Mental Health Problems After Disaster

Symptomatology and Psychopathology

of Mental Health Problems After Disaster
Edna B. Foa, Ph.D.; Dan J. Stein, M.D., Ph.D.;
and Alexander C. McFarlane, M.D.

A variety of reactions are observed after a major trauma. In the majority of cases these resolve
without any long-term consequences. In a significant proportion of individuals, however, recovery
may be impaired, leading to long-term pathological disturbances. The most common of these is post-
traumatic stress disorder (PTSD), which is characterized by symptoms of reexperiencing the trauma,
avoidance and numbing, and hyperarousal. A range of other disorders may also be seen after trauma,
and there is considerable overlap between PTSD symptoms and several other psychiatric conditions.
Risk factors for PTSD include severe exposure to the trauma, female sex, low socioeconomic status,
and a history of psychiatric illness. Although PTSD may resolve in the majority of cases, in some
cases risk factors outweigh protective factors, and symptoms may persist for many years. PTSD often
coexists with other psychiatric disorders, such as depression, anxiety disorders, and substance abuse,
and with physical (somatization) symptoms. There is growing evidence that PTSD does not merely
represent a normal response to stress, but rather is mediated by specific neurobiological dysfunctions.
(J Clin Psychiatry 2006;67[suppl 2]:15–25)

A cute stress reactions are a normal and expected re-

sponse to a traumatic event, seen in the majority of
cases. Nevertheless, pathologic persistence of symptoms,
POSTTRAUMATIC PSYCHOPATHOLOGY

A variety of reactions may be observed after a major

or posttraumatic stress disorder (PTSD), is seen in a minor- trauma. The precise combination of reactions that is
ity of cases. The development of PTSD depends on com- observed depends on numerous factors, including the se-
plex interrelationships between the nature of the trauma verity and intensity of the initial trauma, the duration of
itself, the characteristics of the victim, and the social cir- exposure, and the individual characteristics and social cir-
cumstances and support networks available to the victim. cumstances of the survivor. These predictors will be dis-
In each case, however, a central feature is the formation of cussed in more detail (see The Sequential Etiological Pro-
a traumatic memory of the event.1,2 The challenges there- cess Leading to PTSD and Its Predictors).
fore are to understand the defining features of the event In a review of 160 studies of disaster victims, Norris et
that form the basis of this traumatic memory and the factors al.3 identified 6 discrete groups of outcomes following
that influence how the traumatic memory is subsequently major trauma: specific psychological disorders such as
manifested as acute and chronic illnesses. PTSD, depression, or anxiety; nonspecific distress; health
This article reviews the symptomatology and psycho- problems; chronic problems in living; resource loss; and
pathology of major trauma experienced by disaster victims. problems specific to youth (Table 1). Overall, 77% of the
studies identified specific psychological disorders such as
PTSD, major depressive disorder (MDD), or anxiety, in-
From the Center for the Treatment and Study of Anxiety,
cluding generalized anxiety disorder (GAD) and panic dis-
Department of Psychiatry, University of Pennsylvania, order. PTSD was the most commonly observed disorder,
Philadelphia (Dr. Foa); the Department of Psychiatry, being identified in 68% of studies, followed by depression
University of Cape Town, Cape Town, South Africa (Dr. Stein);
and the University of Adelaide, Department of Psychiatry, in 36% and anxiety in 20%. In addition, health-related
Queen Elizabeth Hospital, Woodville, Australia problems such as somatic complaints, sleep disturbances,
(Dr. McFarlane).
Presented at the symposium “After the Tsunami: and substance abuse were reported in 23% of studies.
Mental Health Challenges to the Community for Today Initial psychological reactions to trauma may include
and Tomorrow,” which was held February 2–3, 2005, in feelings of fear, horror, or helplessness (symptoms essen-
Bangkok, Thailand, and supported by an educational grant
from Pfizer Inc. tial for the diagnosis of PTSD; see Symptoms of PTSD).
Corresponding author and reprints: Edna B. Foa, Ph.D., Sometimes, individuals struggle to find the language to
Center for the Treatment and Study of Anxiety, Department of
Psychiatry, University of Pennsylvania, 3535 Market Street, express the overwhelming emotion that is experienced and
6th Floor, Philadelphia, PA (e-mail: foa@mail.med.upenn.edu). will use words such as “shock,” “unbelievable,” or “im-

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Foa et al.

