Psychological Reactions after Disasters

Abstract

As the world’s population increases and resources are limited, societies become increasingly vulnerable to disasters. Regardless of the objective destructive effects, the psychosocial effects and consequences of natural disasters are quite clear in humans. Natural disasters exert different psychological effects on the exposed people, including but not limited to Post-Traumatic Stress Disorder (PTSD), depression, anxiety, and suicide. Yet, disasters can cause positive reactions. For example, through post-traumatic growth, one takes new meaning from his or her trauma and resumes living in a way completely different from their life prior to the trauma. Additionally, many people display remarkable resilience in the wake of the disasters they struggled with. Many factors such as disaster type, level of destruction, duration of disasters, timing (time of day, day of week, season) also individual indicators such as age, gender, marital status, education, pre-disaster mental health, social and economic status, and resilience are affecting the consequences of disasters. Given the many studies that focus on post-disaster psychological outcomes, in this chapter, we not only describe outcomes but also discuss psychosocial support in disasters.

1. Introduction

About 200 million people are annually exposed to disasters worldwide, according to the Centre for Research on the Epidemiology of Disasters [1]. Definitions of disasters have varied in the literature. Some authors have defined disaster as a serious disruption in the functioning of society due to an event or natural disaster such as an earthquake, flood, tsunami, etc., leading to environmental, human, economic, and biological damage [2]. On the other hand, Davidson & Baum defined disaster as the subjective psychological response to any event [3]. Regardless of the definition, many studies indicated that disasters have both objective destructive effects and psychosocial effects and consequences [4].

Today, there is extensive information based on studies on psychological and behavioral issues caused by natural disasters. A systematic review showed that the burden of PTSD among persons exposed to disasters is substantial [5]. Other adverse psychological outcomes such as depression, anxiety, stress, and suicide were also mentioned in some studies as disasters’ outcomes [6]. For instance, the prevalence rates of depression among youth post-disaster reported in a review ranged from 2 to 69%. This rate depended on potential risk factors identified, including female gender, exposure stressors, and post-traumatic stress symptoms [7]. Although mental disorders usually decrease in the second year after the disaster, in some cases, complications remain chronic [8]. Another critical issue is the vulnerability of the people themselves and the possibility of previous disorders in these people, which will undoubtedly lead to more severe reactions [9]. The simultaneous presence of several mental illnesses increases the intensity of mental damage. The most common disorder we deal with is post-traumatic stress disorder (PTSD), although in many cases, we find this disorder together with other disorders [10]. The most common co-occurring disorders are major depression, panic, and phobia. In fact, after a disaster, mental disorders attack a person, such as multiple injuries [11].

In addition to the negative psychological outcomes of disasters, there are some positive consequences, such as post-traumatic growth (PTG). For some people, exposure to disasters or any traumatic events, which may contain great suffering and loss, can lead to very positive changes in the individual [12]. About 30–90% of people with traumatic experiences at some point in their life have reported at least one form of PTG [13]. Different traumatic events have different effects on PTG, with people with severe trauma reporting greater benefits, and chronic events can have very different psychological effects than acute events [14]. In general, PTG refers to positive psychological changes and greater growth than the pre-crisis level of performance, which through cognitive reconstruction makes the person adapt to the new reality [14].

Another object that is related to psychological outcomes after disasters is resilience. There are many resources of stress in life; also, there is so much variability in how people respond to and manage life’s stressors. Resilience refers to the process of a person’s return to normal functioning after a stressful event or uncomfortable experience, but PTG refers to growth compared to the pre-disaster situation. We will explain this in a separate section [15].

Furthermore, the research results related to mental reactions after disasters give us a view of the common disorder and the needs of the survivors. We tried to explain psychosocial support in disasters according to our experiences after defining resilience.

