no longer fun. The person may smoke or drink more and withdraw from others.
These symptoms can impair functioning at school or work and within the family.
For a diagnosis of ASD to be made, the condition must come on within four weeks of a trauma and last more than a couple of days. If significant symptoms persist for longer than a month, it is likely that the ASD has progressed to PTSD (see below).
Watching television ceaselessly can aggravate a person's distress, so people should limit their television viewing so that they remain informed but not compound their worries. Parents should monitor what their children watch. They should also provide them reassurance and hope, since children do well when they feel protected and comforted by those they depend upon and trust.
PTSD is a more persistent and severe response to trauma than ASD, which always precedes it. Symptoms of PTSD include re-experiencing of the traumatic event, avoiding cues of the trauma, emotional numbing that can become consuming, and persistent symptoms of heightened arousal. PTSD can only be diagnosed if it has been at least a month since the catastrophe.
There are other conditions besides PTSD that commonly emerge in the days, weeks and months after a disaster. These include depression; anxiety disorders other than PTSD such as generalized anxiety and agoraphobia; alcohol, tobacco and drug overuse and abuse; and worsening of pre-existing mental and addictive disorders.
A singular focus on identifying PTSD is apt to miss these other serious and potentially disabling conditions, which can exist independently or occur alongside the disorder.
The more life-threatening and ghastly the disaster, and the greater the degree of what is called "exposure" -- when a person experiences direct and continuous visual, olfactory, and auditory sensations after the disaster -- the more likely a traumatic state will ensue.
Direct victims of a disaster are at greatest risk of developing post-traumatic emotional problems, followed by rescue workers, followed by some of the general public. Once PTSD sets in there is evidence that it can and does persist, especially for those with early onset of the symptoms.
No definitive psychological profile characterizes those who are apt to do poorly after a disaster, except for those who already had poor coping skills. People with active or past mental disorders or who have been previously traumatized are also at greater risk. Yet not everyone exposed to a severe traumatic event will develop ASD or PTSD. In fact, most will not.
Perhaps the safest and most effective disaster mental health approach that has evolved from experience emphasizes careful listening to assess a person's response, assessment of an individual's capacity to cope and their risk of self-destructive behavior, non-judgmental education to help a person appreciate that their response may indeed be a "normal response to an abnormal situation," and urging people to seek support from those they can trust. Practical coping strategies, such as getting sleep, not being alone and not abusing alcohol and drugs -- coupled with the realistic provision of hope -- are also essential.
Psychological first aid, which employs many of these approaches, is becoming a standard of care for trauma victims. Individuals can benefit from being in a calm setting and a supportive environment, and when possible, psychological first aid is delivered in the affected community, making use of its local constituents to establish trust and ensure cultural and linguistic competence. Health-care workers are tasked with first making sure that those they see are physically and psychologically safe. Individuals showing extreme reactions are identified and referred to professional treatment when possible.
Seeking assistance need not be shameful, and should be encouraged by public authorities and others.
Because post-disaster disorders like depression, anxiety, PTSD and abuse of alcohol and drugs can emerge many months after an event, public messages can be very useful when maintained over time.
After 9/11, the effort to get first responders -- uniformed personnel including firefighters, police, emergency medical technicians and other health-care workers -- mental health services included a powerful ad campaign with the message "Even Heroes Need to Talk." It is only over time that first responders may begin to suffer problems and need communication about how to seek help for themselves.
Perhaps the greatest lesson we have learned from natural and human-made disasters is how resilient most people can be. But one should not go it alone in the face of disaster, whether an individual, community, city or nation.
A disaster experience can be indelible in a person's memory and can put lives on a very different trajectory, but that does not mean one's response is an illness. We know that the more we support one another and understand and respond to family needs and the needs of our neighbors and community, the more likely we will be able to manage trauma -- with unfortunate distress, but without disorder.
For immediate assistance, people with psychic distress that exceeds what family and friends can provide have many places to turn. The American Red Cross is on-site and familiar with the emotional aftermath of a disaster. Family physicians, clergy and local mental health clinics are also important resources for people who need further assistance. Information and referral services are also promptly and capably available in New York City 24 hours a day from Lifenet (1-800-LIFENET). Other impacted communities can turn to the National Suicide Prevention Lifeline (1-800-273-TALK (8255)), whose services extend far beyond suicide prevention.
For more by Lloyd I. Sederer, M.D., click here.
For more on mental health, click here.
Galea S, Nandi A, Vlahov D (2005). "The epidemiology of post-traumatic stress disorder after disasters." Epidemiological Reviews 27, 78-91.
Sederer LI, Lanzara CB, Essock SM, Donahue SA, Stone JL, Galea S (2011) "Lessons learned from the New York State mental health response to the September 11, 2001 terrorist attacks." Psychiatric Services 62, 1085-1089.
Edited by Elaine Meyer