Table 1. Outcomes Following Major Traumaa cally disadvantaged communities has the ability to wear
Specific psychological problems
people down.
Posttraumatic stress
Depression
Anxiety (including generalized anxiety disorder and panic disorder)
SYMPTOMS OF PTSD
Nonspecific distress
Health problems The Fourth Edition of the American Psychiatric Asso-
Somatic complaints ciation Diagnostic and Statistical Manual of Mental Dis-
Sleep disturbances
Alcohol or other substance abuse
orders (DSM-IV) recognizes 3 distinct symptom clusters
Problems in living associated with PTSD: reexperiencing the event, avoid-
Interpersonal relationships ance and numbing, and hyperarousal (Table 2).6 To qualify
Occupational or financial stress
Environmental concerns
for a diagnosis of PTSD, individuals must have been ex-
Disruption during rebuilding posed to a stressor that triggers feelings of intense fear,
Resource loss helplessness, or horror, and the symptoms must produce
Disruption of family and other social networks
Decreased social participation
clinically significant distress or functional impairment for
Problems related to youth a minimum of 4 weeks.
Clinginess, dependence, aggression, etc, in young children Negative thoughts about the self, other people, and the
Delinquency in adolescents
a
future are a common feature of PTSD. These can lead to a
Based on Norris et al.3
perception that the world is an extremely dangerous place,
and that other people cannot be trusted, or that the victim
is incompetent, that other people could have prevented the
possible to take in.” For some, the emotion that is implicit trauma, and that PTSD symptoms are a sign of weakness.
in these words will only surface in the aftermath of sur- Such negative thoughts are influenced by a variety of fac-
vival, when the individual begins to reflect on the full real- tors, including a history of trauma, prior personal or
ity of what has occurred. family psychopathology, and a lack of positive social sup-
Associated symptoms include feelings of guilt, shame port. Avoidance of situations that recall the trauma can
or despair, increased hostility, domestic violence, with- strengthen negative perceptions; conversely, talking and
drawal, social isolation, and loss of belief structures. Im- thinking about the trauma can promote an organized, co-
portantly, these symptoms may occur irrespective of herent narrative of the victim’s experience, enabling the
whether specific psychological disorders such as PTSD victim to recognize that trauma is an uncommon event.
are present. Somatic symptoms include gastrointestinal, Patients with PTSD are often unable to structure their
cardiovascular, neurologic, musculoskeletal, respiratory, recollections of their trauma. In a positron emission to-
dermatologic, or urological problems. mography (PET) study,7 patients with PTSD did not show
Notwithstanding this broad range of psychological and the bilateral activation of the dorsolateral prefrontal cortex
somatic problems associated with trauma, trauma victims that normally occurs during updating of working memory
are generally highly resilient; most develop appropriate in response to trauma-neutral verbal information. By con-
coping strategies and use social support networks to reach trast, the PTSD patients showed increased bilateral activa-
an understanding and acceptance of their experience. As tion of the superior parietal lobe, compared with control
a result, the majority recover with time, becoming able subjects. This might suggest increased reliance on visuo-
to resume normal activities and face reminders of their spatial coding of information in working memory func-
trauma, despite the associated distress. For example, in a tion, rather than verbal cues, among patients with PTSD.
study of 95 female rape victims,4 94% met symptomatic As a result, PTSD patients may have difficulty expressing
criteria for PTSD when interviewed within 30 days of the their feelings of distress after trauma. The neurobiological
assault, whereas only 65% did so at a mean of 5 weeks af- basis of PTSD is discussed further (see The Neurobiology
ter the assault, and 47% showed PTSD symptoms after an of PTSD).
average of 94 days. Similarly, in a study of survivors of the
September 11 terrorist attacks in New York,5 PTSD symp- Physical Symptoms of PTSD
toms had resolved within 1 year after the attacks in 57% of Although the DSM-IV criteria emphasize psychologi-
participants. cal symptoms in the diagnosis of PTSD, it should be noted
In disaster situations where people’s homes and liveli- that many patients with PTSD (particularly in primary
hoods have been destroyed, the longitudinal course of care) present with predominantly physical, rather than
recovery is likely to be quite different. Adversity in the af- psychological, symptoms. Such symptoms may include
termath of the disaster and the continued struggle for sur- physical pain and lower gastrointestinal, dermatologic, or
vival can escalate the individual’s distress in the wake of a skeletomuscular disorders.8 Sleep disturbances, such as
sense of euphoria from having survived the initial on- violent or injurious behavior during sleep, sleep paralysis,
slaught of the disaster. The battle for survival in economi- and sleep talking, are also common in patients with PTSD.

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 Mental Health Problems After Disaster

Table 2. Symptoms of Posttraumatic Stress Disorder According to DSM-IVa

Reexperiencing Avoidance and Numbing Hyperarousal
Recurrent, intrusive, distressing memories Avoiding thoughts, feeling, or conversations connected Difficulty falling or staying asleep
Recurrent distressing dreams to the event Irritability or outbursts of anger
Illusions, hallucinations, dissociative Avoiding activities, places, or people connected to the event Problems concentrating
flashback episodes Amnesia about certain important aspects of the event Hypervigilance
Intense psychological distress when exposed Decreased interest in once-enjoyed activities Exaggerated startle response
to reminiscent cues Feeling detached from others
Physiological reactivity on exposure to Emotional numbing/restricted range of affect
external or internal cues A sense of foreshortened future
a
Adapted from the American Psychiatric Association.6

Figure 1. Impaired Function and Quality of Life in Vietnam Figure 2. Symptom Overlap Between Posttraumatic Stress
War Veterans With PTSD, Compared With Veterans Disorder (PTSD) and Other Psychiatric Conditionsa
Without PTSDa