2. Psychological reactions after disaster

2.1 Common reactions and symptoms following a disaster

Following the occurrence of severe mental stress caused by a disaster, a group of symptoms and disorders appear in people, which can have an adverse effect on their performance. In some people, we are faced with only one symptom, and in others, we are faced with a combination of symptoms that, if not addressed, can lead to chronic mental disorders. The degree of influence of people from the surrounding events is essentially a function of the previous vulnerability, the extent of the disaster, and the amount of destruction and loss, as well as the status of support and timely attention to the psychosocial issues of the people [16]. Symptoms that are commonly seen in disaster survivors include:

1. Disturbing thoughts: Among the most unpleasant phenomena that children and adults experience after traumatic events are disturbing memories, thoughts, and feelings. These memories may come unread and unwanted at any time of the day due to depression or in response to environmental reminders. They may appear at night in the form of nightmares or terrible dreams [17]. Since these memories are very bright and scary, they impose a lot of psychological pressure on the person. Many people are afraid of going crazy or losing control after such experiences. Therefore, one of the main goals of group counseling sessions is to make people understand that such reactions are normal and do not cause insanity, and they should also be taught skills to control these recurring memories so that they can deal with these memories and have control over them.

2. Over-arousal: Children and adults may show increased psychological arousal after traumatic events. Therefore, people may feel nervous, restless, anxious, and panic very quickly. They may become agitated, suffer from tinnitus, and may experience excessive japer dine or concentration problems [18]. A person’s performance in terms of social relationships and academic as well as occupational performance is strongly influenced by over-arousal, which in turn exacerbates the experience of distressing memories. The negative and direct effect of excessive arousal on a person’s life and its possible role in strengthening other annoying, stressful symptoms after a disaster means that this area is one of the important parts of intervention and prevention in this field. The training of relaxation skills plays a fundamental role in preparing a person for confrontation work and gradual exposure to factors that cause over-arousal [19].

3. Avoidance: Avoidance may be cognitive and conscious (i.e., trying not to think and remember disturbing events); or it may be in the form of behavior (that is, trying to avoid factors that remind of painful and disturbing events, such as some places and people; and avoiding talking about the incident). Among other avoidance symptoms, the following can be mentioned Manifestation: lack of interest or a significant decrease in interest in dealing with important matters, feelings of heartbreak or strangeness among others, a feeling of not knowing everything (for example, he does not expect to have a job or get married and have children) [20]. Avoidance symptoms should be considered targets of interventions for two main reasons. First, avoidance may cause limitations in a person’s performance, which in this case has a direct effect on a person’s life. Second, although avoidance may cause temporary and short-term relaxation, it will keep problems in the long run. Annoying symptoms can cause avoidance behavior, and following avoidance, the processing of information about the incident is disturbed, and finally, a defective cycle is formed, the result of which is the aggravation of symptoms. Also, we should remember that although avoidance will bring peace in the short term, it will cause more anxiety and tension in the long term [21].

4. Sleep disorder: It can be said that most of the survivors of unexpected events suffer from sleep disorders at some point in time. All the changes that have occurred around people, including loss of loved ones, fear of possible future events, loss of assets, and change of residence, can lead to sleep problems [22]. Sleep problems can exist alone or together with other symptoms, especially symptoms of hyperarousal [23]. The disorder is usually in the form of difficulty falling asleep, lack of continuity of sleep, and nightmares. In addition to being annoying for a person in itself, sleep problems cause a delay in mental balance and are affected by other symptoms, such as the repetition of disturbing thoughts [24]. In fact, the various symptoms seen in people following disasters can lead to the formation of a vicious cycle and ultimately intensify each other. On the other hand, daily fatigue and lack of energy renewal during the night hours can cause damage to the cardiovascular system and the immune system and make a person susceptible to the occurrence of diseases.

