Natural Disasters

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Intense, uncontrollable, and powerful natural forces can dramatically change the lives of thousands of people in the blink of an eye. The devastating effects of sudden natural disasters, such as earthquakes, hurricanes, tornadoes, tsunamis, volcano eruptions, "oods, and landslides, have been witnessed many times in recent history. One example is an earthquake in the Los Angeles area in 1994 that resulted in 72 fatalities and caused $12.5 billion in property damage (McMillen, North, & Smith, 2000; Reich, 1995).

The predictability and impact of natural disasters vary greatly. Every year, the Southeastern states of the United States and neighboring countries experience a hurricane season. People living in such areas are able to take precautions before a hurricane hits. Although such an event is predictable, neither the course of the hurricane nor its devastating effects can be in"uenced. In contrast, earthquakes are virtually unpredictable and take people by surprise. Often lasting only a few seconds or minutes, the destruction of property and the disruption of lives can take months or even years to restore, if at all.

Both short- and long-term psychological and physiological effects of disasters have been widely studied. Large-scale disasters leave behind at least three groups of victims: (a) individuals who have witnessed the event, (b) individuals who were absent then, but are effected by the devastation, and (c) rescue personnel confronted with the devastation. Such extreme experiences have often been studied in trauma research. Individuals who were exposed to extreme stressors are prone to develop PTSD. Very often, the onset of the disorder is delayed for years (see also Kimerling, Clum, & Wolfe, 2000).

Surprisingly, according to McMillen et al. (2000), victims of natural disasters report the lowest rates of PTSD. On the contrary, Madakasira and O'Brien (1987) found a high incidence of acute PTSD in victims of a tornado "ve months postdisaster. Again, methodological differences make it dif"-cult to compare various studies, especially when short-term and long-term effects are mingled. Green (1995) found that especially one year or more after the disaster, diagnosable pathology is the exception rather than the rule. Moreover, only a systematic and detailed analysis of the individual experience (e.g., loss of family members and/or property) would help to determine under which conditions PTSD and other psychiatric symptoms are likely to occur. Nevertheless, individuals involved in other traumatic events, such as combat, criminal victimization, or technological disasters, are far more likely to witness grotesque and violent scenes, which in turn may lead to higher incidence rates of PTSD.

Low incidence rates of PTSD should not lead to the conclusion that posttraumatic stress does not exist among the survivors of natural disasters. Survivors may experience a number of PTSD-related symptoms (e.g., unwanted memories, nightmares, event amnesia, sleeping problems), but do not meet all criteria for a psychiatric diagnosis (McMillen et al., 2000). In a study by Sharan, Chauhardy, Kavethekar, and Saxena (1996), 59% of earthquake survivors in rural India received a psychiatric diagnosis that was either PTSD or depression. Here, psychiatric morbidity was associated with gender (women) and destruction of property.

Briere and Elliot (2000) give an impressive overview of a number of studies dealing with the potential effects of exposure to natural disasters (e.g., bush"res; cf. McFarlane, Clayer, & Bookless, 1997). Among the various symptoms that are likely to occur in the aftermath of a natural disaster are anxiety, PTSD, somatic complaints, and substance abuse (Adams & Adams, 1984; McFarlane, Atchison, Rafalowicz, & Papay, 1994). Escobar, Canino, Rubio-Stipec, and Bravo (1992) examined the prevalence of somatization symptoms after a natural disaster in Puerto Rico. They found higher prevalence of medically unexplained physical (e.g., gastrointestinal) and pseudoneurological symptoms (e.g., amnesia, fainting) related to disaster exposure.