49.2
50 PTSD
Non-PTSD Depression
39.5 Brief
Personality
35.5 Reactive
33.2 Disorder
Psychosis
Patients (%)

26.5
25 22.6
Substance
Panic
Use PTSD
16.0 Disorder
Disorders
9.8 9.9

4.3 Obsessive-
Somatization Compulsive
0 Disorder
Not Fair/Poor Reduced Physical Severe Personality
Working Health Well-Being Limitation Violence in Disorder
Past Year Dissociation

a
Data from Zatzick et al.11
a
Abbreviation: PTSD = posttraumatic stress disorder. Based on Kessler et al.14

In one study of a general urban population,9 for example, illness, compared with patients with a history of trauma
sleep disturbances were present in approximately 70% of but no PTSD.
patients with PTSD. Fatigue and sense of ill health can
contribute significantly to the disability that an individual Overlap Between PTSD Symptoms and
develops. Those of Other Psychiatric Conditions
The diagnosis of PTSD is a useful organizing construct
Impact of PTSD Symptoms on to categorize symptoms following trauma. However, it is
Functioning and Quality of Life important to recognize that there is considerable overlap
PTSD can have a devastating impact on the victim. between the symptoms of PTSD and those of a number of
Data from the National Comorbidity Survey (NCS) in the other psychiatric conditions, including MDD, GAD, panic
United States show that individuals with PTSD are 6 disorder, obsessive-compulsive disorder, and reactive psy-
times more likely than those without PTSD to attempt chosis (Figure 2).13,14 Indeed, PTSD may not necessarily
suicide and that, overall, 19% of PTSD patients will at- be the most common disorder after trauma; rather, it is the
tempt suicide.10 This reflects a substantial impairment of one whose onset is most easily defined.
quality of life and normal functioning in patients with
PTSD. In a study of 1200 Vietnam War veterans,11 for ex- THE SEQUENTIAL ETIOLOGICAL PROCESS
ample, participants with PTSD were significantly more LEADING TO PTSD AND ITS PREDICTORS
likely than those without PTSD to be not working, to re-
port impaired health and physical functioning, and to PTSD represents a failure of natural recovery following
have committed a violent act within the previous year an acute stress, and as such is not a normal event. It is the
(Figure 1). Similarly, in a longitudinal study of patients fifth most common psychiatric disorder in the United
with anxiety disorders,12 patients with PTSD showed sig- States, with a lifetime prevalence of 7.8% in the NCS.14
nificantly higher incidences of suicide attempts, alcohol However, trauma is a much more common occurrence, af-
abuse or dependence, and hospitalization for psychiatric fecting 61% of men and 51% of women in the NCS.14

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Foa et al.

Figure 3. Incidence of Posttraumatic Stress Disorder (PTSD) Table 3. Risk Factors for Posttraumatic Stress Disorder After
in Relation to Type of Trauma in the National Comorbidity a Major Disastera
Surveya Severe exposure to the trauma
Living in a highly disrupted community
60 Exposure to Trauma Female gender
Developed PTSD Belonging to an ethnic minority group
50 Middle age
Incidence (% of patients)

Poverty or low socioeconomic status

40 Presence of children in the home
Presence of a distressed spouse
30 Psychiatric history
Impoverished support system
20 a
Based on Norris et al.3
10