5. Grief reaction: Grief is a reaction that occurs naturally in response to the loss and lack of what a person has depended on. Loss can be due to the loss of relatives and friends, assets and belongings, or a person’s future career [25]. It should be remembered and emphasized that grief is completely normal, and we naturally expect such a reaction after unexpected events [25]. Grief reaction is a set of emotions that are different depending on the culture that governs the society. Naturally, this reaction is expected to resolve within two months. The severity of the symptoms and the time of their occurrence also play a role in determining whether this reaction is normal or abnormal. In general, the intensity of the mourning reaction should be proportional to the loss that the person is facing, to be resolved within 2 months, and not started late. Its symptoms should gradually decrease, and the bereaved person should be able to return to their previous level of performance within 2 months. In fact, mourning is a process that ultimately leads to the acceptance of abandonment by humans [26]. In some cases, people are wrongly prohibited from expressing their feelings, crying and mourning, and refraining from expressing feelings is interpreted as “resistance.” In certain conditions, the probability of morbid grief increases, including in cases where the loss was very extensive, accompanied by great panic, or happened very quickly, in cases where the person already had a high vulnerability, was isolated, and lacked a social support network, or suffered from disorders such as depression [26]. Also, people who somehow consider themselves involved in the occurrence of the accident or the extent of its effects are more prone to abnormal reactions during mourning. The role of specialists who work in the field of psychosocial interventions is to facilitate the mourning process. In order to achieve this goal, we can also seek help from religious leaders.

2.2 Common mental disorders following disasters

The executive policy of mental health officials should be focused on normalizing reactions caused by disasters. In fact, it should be acknowledged that most of the reactions that occur after disasters are natural reactions to the very unusual incident. One of the general goals of psychosocial support during disasters and unexpected events is to empower the victims and improve their adaptive mechanisms. A disease-oriented approach in community-based psychiatry in disasters will be a serious obstacle to reaching these goals. Therefore, the use of the words disease and disorder should be done very carefully. Of course, there is no doubt that depriving the victims of proper treatment when a definite diagnosis of a psychiatric disorder is involved is also an unethical act, and in necessary cases, there may be a need for more serious treatments, even hospitalization.

The most common disorders that are observed after unexpected events are: acute stress disorder, post-traumatic stress disorder, depression, abnormal grief, somatic disorders, and various anxiety disorders [27].

1. Acute stress disorder: This disorder occurs in situations where a susceptible person has experienced traumatic events with the threat of death or serious harm to his or others’ health and, following this experience, a feeling of intense fear and panic accompanied by all or some of the following symptoms:

   • Feeling numb and emotional indifference

   • Decreased awareness of the surrounding environment

   • The feeling of unreality of oneself or the feeling of unreality of the world around us

   • Psychogenic forgetfulness

The traumatic event may be repeated by itself or following thoughts, dreams, sensory errors, repetition of memories by the people around, or the feeling of the incident happening again for the survivor [28]. Avoidance is one of the common and obvious symptoms of this disorder because the person tries to avoid recalling painful memories and re-experiencing the arousal caused by them. Different types of sleep disorders, excitability, problems in concentration, restlessness, excessive ringing, and severe startle reflex are some of the other symptoms that we expect in this disorder [28]. The main difference between this disorder and post-traumatic stress disorder is the duration of the illness, this disorder lasts between 2 days and 4 weeks, and if it is not resolved in this period of time, it turns into post-traumatic stress disorder. The affected person clearly suffers a drop in personal and social functioning [29].

1. Post-traumatic stress disorder: As explained earlier, the symptoms of this disorder are similar to an acute stress disorder, and the main difference between the two is the time of illness. The survivor feels helpless after the accident, and the traumatic incident is repeated for him or her repeatedly. The occurrence of this disorder is possible at any time after the accident; it can be immediately after the accident or even delayed 30 years after the accident. But what is certain is that quick and timely intervention in the case of single symptoms seen in people or intervention in the case of acute stress disorder can be effective in reducing the prevalence of this disorder in the Asian community [29]. The symptoms of this disorder are mainly in the areas of repetition of the accident (the feeling of the accident happening again, in the form of mental images, dreams, repetitive games about the accident in children, etc.), avoidance (avoiding the place of the accident, people who were in that time being close to the person, avoiding talking and discussing, problems in recalling traumatic memories), feeling numb and helpless along with feelings of strangeness and alienation, as well as symptoms of hyperarousal (ears ringing excessively, problems falling asleep or continuity of sleep, problems in concentration and intensification of jumping reflex) are observed [29].