In a study on the long-term sequelae of natural disasters in the general population of the United States, Briere and Elliot (2000) found that 22% of the participants had been exposed to a natural disaster (earthquake, hurricane, tornado, "ood, or "re). Though the mean period from the last disaster exposure until the study took place was 13 years, researchers found current elevations on 6 of 10 scores in the Traumatic Symptom Inventory (Briere, 1995). Type of disaster did not determine the symptomatology, but the disaster characteristics, such as physical injury, fear of death, and property loss, did. Apparently, the number of characteristics people were exposed to effected the extent to which symptoms were experienced. Individuals who had suffered all (injury, fear of death, and property loss) scored at clinical levels (see also Rotton, Dubitsky, Milov, White, & Clark, 1997). As the authors conclude from their data, more research efforts should aim at the long-term effects rather than the immediate sequelae of disaster experience.

Finally, a number of studies have looked at the physiological changes that occurred in survivors of natural disaster. For example, in a longitudinal study by Trevisan et al. (1997), factory workers* uric acid levels were measured on three occasions within 12 years. In between, a major earthquake interrupted the study, so that some of the participants were measured before, others after the quake. Those workers measured after the quake had signi"cantly lower levels of serum uric acid than those examined before. Seven years later, workers who reported suffering from the aftermath of the quake had elevated levels of uric acid compared to unaffected individuals.

Technological Disasters

Unlike natural disasters, technological disasters are caused by people. Nevertheless, their occurrence is as dif"cult to predict as natural forces. In modern civilization, we are surrounded by numerous potentially health-threatening technological devices. Although a large number of speci"c precaution measures are employed, power plants, giant dams, atomic submarines, or contemporary air traf"c harbor a risk of failure with potentially disastrous effects.

Among others, the list of technological hazards includes the release of radiation (e.g., Three Mile Island, Chernobyl), leaking toxic waste dumps (e.g., Love Canal), and aviation and maritime accidents, such as the Exxon Valdez oil spill in 1989. Despite similarities between natural and technological disasters as to their unpredictability, uncontrollability, devastation, and impact for the individual and the community, considerable differences may contribute to various mental as well as physical health outcomes.

By de"nition, technological disasters could have been prevented. Thus, someone can be blamed for the harm and damage, and anger and frustration can be addressed to authorities, companies, or single persons. As Green (1995) argues, because of these characteristics, such events might be more dif-"cult to process than natural disasters, which can be seen as inevitable or fate. Effects of technological catastrophes appear to be longer lasting. Support for this assumption comes from a study by Baum, Fleming, Israel, and O*Keefe (1992), who compared 23 "ood victims with 27 people living near a leaking hazardous toxic waste dump and 27 control persons. Nine months postevent, those persons exposed to the hazardous material were more depressed, anxious, alienated, and aroused than those in the other two groups. Such effects have been found for technological failures as well (e.g., Bromet, Parkinson, & Dunn, 1990; L. Davidson, Fleming, & Baum, 1986).

Green (1995) studied the effects of the Buffalo Creek Disaster. In winter 1972, a dam constructed from coal mining waste collapsed, releasing millions of gallons of black water and sludge. In the community below the dam, 125 people were killed and thousands were left homeless. Typical for small communities where people know each other well, many residents lost close friends or family members. Looking at the long-term effects on adults, the results indicate a decrease in the psychopathology over one to three years. However, even 14 years later, a subset of survivors still showed continuing effects of the traumatic experience.

Arata, Picou, Johnson, and McNally (2000) examined the effects of the Exxon Valdez oil spill on commercial "shermen six years after the incident. According to their hypotheses, the "shermen had higher levels of depression, anxiety, and PTSD symptoms compared to a normative sample. One-"fth of the "shermen showed clinically signi"cant symptoms of anxiety, and more than one-third suffered from depression and/or PTSD. Despite methodological limitations, "ndings are consistent with other research, suggesting chronic impairment as a result from technological disasters (Freudenburg & Jones, 1991; Green, 1995). Posttraumatic stress disorders as a consequence of toxic spills were found in several studies (e.g., Freed, Bowler, & Fleming, 1998).