0
Disaster Accident Assault Molestation Combat Rape time of trauma, socioeconomic status, education, intelli-
a
gence, race, previous psychiatric history, reported abuse in
Data from Kessler et al.14
childhood, reports of previous traumatization, reports of
other adverse childhood factors, family history of psychi-
atric disorder, trauma severity, posttrauma life stress, and
Clearly, as noted above, not all traumatized individuals de- posttrauma social support. Each of these was found to be
velop PTSD. The incidence is higher in specific high-risk highly significant statistically, but the size of the effects
groups, and certain types of trauma are more likely to re- varied markedly. The largest effects were seen with factors
sult in PTSD than others. operating during or after the trauma: trauma severity, lack
of social support, and posttrauma stress. In general, factors
Risk Factors for Acute PTSD that were present before the trauma had relatively little ef-
Data from the NCS show that the prevalence of general- fect on the risk of PTSD.
ized PTSD varies markedly according to the nature of the
trauma involved. Although rape was a relatively uncom- Time Course of PTSD
mon trauma, it was associated with the highest prevalence PTSD should be considered as occurring in a series of
of PTSD in both men and women (Figure 3).14 By contrast, stages.1 Symptoms developing within 4 weeks after the
natural disasters and accidents affected a higher proportion trauma are considered to represent an acute stress disorder
of the population, but accounted for relatively low preva- that constitutes a normal response to stress. The majority
lences of PTSD. of patients with such symptoms do not develop any patho-
The same study showed that the lifetime incidence of logical sequelae. Thus, PTSD does not begin in the imme-
PTSD was approximately twice as high in women as in diate aftermath of the trauma, but may represent a lack of
men (10.4% vs. 5.0%, respectively, p < .05).14 The lifetime resolution of the acute stress response.1 Although PTSD
prevalence was higher among the previously married than resolves in approximately 60% of cases (Figure 4),14 some
among the currently married, but this was significant only individuals go on to develop chronic, unremitting PTSD.
in women (18.9% vs. 9.6%, p = .004). The prevalence was According to the DSM-IV criteria, PTSD is considered
also higher among the married than among the never mar- acute if symptoms resolve within 3 months or chronic if
ried, but this was significant only in men (6.1% vs. 1.9%, symptoms persist for 3 months or longer.6 Acute PTSD
p = .001). is attributed to time-dependent sensitization following
It is worth noting that the increased rate of PTSD in trauma. By contrast, chronic PTSD results from prolonged
women may not be universal and may be influenced by exposure to the normal adaptive responses to changing cir-
cultural factors. For example, in the Australian replication cumstances.17 Secondary stressors, such as loss of home or
of the NCS, the rates of PTSD were similar in men and livelihood after a disaster, are likely to play an important
women.15 role in the development of chronic PTSD.
Individual factors render some people more susceptible Delayed-onset PTSD, which develops at least 6 months
to PTSD than others. The review of 160 studies of disaster after the trauma, is recognized as a discrete subcategory
victims cited previously identified a number of risk factors of PTSD, but relatively little is known about this con-
for adverse outcomes such as PTSD, including severity of dition. The available evidence suggests that delayed-onset
exposure to trauma, secondary stressors such as financial PTSD is uncommon following disasters.1,18 For example,
difficulties, prior psychiatric illness, and deteriorating in a study of 469 Australian firefighters exposed to a major
psychosocial resources (Table 3).3 bushfire,18 a delayed onset of PTSD was rare, and some
A meta-analysis by Brewin et al.16 examined the impact patients who reported such a course could not recall their
of 14 risk factors for generalized PTSD: gender, age at the acute posttraumatic symptoms. Other studies have re-

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2006;67 , INC2).
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 Mental Health Problems After Disaster

Figure 4. Kaplan-Meier Curves Showing the Duration of Symptoms in Patients With Posttraumatic Stress Disorder in the
National Comorbidity Surveya,b

1.0 Treatment (N = 266)

0.9 No Treatment (N = 193)
Surviving Without Recovery

Lee-Desu χ2 = 5.0, df = 1, p < .05

0.8
Proportion of Patients

0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
0 6 12 18 24 30 36 42 48 54 60 66 72 78 84 90 96 102 108 114 120

Duration of Symptoms (mo)

a
Reprinted with permission from Kessler et al.14
b
Mean duration of symptoms was 64 months in people who never received treatment, compared with 36 months in people who received treatment.

ported marked fluctuations in PTSD symptoms during with nonchronic PTSD. Female sex and a family history
long-term follow-up of survivors of natural disasters, of PTSD were independent risk factors for chronic PTSD.
which may explain the occurrence of at least some cases Avoidance behaviors in response to stressors also influ-
of apparently delayed onset of PTSD.1,19 ence the development of chronic PTSD. Avoidance symp-
PTSD symptoms can persist for many years after the toms tend to increase with time, whereas intrusive symp-
trauma. The NCS data show that the mean duration of toms decrease.1,23 Such symptoms may prevent recovery by
symptoms in people who never received treatment was 64 limiting exposure to experiences that correct negative per-
months, compared with 36 months in people who re- ceptions and beliefs and by preventing the organization of
ceived treatment for their symptoms.14 Moreover, in more the memory and consignment of the trauma to the past.
than one third of affected individuals, symptoms per- Furthermore, avoidance symptoms can maintain the in-
sisted even after many years, and even when treatment dividual’s perception that the world is a dangerous place
was given (Figure 4). This is consistent with data from and that he or she cannot cope effectively with stress.
survivors of 2 disasters in the United Kingdom.20,21 In a
study of survivors of the 1988 Piper Alpha oil platform THE NEUROBIOLOGY OF PTSD
fire,20 21% of participants met the most stringent criteria
for PTSD more than 10 years after the event. Approxi- Stressful situations trigger adaptive responses aimed
mately one third of participants reported persistent feel- at maintaining a constant internal environment in the face
ings of guilt at 10 years, and this, together with physical of changing demands on the individual, a process known
injury during the disaster, was significantly associated as allostasis.17,24 These responses, although beneficial
with high levels of posttraumatic symptoms. A second in the short term, impose an allostatic load on the indi-
study21 investigated the long-term outcome in survivors vidual, which if maintained can result in PTSD and other
of the 1966 Aberfan disaster, in which a coal slag heap disorders.
collapsed onto a primary school, killing 116 children. The hypothalamus-pituitary-adrenal (HPA) axis plays
After 33 years, 46% of survivors had experienced PTSD an important role in the acute response to stress. During the
at some time, compared with 20% of matched controls acute phase, glucocorticosteroid release has a number of
(odds ratio [OR] = 3.38, 95% confidence interval [CI] = effects that are beneficial for short-term survival, including
1.40 to 8.47), and 29% met the diagnostic criteria for cur- suppression of immune function, activation of the auto-
rent PTSD. nomic nervous system, and replenishment of energy re-
serves by promoting the conversion of proteins and lipids
Risk Factors for Chronic PTSD into carbohydrates.24,25 However, prolonged stress results
What factors influence the development of chronic in sustained elevation of circulating glucocorticosteroids,
PTSD? In a study of young adults,22 individuals with which can produce structural and functional changes in ar-
chronic PTSD showed a higher total number of PTSD eas of the brain involved in learning and memory process-
symptoms, and higher rates of numbing and hyperreactiv- ing (see Neuroanatomy of PTSD).24
ity to stressors, anxiety or affective disorders, and other PTSD patients show a number of alterations in the HPA
comorbid medical conditions, compared with individuals system. Concentrations of corticotropin-releasing factor