2. Complicated grief: In cases where the mourning reaction does not disappear within 2 months, the severity of the symptoms during the mourning period is more than expected, or there is a delay in the onset of bereavement symptoms, we are facing complicated bereavement that needs immediate intervention. Sometimes the symptoms of mourning do not appear at all [30]. Women are more prone to such complications than men. If there is no timely intervention, there is a possibility of other psychiatric disorders, such as major depression [31].

3. Major depression: Although all the survivors have a natural grief reaction, and after it is resolved, they feel sad by recalling past memories, it should be remembered that this natural psychological reaction to a great loss is completely different from depression [26]. Depression is not a natural reaction to a crisis, and if it occurs, it needs serious and immediate intervention. Its prominent feature is a depressed mood with hopelessness and helplessness, anxiety, decreased energy, sleep disorder, loss of appetite, memory disorder, sense of emptiness and worthlessness, and sometimes suicidal thoughts. Depression is one of the most common disorders [32].

4. Types of anxiety disorders: Panic attacks and anxiety can be seen alone or together with other disorders in people who survived the accident, although more commonly, we find these disorders together with other disorders. The presence of such disorders causes a decrease in performance and a slow return to normal life [33].

5. Somatic disorders: Paying attention to the higher prevalence of pseudo-somatic disorders following disasters is one of the points that should always be considered by the doctors treating the survivors. Because if the psychogenic origin of these disorders is not diagnosed, they are treated as physical symptoms [34]. Usually, in communities that survived an unexpected accident, the number of physical complaints is high. Although the efforts of the medical personnel to find the organic origin of these pains and symptoms are not successful, the patient believes that she or he has an undiagnosed disease and worries too much about her or his body’s health. Of course, there may be physical problems and diseases in some cases, but in this case, the amount of complaints from the patient is disproportionate to the severity of the physical problems. The symptoms of this difference cover a wide spectrum, including digestive symptoms, sensory movement, and even paralysis and diplopia. In normal conditions, 20–30% of adult patients referred to health centers have pseudo-physical problems. This amount increases significantly after unexpected events. A point that should be noted is avoiding unnecessary diagnostic measures in these patients. Due to the referral of these people to general practitioners and non-psychiatrist specialists, training this category of healthcare workers is of particular importance.

2.3 Resilience

As mentioned earlier, the effects of disasters are influenced by a variety of variables, including disaster type, degree of destruction, duration, timing (time of day, day of week, season), and individual indicators, including age, gender, marital status, education, pre-disaster mental health, social and economic status, and resilience. Many of studies explained these variables [35, 36]. Nevertheless, the role of resilience in the effects of disasters has not been addressed much. Therefore, in this section, we describe the role of resilience in disasters.

First, we want to ask you to check Figure 1. This figure shows a building that was not destroyed in an earthquake in Iran because it was strong against the earthquake, although other buildings have been completely destroyed. We have shown this image from another angle in Figure 2. The building captured in the shot is a real-life example of resilience: the ability to become strong, happy, or successful again after a difficult situation or event [37]. This means you will be happy, strong, successful, and outstanding under high-risk conditions. We imagine that resilience is displaying outstanding strength against problems, and it is the kind of post-traumatic growth (PTG). On the contrary, PTG is positive psychological alterations, and performance improvements over pre-crisis levels enable the individual to adapt to the new environment through cognitive restructuring. It means you have grown compared to before in five aspects including: “Recognizing Personal Strength” occurs when a person feels more confident. “Finding Unknown Possibilities and Opportunities” is experienced when people find a new way of life that would not be available if they did not experience a traumatic event. The domain of “Experiencing Positive Changes in Relationships” that shows a sense of kindness or closeness to others. “Appreciation of life” seems to have more appreciation for each new day of life. Finally, the scope of “Spiritual and Existential Change” understands personal growth that has a much better understanding of spiritual issues [14]. In PTG, you will grow more than before, but in resilience, you come back to the before situations or not negative changes after disasters. Several major studies have documented resilience as the “ability to go on with life,” “Bend, but not break,” or rebound from adversities; learn to live with ongoing fears and uncertainty [38, 39].