War and Genocide

A section about disasters caused by humans cannot be concluded without mentioning the most terrible disasters that continue to happen daily at some place in the world, namely, war and genocide. Research on the health effects of stressful life events started with recording reactions to war experience. During the two world wars, psychiatrists examined shell shock and battle fatigue among soldiers. Long-term effects of the Holocaust and the wars in Vietnam and Korea were studied as well. Posttraumatic stress disorder is one of the most frequently addressed phenomena in this line of research. Studies focus mainly on speci"c aspects of the war experience rather than the event as a whole. For example, there is a large body of research literature on torture victims (Neria, Solomon, & Dekel, 2000), Holocaust survivors (e.g., Lomranz, 1995), and combat stress (e.g., Z. Solomon, 1995). There is overlap with studies on migration effects, since ethnic con"icts, combat, and political persecution are among the most common reasons for people to emigrate.

Psychological and physical impairment can transpire even decades after the traumatic experience. Landau and Litwin (2000) compared a community-based sample of Holocaust survivors at age 75 and older with control persons of a similar age and sociocultural background. The assessment of vulnerability included physical as well as mental health and PTSD. The "ndings suggest that extremely traumatic events have long-lasting effects on the victims. Men who survived demonstrated a higher prevalence of PTSD, whereas women reported greater health-related dif"culties and poorer health (Wagner, Wolfe, Rotnitsky, Proctor, & Ericson, 2000).

In line with the former "ndings, Falger et al. (1992) found among 147 Dutch World War II resistance veterans the highest scores on cardiovascular disease (i.e., angina pectoris, Type A behavior, life stressors, and vital exhaustion) compared to age-matched patients with myocardial infarction and patients who underwent surgery. Moreover, veterans diagnosed with PTSD reported more risk factors.

Eberly and Engdahl (1991) analyzed medical and psychiatric data for American former prisoners of war (World War II and Korean War). In comparison with the general population, PTSD prevalence rates were greatly elevated, whereas lifetime prevalence rates of depressive disorders were only moderately increased. However, the authors did not "nd evidence for generally higher rates of hypertension, diabetes, myocardial infarction, alcoholism, and other psychiatric disorders. Within the study group, those former prisoners who had suffered massive weight loss demonstrated a greater number of psychiatric disorders than their comrades.

More evidence for the long-term effects of trauma comes from a study by Desivilya, Gal, and Ayalon (1996), who investigated the effects of early trauma in adolescence for victims* mental health and adaptation in later life. The critical incident took place in 1974 in a small town close to the border of Israel and Lebanon, when hundreds of hostages were taken during a terrorist attack, most of them adolescents. Participants in the study displayed signi"cantly more health problems 17 years later than the nontraumatized individuals in the control group. Also, survivors of the early traumatic event later showed greater vulnerability to psychological dif"culties when Israel was attacked by Iraqi Scud missiles in 1991 (see also Ben-Zur & Zeidner, 1991; Zeidner & Hammer, 1992). As the authors conclude, the scars of the event remained for a lifetime.

These studies, together with other empirical evidence on the effects of traumatic events, underline the importance of long-term observation of health outcomes in traumatized individuals in facilitating appropriate intervention and rehabilitation programs beyond acute needs for help.

Conjugal Loss and Bereavement

Experiencing loss is one of the major factors in the explanation of stress reactions. According to Hobfoll*s (1989, 1998) conservation of resources (COR) theory, the threat or the actual loss of resources is considered to be a powerful predictor of psychological stress. This can occur in many ways: loss of health, job, property, and loved ones. For most stressful life events, loss is an inherent characteristic. This section focuses on conjugal loss and the health effects resulting from bereavement.

Loss of a spouse is regarded as the most stressful experience on the Social Readjustment Rating Scale (SRRS; Holmes & Rahe, 1967). Considering the frequency and likelihood of such an event among those who have close long-term relationships, the relevance of research in this "eld becomes evident. In fact, the only way to protect yourself from that experience is to die either before or at the same time as the partner.

The effects of bereavement on morbidity and mortality have been widely studied (for an overview, cf. M. Stroebe, Stroebe, & Hansson, 2000; W. Stroebe & Stroebe, 1992). In particular, gender and age differences in responding to the death of a spouse have received most attention.