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Foa et al.

Figure 5. Anatomical Areas Involved in Memorya,b ventions, including prolonged stress, glucocorticosteroid
treatment, and developmental lead exposure result in re-
Habits
modeling and atrophy of hippocampal pyramidal neu-
Valence
Features rons.24,32,33 The effects of stress on the hippocampus can be
Cerebellum blocked by an inhibitor of adrenal steroid synthesis, indi-
and Striatum Neocortex Amygdala
cating that they are a result of prolonged exposure to
Meanings glucocorticosteroids.24 The effects of glucocorticosteroids
on hippocampal cell volume may be due both to direct glu-
cocorticoid effects on cell metabolism and an increased
Context susceptibility to excitatory amino acids and other neuro-
toxic agents.34
Hippocampus and Studies using imaging techniques such as functional
Prefrontal Cortex
magnetic resonance imaging (fMRI) and PET have pro-
a
Based on Nadel and Moscovitch.28 vided data on changes in hippocampal volume in patients
b
According to this model, semantic information (information about with PTSD and healthy controls. For example, Bremner et
feelings and meanings of words) is stored in the neocortex, habitual
information (that required for acquired skills such as playing a al.,35 in an MRI study of 26 Vietnam veterans with PTSD,
musical instrument) in the cerebellum and striatum, and information showed that the volume of the right hippocampus was re-
about feelings (valence) in the amygdala. The hippocampus and
prefrontal cortex are necessary for retrieval of episodes and their
duced by 8% (p = .03), compared with that in matched
contextual framework, and for extraction of semantic information to control subjects; the volume of the left hippocampus was
be stored in the neocortex. Posttraumatic stress disorder is associated also reduced, by 3.8%, but this difference was not statisti-
with hippocampal damage, resulting in difficulties in forming
structured contextual memories of the trauma. cally significant. In a second study,36 quantitative volumet-
ric MRI techniques were used to compare hippocampal
volumes in 7 Vietnam veterans with PTSD, with those in 7
(CRF) in the cerebrospinal fluid are elevated,25 pre- combat veterans without PTSD and 8 normal control sub-
sumably reflecting hypersecretion of this peptide by the jects. Both left and right hippocampal volumes were sig-
hypothalamus. Paradoxically, however, circulating corti- nificantly lower in veterans with PTSD than in the other
sol concentrations are reduced, compared with individuals 2 groups, and these differences remained after adjustment
without PTSD.26 This could be due to down-regulation for age, whole brain volume, and lifetime alcohol con-
of the adrenocorticotropic hormone (ACTH) response to sumption. A reduction in hippocampal volume, compared
CRF,27 which would result in decreased secretion of corti- with control subjects, has also been reported in adult pa-
sol. In animal models, CRF release is associated with an tients with PTSD related to childhood physical or sexual
increase in the number and sensitivity of glucocortico- abuse.34,37 A meta-analysis of 9 studies38 reported a signifi-
steroid receptors in brain areas involved in memory and cant reduction in volume of both the right and left hip-
the control of fear and arousal responses, such as the hip- pocampi in 133 adults with PTSD compared with 148
pocampus.25 Such findings suggest that hypersecretion of healthy controls. However, other studies have failed to
CRF in PTSD patients would result in the promotion of demonstrate such an association.38
anxiety and fear-related behaviors. Several studies have reported correlations between de-
creases in hippocampal volume and PTSD symptoms. In a
Neuroanatomy of PTSD study of 21 women who reported being severely sexually
Data from animal and clinical studies are converging to abused during childhood,37 the volume of the left hip-
indicate that multiple memory systems exist, with distinct pocampus was decreased by 5%, compared with non-
anatomical localizations and organization.28,29 According abused controls; there was a significant negative correla-
to this view, different types of information are stored in tion between left hippocampal volume and the severity of
the cerebellum, neocortex, and amygdala, and the hip- dissociative symptoms (r = –0.73, p < .0002), although no
pocampus is necessary for “explicit” memory—the re- correlation was seen between left hippocampal volume
trieval of episodes and their contextual framework (Figure and measures of explicit memory functioning. Bremner et
5).28 The hippocampus is also responsible for suppressing al.34 reported a similar decrease in left hippocampal vol-
the fear response in the amygdala under conditions of ume in adult survivors of childhood physical or sexual
medium stress, but this pathway is blocked under condi- abuse. In this study, however, there was only a weak and
tions of extreme stress, resulting in an exaggerated fear nonsignificant correlation between left hippocampal vol-
response.30,31 ume and the number of PTSD symptoms present (r = 0.29,
The hippocampus is a major target organ for p = .31).
glucocorticosteroids in the brain32 and is particularly vul- Such findings suggest that PTSD is associated with
nerable to neurotoxicity resulting from high levels of damage to the hippocampus, which might result in deficits
glucocorticosteroids following stress. A number of inter- in explicit memory functioning. It is important to recog-