Figure 1.

The building that was not destroyed in an earthquake.

Figure 2.

The building that was not destroyed in an earthquake.

Now that we know the importance of resilience, we should know that psychosocial support is one of the factors that influence the resilience and PTG.

2.4 Psychosocial support

One of the main topics in psychosocial support is familiarity with the basic principles in this field. In this section, we try to explain these main topics. It is necessary to observe the following principles before and during the implementation of the program:

1. Taking a community-based approach: In this approach to build a local resource, including education and services, attention is paid to the whole community. In this way, the people who provide services offer their knowledge and skills to similar groups in the community, and these trained local resources become the cause of the relief and peace of their community. Focusing on groups and social networks instead of individuals can help more people. In addition, paying attention to the ruling values of the society will provide an appropriate answer to the culture in that society.

2. Trained volunteers: The main principle of the support program is to use volunteers. The purpose of training volunteers is to learn basic skills in the field of crisis. Due to the fact that these people are members of the affected society, they can react immediately in times of crisis, and therefore they are considered a valuable resource. In addition, since these people are members of the affected society, the injured have more trust in them.

3. Empowerment: In emergency aid programs that are always there, the danger is to humiliate, passivate, disempower, and make the survivors dependent on the relief forces. In general, relief organizations should be aware of that the quality of relief should be based on the principles of self-respect and independence of people so that it leads to the empowerment of people and emphasizes their abilities and strengths. For this purpose, survivors should actively participate in all programs.

4. Social participation of survivors in relief and reconstruction: Having a sense of control over the environment causes empowerment of people, a sense of belonging and ownership, and more effort to solve problems. Therefore, in programs that use the participation of local people, the results are more stable and prosperous. Because people feel that they have control over their lives and community through participation.

5. Accuracy in the use of specialized terms: Care must be taken in using specialized terms, because, for example, after a disaster such as an earthquake, many people may have symptoms such as re-occurrence or avoidance or feelings of sadness and depression, but all of them do not go beyond one sign, and we cannot make diagnoses such as post-traumatic stress disorder or major depression. Conversely, using words with positive meaning can evoke a feeling of empowerment and participation, such as the term active survivors.

6. Providing services from the first moment: Providing these services from the first moment can be an important factor in helping people to deal with the crisis. Neglecting emotional reactions causes the creation of passive victims. And as a result, the process of recovery and reconstruction of people progresses more slowly than usual.

7. Practical and ongoing interventions: Due to the short-term and long-term effects that disasters have on people, Psychological problems caused by disasters may not appear immediately, but they will take some time. As a result, it is necessary to continue the programs of support and participation of local forces by training local resources.

8. Providing service according to the support pyramid: Interventions and psychosocial support during disasters and accidents should be provided at different levels. This means that different affected people need different support. Figure 3 shows that different people need interventions in different layers and levels [40].

Figure 3.

Intervention pyramid for mental health and psychosocial support in emergencies [40].

3. Conclusions

Following disasters, most people experience unpleasant emotions and experiences. Reactions may be a combination of confusion, fear, despair, helplessness, insomnia, physical pain, anxiety and anger, grief, shock, violence and mistrust, guilt and shame, and loss of trust and self-confidence. Psychological first aid provides a safe, comfortable, connected, self-efficacious, empowered, and hopeful environment.

Acknowledgments

Open-access availability of this work supported by UC Davis.

Conflict of interest

“The authors declare no conflict of interest.”