A quarter of a century ago, Bartrop, Luckhurst, Lazarus, Kiloh, and Penny (1977) described immunological changes associated with conjugal loss. The death of a spouse is suspected to lead to increased mortality in response to diseases that are presumed to depress the immune function (reduced lymphoproliferative responses, impaired natural killer cell activity). It has not been demonstrated, however, that morbidity and mortality following conjugal loss are the direct results of stressor-induced changes in immune function (Ader, 2001).

Considerable differences between widowers and widows regarding the physical and psychological reactions to an event as well as the coping strategies have been found. One set of studies suggests that men suffer more after losing their partner than women, whereas others report more health complaints of bereaved women.

Miller and Wortman (in press) suggest examining the impact of loss for the spouse who is left behind. You might conclude that women should be at more of a disadvantage. Is there any evidence for such an assumption? Traditionally, women depend economically on their husbands. Although norms and values regarding self-determination and economic independence of women have greatly changed over the past decades, elderly couples are more bound to traditional roles. Therefore, in addition to the loss of the intimate partner, women also face the loss of income and "nancial security, which in turn could enhance the vulnerability for illness and the frequency of ailments. With increasing age, conjugal loss becomes a normative life event more often for widows, who outlive their husbands. In turn, widowers have a greater chance to engage in new romantic relationships simply because there are more potential partners available. These objective disadvantages for widows do not necessarily translate into greater health impairment. In contrast, bereaved men are at higher risk for mental health problems, morbidity, and mortality.

Can the life event of losing a spouse be so detrimental that it results in the premature death of the survivor? For decades, studies addressing this question have found, on average, that the mortality risk for widows/widowers is increased, compared to those who do not experience this loss (see M. Stroebe et al., 2000). The risk seems to be greatest for men during the "rst six months of bereavement. There may be several reasons for this gender difference: Men typically have a smaller social network than women, so their loss cuts more deeply into their network (Weidner, in press). Also, bereavement occurs at an older age for men than for women because men, on average, die earlier than their spouses, due to age differences in couples and biological gender differences in longevity. As a result, the death of a wife leaves a man who is older and more in need of support. Moreover, men usually con"de in their spouse as their only intimate partner, whereas women cultivate a larger network of family members and friends, to whom they "nd it easier to turn in times of need. This higher social integration and support may buffer the stressful experience of losing their husbands.

Traumatic grief has been shown to be a risk factor for mental and physical morbidity (Miller & Wortman, in press). When widowers feel socially isolated during the grieving process, they may develop depression and loneliness, which in turn may lead to more severe consequences. In other cases, their immune system or cardiovascular reactivity may be affected, resulting in illness and eventually in death. The mechanism of pathogenesis needs to be further explored. Not only is death from all causes higher among widowers, but also speci"c causes of death, such as suicide. Li (1995), for example, showed a "ve times higher risk of suicide for elderly widowers than for married men. In contrast, the relative risk to commit suicide among the widows was near zero.

Widowed individuals show impaired psychological and social functioning. Nonetheless, frequency of sick days, use of ambulant services, and onset of illness according to medical diagnosis seem to be about the same for widowed persons and for controls. Schwarzer and Rieckmann (in press), examining the effects of social support on cardiovascular disease and mortality, found that cardiac events are more frequent among isolated and unsupported widowers. However, there is not much evidence that the onset of speci"c diseases, such as cancer or coronary heart disease, is actually caused or triggered by conjugal loss or a different kind of bereavement. This may be explained by the long time span of pathogenesis.

For example, it takes many years to develop chronic degenerative diseases, and other factors that contribute synergisti-cally to illness may emerge during this time.

Miller and Wortman (in press) analyzed data from 13 studies in terms of gender differences in mortality and morbidity following conjugal bereavement. They provide evidence of greater vulnerability among bereaved men (Glick, Weiss, & Parkes, 1994; Goldman, Korenman, & Weinstein, 1995) and showed that widowers are more likely to become depressed, to become susceptible for various diseases, and to experience greater mortality than widows. These effects are more pronounced among younger men.