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2006;67 , INC2).
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 Mental Health Problems After Disaster

nize, however, that the relationship between PTSD and Resilience and vulnerability in the face of extreme
hippocampal volume may not be causal. It is possible, for stress are mediated by multiple neurochemical and
example, that hippocampal damage is present before the neuroendocrine mechanisms.45 There is evidence that
onset of PTSD and may in some way predispose the indi- corticotropin-releasing hormone (CRH), dopaminergic
vidual to develop the condition.39 and glutamatergic systems, and estrogens are among the
There are data to suggest that emotions associated with factors involved in the mediation of vulnerability; con-
PTSD symptoms are mediated by the limbic and paralim- versely, factors mediating resilience include dehydroepi-
bic systems in the right hemisphere.12,40–42 In one study, for androsterone (DHEA), neuropeptide Y, galanin, testos-
example, activation of different brain areas was measured terone, serotonin acting via the 5-HT1A receptor, and
by PET in 8 PTSD patients following exposure to audio- benzodiazepine receptor function.45
taped trauma-related or neutral scripts.40 Compared with Treatment of PTSD, whether by medication or psycho-
control conditions, traumatic stimuli provoked marked ac- therapy, may reverse the functional and structural changes
tivation of the right-sided limbic, paralimbic, and visual in the affected systems, leading to normalization of re-
areas and decreased activation of the left inferior frontal sponses to stress. Evidence for this hypothesis comes from
and middle temporal cortex. Such activation of the visual a study in which 11 patients with PTSD underwent single
cortex may be responsible for reexperiencing phenomena photon emission computed tomography (SPECT) scan-
in PTSD, since it has been shown that visual imagery is ning before and after treatment with a selective serotonin
mediated by topographically organized visual cortex.43 reuptake inhibitor (SSRI).48 Significant deactivation of the
However, reexperiencing phenomena are distinct from or- left medial temporal cortex was observed following SSRI
dinary visual mental images—to the person experiencing treatment, irrespective of antidepressant response. There
a flashback, it feels as if the trauma is reoccurring6—and was a significant correlation between reductions in PTSD
hence these may require activation or deactivation of other symptoms and activation of the left paracingulate region
brain areas in addition to activation of visual cortex.40 The (medial prefrontal cortex). Such findings suggest that
finding that Broca’s area (the left inferior frontal cortex SSRI treatment may eliminate learned fear responses by
and middle temporal cortex) was deactivated following reversing the abnormal regulation of amygdala activity by
exposure to trauma-related stimuli may indicate move- the medial prefrontal cortex seen in PTSD.48,49 A second
ment of resources from higher cognitive functions, such as study,50 involving 28 PTSD patients, has shown significant
language processing and verbalization. This would be reductions in PTSD symptoms, which were associated
consistent with the finding that PTSD patients have diffi- with a 4.6% increase in mean hippocampal volume on
culty in cognitively structuring their traumatic memories MRI, following treatment with an SSRI for 9 to 12
and make less use of verbal memory in structuring their months.
experiences.7
In summary, the available evidence suggests that PTSD PSYCHIATRIC AND PHYSICAL
is associated with an increased allostatic load, with pro- COMORBIDITY FOLLOWING TRAUMA
longed activation of the HPA axis. A decrease in hip-
pocampal volume might precede or follow, resulting in the Although PTSD may be the most common disorder fol-
impairment of explicit memory and perhaps also loss of lowing trauma, it represents only a part of the clinical
restraint of fear responses mediated by the amygdala and picture. Comorbidity with other psychiatric or somatic
other components of the limbic system. The damage to the disorders is common (Figure 6)6,14,51–54; indeed, the epi-
hippocampus might mean that the individual is unable to demiologic evidence suggests that psychiatric comorbid-
form structured contextual memories of the trauma, while ity is the rule rather than the exception.13 In the NCS, a
deactivation of Broca’s area might prevent the individual lifetime history of at least 1 other psychiatric disorder was
from developing verbal representations of the trauma. present in 88.3% of men and 79% of women with a life-
time history of PTSD; 59% and 44%, respectively, had 3
Neurochemical Systems Involved or more concomitant disorders.14 Typically, however,
in the Psychopathology of PTSD PTSD precedes other disorders; in the NCS, PTSD was the
Exposure to traumatic stressors leads to activation of primary diagnosis in 29% to 51% of men and 41% to 58%
arousal responses mediated by the serotonergic and nor- of women with comorbid disorders.14
adrenergic systems and to changes in numerous other neu- Despite the high prevalence of comorbid disorders in
rotransmitter and neuroendocrine systems.44,45 In animal patients with PTSD, little is known about risk factors for
studies, serotonergic mechanisms have been shown to be comorbidity. For example, a study of reactions to the Sep-
involved in the conditioned fear responses, mediated by tember 11 terrorist attacks showed a higher prevalence of
the amygdala, and involving CRF release, and in symp- probable PTSD among residents of the New York City
toms such as intrusions, depression, depersonalization, metropolitan area than among residents of other major
and avoidance behaviors.46,47 U.S. urban centers, but noted that further research would

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Foa et al.

