TERRORISM and PTSD
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Risk Factors for Adverse Outcomes in Natural and Human-Caused Disasters: A Review of the Empirical Literature
The focus of this report is on within-sample factors that influence who is most likely to experience serious and lasting psychological distress. As suggested by Freedy et al. (1992), we differentiated between predisaster, within-disaster, and postdisaster factors.
Predisaster Factors
Gender influenced postdisaster outcomes in 45 samples, as follows:
In 42 (93%) of 45 samples, women or girls were affected more adversely by disasters than men or boys. Panel studies indicated that psychological effects were not only stronger among women but more lasting as well.
The effects occurred across a broad range of outcomes, but the strongest effects were for PTSD, for which women's rates often exceeded men's by a ratio of 2:1.
The effects of gender were greatest within samples from traditional cultures and in the context of severe exposure.
Age and experience influenced disaster victims' outcomes in 17 samples, as follows:
Findings within the 3 child and adolescent samples did not yield a consistent pattern.
Older adults were at greater risk than were other adults in only 2 (14%) of the 14 adult samples. Rather than as an at-risk group, older adults might be viewed as a resource for disaster stricken communities.
In every American sample where middle-aged adults were differentiated from older and younger adults, they were most adversely affected. Some research suggests that middle-aged adults are most at risk because they have greater stress and burden even before the disaster strikes and assume even greater obligations afterwards.
Cross-cultural research suggests that the effects of age may differ across countries according to the social, political, economic, and historical context of the setting involved.
At least in lower magnitude disasters, prior experience with the specific type of event may reduce anxiety. People who have experienced disasters previously show higher levels of hazard preparedness and are more likely to evacuate when authorities suggest they do.
Professionalism and training increase the resilience of recovery workers, although past trauma per se does not.
Culture and ethnicity shaped the outcomes of disaster victims in 14 samples, as follows:
Cross-cultural studies of similar events using similar methods across 5 samples found effects to be greater in developing countries than in the United States.
Among youth, results for ethnicity were not consistent. In 2 (50%) of the 4 samples, majority groups fared better, and in 2 (50%) minority groups fared better.
Among adults, results for ethnicity were quite consistent. In 100% of the 5 samples, majority groups fared better than ethnic minority groups.
There is little explanatory research available, but the disproportionate risk of ethnic minorities appears to follow both from differential exposure to more severe aspects of the disaster and from culturally specific attitudes and beliefs that may impede seeking help.
Socioeconomic Status (SES), as manifest in education, income, literacy, or occupational prestige, was found to affect outcomes significantly in 11 samples of disaster victims. In 10 (91%) of these, lower SES was associated consistently with greater postdisaster distress. The effect of SES has been found to grow stronger as severity of exposure increases.
Family Factors influenced outcomes in 19 samples, as follows:
Married status was a risk factor for women. Husbands' symptom severity predicted wives' symptoms more strongly than wives' symptom severity predicted husbands'. Marital stress has been found to increase after disasters.
Being a parent also added to the stressfulness of disaster recovery and, especially for events involving uncertain threats, mothers were especially at risk for substantial distress.
Children were highly sensitive to postdisaster distress and conflict in the family. Parental psychopathology, when measured, was typically the best predictor of child psychopathology. Less irritable, more supportive, and healthier parents had healthier children.
Interventions for children may be of limited effectiveness if the family is not considered as a whole. In fact, providing care and support to their overly stressed parents might be among the most effective ways to provide care and support to the children affected by disaster.
Predisaster Functioning and Personality influenced outcomes in 22 samples, as follows:
Regardless of the method of data collection, predisaster symptoms were almost always among the best predictors (if not the best predictor) of postdisaster symptoms.
Many of these studies used lifetime diagnostic measures to assess a wide range of conditions before and after the disaster. Persons with predisaster psychiatric histories were disproportionately likely to develop disaster-specific PTSD and to be diagnosed with some type of postdisaster disorder.
In prospective studies using continuous measures of current symptoms, predisaster symptoms have been found to interact with severity of exposure. Participants with higher preflood symptoms were more strongly affected by the disaster than were participants with lower preflood symptoms.
A "neurotic," as opposed to stable and calm, personality increases the likelihood of postdisaster distress. "Hardiness" decreases the likelihood of postdisaster distress.
Within-disaster Factors
Individual- or household-level severity of exposure was an important predictor of outcomes in almost all samples, as follows:
All of the following have been found, at least in some studies, to predict adverse outcomes among survivors:
Bereavement
Injury to self or another family member
Life threat
Panic or similar emotions during the disaster
Horror
Separation from family (especially among youth)
Extensive loss of property
Relocation or displacement.As the number of these stressors increased, the likelihood of psychological impairment increased.
In general, injury and life threat were most predictive of long term adverse consequences, especially PTSD.
Neighborhood- or community-level severity of exposure was assessed only occasionally but had modest outcomes, as follows:
Personal loss was more strongly related to increases in negative affect, but community destruction was more strongly related to decreases in positive affect, reflecting a community-wide tendency for people to feel less positive about their surroundings, less enthusiastic, less energetic, and less able to enjoy life.
Such findings are an excellent reminder that disasters impact whole communities, not just selected individuals. No one would suggest that such "symptoms" constitute psychopathology or require professional intervention. Nonetheless, disasters may impair the quality of life in a community for quite some time.
Postdisaster Factors
Both life-event stress (discrete changes) and chronic stress were strong predictors of survivors' health outcomes. Moreover, stability and change in psychological symptoms were largely explained by stability and change in stress and resources.
Some research suggests that the long-term effects of acute stressors (the individual-level aspects of exposure outlined above) on psychological distress operate through their effects on chronic stressors, such as marital stress, financial stress, and ecological stress.
Attention needs to be paid to stress levels in stricken communities long after the disaster has happened and passed.
Because resources are such an important feature of the postdisaster environment, they are addressed in detail in Psychosocial Resources in the Aftermath of Disaster.
Summary and Conclusions
A substantial amount of research pertinent to understanding risk factors for adverse outcomes has been published over the past 20 years. The research base is larger and more consistent for adults than it is for youth. Even for adults, more research on many of these topics would be quite useful and could eventually change the weight of the evidence. Nonetheless, at present, the literature reviewed for PART II yields the following conclusions:
An adult's risk will increase linearly along with the number of these factors that are present:
Female gender
Age in the middle years of 40 to 60
Little previous experience or training relevant to coping with the disaster
Ethnic minority group membership
Poverty or low socioeconomic status
The presence of children in the homeFor women, the presence of a spouse especially if he is significantly distressed
Psychiatric history
Severe exposure to the disaster, especially injury, threat to life, and extreme loss
Living in a highly disrupted or traumatized community
Secondary stress and resource loss
With a few modifications �x2014; primarily the deletion of age and minority group status -- this risk-factor model holds reasonably well for children and adolescents.
Families are extremely important systems and constitute the most important unit for postdisaster treatment and intervention efforts.
Outreach efforts for intensive services should focus on areas of the community where at-risk individuals and families are most likely to live. Treatments and interventions known to be effective for them should be implemented. Attention to issues of diversity is important. Less intensive services, such as support groups and psycho-educational programs, may be adequate services for groups at lower risk.
It is important to provide support to the supporters, especially wives and mothers.
Groups at very low risk, such as older adults and childless men, should assume a greater share of the burden for the community's recovery through appropriate volunteer and paraprofessional activities.
The information on this Web site is presented for educational purposes only. It is not a substitute for informed medical advice or training. Do not use this information to diagnose or treat a mental health problem without consulting a qualified health or mental health care provider.
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