Some of the causes of death among widowers are alcohol-related diseases, accidents, suicide, and chronic ischemic heart disease. Miller and Wortman discuss various possible explanations for their "ndings. The "rst reason for experiencing widowhood differently may be the different marital roles. Men tend to rely solely on their spouses in many ways. Wives are often the main con"dant for their husbands, but they also tend to have larger and tighter social networks that they can mobilize and rely on in taxing situations. Second, women are found to recognize themselves as support providers rather than as receivers. Until recently, women maintained the main responsibility for household and childcare. If such a strong anchor is lost, bereaved men»s stress is doubled, not only by taking on new roles in the family, but also by lacking adequate support. Third, for men, widowerhood takes away a powerful agent for social control. Lack of control can translate into a higher risk for men to engage in health-compromising behavior, for example, heavy drinking or risky driving. In many marriages, women are responsible for the family's psychological and physical well-being. Wives provide care during illness, are likely to be attentive to necessary changes in health behavior (e.g., dieting), and remind their husbands of regular health check-ups or prevent them from engaging in behaviors that are hazardous to their health.

Criminal Victimization

Whenever a person becomes the victim of an intentional negative act, we speak of criminal victimization. There is an ever-growing public interest in reports on criminal offenses. So-called »reality TVZ provides life coverage from crime scenes, and daily news broadcasts give an update of the latest developments and the condition of the victims. But many crimes remain undetected. Domestic violence is one of the most common crimes that is committed in silence and privacy. The number of cases reported is far lower than the actual prevalence rate. In most cases, it is women who report physical abuse by their partners. But many battered women do not dare to seek professional help. Instead, they blame themselves for provoking the incident, or they are ashamed or threatened by their abusive partners. Physical nonsexual abuse in this context could be de"ned as behavior, such as hitting, biting, hitting with an object, punching, kicking, or choking.

Clements and Sawhney (2000) investigated the coping responses of women exposed to domestic violence. Almost half of the battered women reported dysphoria consistent with a clinical syndrome of depression. Abusive severity seemingly did not play a role. Feeny, Zoellner, and Foa (2000) report that 33% of the women living in the United States will experience a sexual or nonsexual assault at least once in their lifetime. Although victims of domestic violence, rape, burglary, robbery, and other severe traumatic events, such as accidents, show surprising commonality in their emotional reactions to the event (Hanson Frieze & Bookwala, 1996), the physical effects of each of these events can differ greatly. The immediate response after confronting extreme stressors may be denial, disbelief, self-blame, numbness, and disorientation. Another common outcome of exposure to unusually stressful situations is PTSD. Symptoms include, for example, reexpe-riencing the event, avoiding reminders, trouble with sleeping, nightmares, and chronic hyperarousal.

Traumatic events not only contribute to mental health problems, they also lead to increased physical health complaints. According to Zoellner, Goodwin, and Foa (2000), unspeci"c complaints, such as headaches, stomachaches, back pain, cardiac arrhythmia, and menstrual symptoms, are among the most common problems.

The question arises whether the event itself or its psychological correlates can be held responsible for somatic complaints. As discussed in the section on combat veterans, PTSD was associated with an increased risk for cardiovascular disease. To date, research on the relationship between a stressful event and physical health with PTSD as the moderating variable have remained relatively scarce.

Zoellner et al. (2000) conducted a study with 76 women who were victims of sexual assault suffering from chronic PTSD and who were seeking treatment. The results show negative life events, anger, depression, and PTSD severity related to self-reported physical symptoms. Moreover, PTSD severity predicted self-reported physical symptoms in addition to these factors.