Figure 6. Comorbidity of PTSD and Other Psychiatric Table 4. Diagnostic Criteria for Traumatic Griefa
Disordersa Criterion A
Major depression is present in: Person has experienced the death of a significant other
Response involves 3 of the 4 symptoms below experienced
at least sometimes:
48% of Patients
With PTSD 50%–65% of Patients Intrusive thoughts about the deceased
With Panic Disorder Yearning for the deceased
Searching for the deceased
Loneliness as a result of the death
PTSD 8%–39% Criterion B
Panic Disorder
of Patients In response to the death, 4 of the following 8 symptoms
With GAD are experienced as mostly true:
Major Depression Purposelessness or feelings of futility about the future
Subjective sense of numbness, detachment, or absence
GAD
Social Anxiety of emotional responsiveness
Disorder Difficulty acknowledging the death (eg, disbelief)
OCD Feeling that life is empty or meaningless
Feeling that part of oneself has died
34%–70% of Patients With
Shattered worldview (eg, loss of sense of security, trust,
Social Anxiety Disorder 67% of Patients or control)
With OCD Assumes symptoms or harmful behaviors of, or related to,
a
the deceased person
Based on references 6, 14, and 51–54. Excessive irritability, bitterness, or anger related to the death
Abbreviations: GAD = generalized anxiety disorder, OCD = obsessive- Criterion C
compulsive disorder, PTSD = posttraumatic stress disorder. Duration of disturbance (symptoms listed above) is at least 2 months
Criterion D
The disturbance causes clinically significant impairment in social,
be necessary to document the time course and outcome of occupational, or other important areas of functioning
a
psychiatric disorders in affected individuals.55 This lack Adapted with permission from Prigerson et al.57
of data reflects the difficulties involved in designing epi-
demiologic studies of psychiatric illness after major disas-
ters.56 Such studies require careful attention to timing, means, traumatic grief can itself give rise to and perpetu-
sampling, measurement, and interpretation of data. More- ate PTSD symptoms.
over, reactions to different types of trauma can vary con-
siderably: for example, survivors of natural disasters may Major Depressive Disorder
show different reactions to survivors of terrorist attacks, The core symptoms in MDD are a depressed mood and
while even within the context of an individual disaster, anhedonia (an inability to feel normal happiness or plea-
differing reactions may be seen in subpopulations of sure). These are usually accompanied by a range of both
survivors.56 psychological symptoms, such as feelings of worthless-
ness, excessive guilt, and suicidality, and physical symp-
Traumatic Grief toms such as changes in appetite, sleep disturbances, and
Traumatic grief is common after a major disaster. The loss of energy.
symptoms of traumatic grief are distinct from those of de- MDD is the most common concomitant psychiatric dis-
pression and anxiety, but show clinical correlations with order in patients with PTSD.13 In the NCS, for example,
those of depression. Moreover, traumatic grief symptoms 48% of men and 49% of women with PTSD had a lifetime
are predictive of mental and physical health impairments, diagnosis of MDD.14 This is perhaps not surprising, as
independent of the effect of depressive symptoms. For there is a well-established causal relationship between
these reasons, traumatic grief is now considered to be a stressful events and depressive illness.58 Conversely, how-
distinct clinical syndrome in its own right.57 ever, a history of MDD is predictive of PTSD after expo-
Traumatic grief can produce symptoms that overlap sure to major trauma.13 The frequent coexistence of PTSD
with those of PTSD, such as recurrent intrusive thoughts and MDD reflects the shared neurobiology of the 2 condi-
and images of death and avoidance of situations, activities, tions. In both cases, sensitization resulting from exposure
or people associated with the event. In addition, however, to secondary stressors can lead to “kindling” effects that
traumatic grief can produce symptoms such as intense exacerbate symptoms and impair normal recovery.
yearning and longing for the dead person and extreme sad- The presence of MDD is associated with greater func-
ness rather than anxiety and arousal (Table 4).57 As a re- tional impairment in patients with PTSD. For example, in
sult, the grieving process following a disaster may differ a study of trauma survivors recruited from an emergency
from that in the absence of trauma. In normal grief, the in- room,59 individuals with concomitant PTSD and MDD
dividual is able to retrieve positive memories of the de- showed more severe symptoms and lower functioning
ceased person, whereas following a disaster, traumatic than those with either disorder alone. Similarly, a study of
memories may intrude and inhibit this process. By this motor accident survivors60 showed that PTSD and MDD

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J Clin Psychiatry PRESS
2006;67 , INC2).
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 Mental Health Problems After Disaster

were correlated but independent responses to the trauma; longitudinal study of Australian firefighters exposed to a
again, individuals with both disorders showed greater natural disaster, PTSD was associated with both increases
functional impairment and were less likely to show remis- and decreases in alcohol consumption, and these changes
sion of symptoms over 6 months. could be attributed to PTSD rather than exposure to
stress.18,66,67 However, the association is not simple: for ex-
Generalized Anxiety Disorder ample, some people may use alcohol or narcotics as a form
Generalized anxiety disorder is defined by excessive of self-medication to relieve the symptoms of PTSD, and
worry and apprehension about events or activities, occur- this may obscure the association by modifying the under-
ring most days for at least 6 months, which is difficult to lying symptoms.66
control and unrelated to other Axis I disorders.6 Psycho- Although some studies have suggested that substance
logical symptoms of GAD include persistent feelings of abuse is more common among combat veterans than
fearful anticipation, irritability, impaired concentration, among survivors of natural disasters,61,68 more recent evi-
and restlessness. Physical symptoms include muscle ten- dence suggests that the intensity of the emotional reaction,
sion and symptoms of autonomic hyperarousal, such as rather than the nature of the trauma, is the predominant
palpitations and tightness or pain in the chest. factor involved. For example, in a study of 84 individuals
In the NCS, GAD occurred in 16.8% of men and 15% who sought support after the 1995 Oklahoma City bomb-
of women with PTSD.14 However, in contrast to comorbid ing,64 those who reported increased smoking or drinking
depressive illness, in which PTSD is usually the primary after the attack showed more severe peritraumatic reac-
disorder, PTSD is more likely to develop after anxiety dis- tions, grief, posttraumatic stress, and worries about safety,
orders such as GAD.13,14 This suggests that symptoms of and greater impairment of functioning, than those who did
arousal and avoidance may develop as a coping mecha- not. There were no significant differences in sensory or
nism following exposure to trauma.13 interpersonal exposure to the trauma between participants
who increased their smoking or drinking and those who
Panic Disorder did not.
Panic disorder is characterized by recurrent, spontane- As with PTSD, substance abuse after trauma may have
ous episodes of intense anxiety with associated somatic a long-term impact on health and well-being. In a study of
and psychiatric symptoms (panic attacks). The incidence New York City residents after the September 11 attacks,65
of panic disorder among persons with PTSD in the NCS the increase in substance use seen following the attacks
was 7.3% in men and 12.6% in women.14 Since some stud- persisted during the first 6 months after the attacks,
ies have found that panic disorder tends to be more com- whereas the incidence of PTSD and depression decreased
mon in individuals exposed to traumas involving extreme by more than 50% during the same period.
autonomic arousal, hypervigilance, and unpredictability, it
has been suggested that panic disorder and PTSD are inter- Somatic Symptoms
related, rather than comorbid, disorders.13,61 In panic disor- Numerous physical (somatization) symptoms may co-
der, however, fear and avoidance are related to the physi- exist with PTSD, and these can have a significant impact
cal symptoms associated with panic attacks (anticipatory on normal functioning and the course of PTSD.69 In a
anxiety), whereas in PTSD they are specifically related to study of young adults,70 the incidence of somatization
trauma-related memories and situations.13 symptoms was 3 times higher in individuals with PTSD
Sometimes, the relationship between the panic symp- than in those without PTSD (24.7% vs. 8.2%, respec-
toms and the subtle triggers of the traumatic experience tively). Moreover, a baseline history of PTSD was associ-
goes undetected. For example, physical sensations such as ated with an increased risk of pain (OR = 2.1) or conver-
pain and movement may have the same somatosensory sion symptoms (OR = 2.3) during follow-up, compared
quality as the traumatic experience, but the individual has with individuals without PTSD. Other studies have dem-
little conscious awareness of this issue. onstrated increased rates of cardiopulmonary, neurologic,
and musculoskeletal symptoms among combat veterans71
Substance Abuse and firefighters72 with PTSD, compared with members of
Abuse of nicotine, alcohol, or narcotic drugs is com- the same groups without PTSD.
mon among patients with PTSD.14,62–65 In the NCS, 52% of Physical symptoms in patients with PTSD may result
men and 28% of women with PTSD reported alcohol from a number of causes, including injuries sustained dur-
abuse or dependence, while 35% and 27%, respectively, ing the original trauma and its aftermath (for example, in-
reported abuse of or dependence on other substances.14 In- fectious diseases following a natural disaster), comorbid
creased substance use after trauma appears to be related to substance abuse, and physiological responses to secondary
PTSD, rather than exposure to stress per se.63,64 The avail- stressors, such as loss of home or livelihood. Physical
able evidence suggests that the association between PTSD symptoms may be present even when the issue of injury
and substance abuse is causal in nature.66 For example, in a has been controlled for. The first explanation for this is

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Foa et al.

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