A number of studies have explored the relationship between sexual abuse and the onset of eating disorders in later life. The contexts of these studies vary (e.g., sexual abuse as part of a torture experience versus domestic sexual abuse during childhood). For example, Matsunaga et al. (1999) explored the psychopathological characteristics of women who had recovered from bulimia and who had a history of sexual abuse. Abused persons revealed a trend toward lifetime diagnosis of PTSD and substance dependence. Judging from these "ndings, authors suggest a possible association between abusive experiences and psychopathogenesis of bulimia nervosa. Moret (1999) did not "nd differences in eating behavior and body image concerns between women with and without sexual abuse in their past. Nevertheless, sexually abused women might be prone to develop an eating disorder because they show more psychological traits commonly associated with these disorders, such as perfectionism, maturity fear, or interpersonal distrust. Teegen and Cerney-Seeler (1998) found a correlation between the severity of traumati-zation in victims of child sexual abuse and the frequency of eating disorder development.

Migration

Migration is increasingly becoming a typical facet of modern society. The globalization and internationalization of industries contribute to a constant "ow of people from one country to another. The reasons why people migrate range from economic dif'culties, civil wars, ecological disasters (e.g., repeated drought or "ood), and political persecution affecting their work and study. Forceful displacement from the homeland and resettlement in a new environment cause physical as well as psychological scars. Extreme stress can occur at any point of the migration process„prior to, during, and after . Thus, exposure to a number of stressors may cumulate and be responsible for health problems long after migration. Many individuals who have escaped war, ethnic cleansing, political persecution, or famine carry into their new countries the burden of these stressful experiences.

After the Islamic revolution in Iran in 1979, for example, many political opponents of the new regime were forced into hiding with the constant threat of discovery, imprisonment, and torture. Many of those in prison had suffered extreme torture, witnessed the killing of other prisoners, and lived in constant fear for their families and friends. Moreover, escaping from the country is often not only dangerous, but also costly, sometimes exhausting the "nancial resources of entire families. Migrants who cannot leave their homeland legally often have to pay large sums of money to traf"ckers who promise to take them to the desired country. Also, the very process of migration itself can be a source of extreme stress. Thousands of illegal migrants are forced to hide, sometimes without food or water for many days, in cars or ships, or even outdoors without shelter. Finally, arriving at their destination, migrants often face new legal and personal problems. Migrants who are weakened physically and psychologically by traumatic experiences and who undergo continuous stress regarding adaptation, acculturation, and integration into the new society, are especially vulnerable to physical and mental illness.

Following Hobfoll's (1998) COR theory, migration stress can be explained by the threat of loss and actual loss of resources of any kind. The chances to compensate these losses and to restore one's resources are very limited, at least at the beginning of the adaptation process in a new country.

Living in a foreign country is inevitably associated with social and material losses as well as new challenges, regardless of the duration or purpose of the stay. To some extent, all newly arrived travelers, sojourners, immigrants, and refugees face similar challenges: different climate, new language, and unfamiliar customs, cultural norms, and values. In cases of involuntary relocation, uncertainty about the duration of the stay can contribute to elevated levels of stress. Also, the greater the cultural differences between the indigenous and host cultures, the more stress is likely to be expected.

Acculturation stress (Berry & Kim, 1988; Schwarzer, Hahn, & Schroder, 1994) often emerges in con"icting situations within an immigrant's own ethnic or cultural group and/or the dominant group of that society. Potential stressors range from everyday life with the family or at the workplace to direct effects that are associated with migration, such as status loss, discrimination, and prejudice. Acculturative stress and the behavior that results from coping with it are very likely responsible for mental health problems and somatic complaints.

Another common source of continuing stress is bad news from the home country, survivor guilt related to leaving family and friends behind, and thoughts about the duty to care for them (Graham & Khosravi, 1997; Lipson, 1993). Studies by Yee (1995) on Southeast Asians in the United States as well as Tran (1993) on Vietnamese con"rmed the hypothesis that acculturation stress coupled with stressful experiences lead to poorer health. Similarly, Cheung and Spears (1995) assume a strong association between negative life events and depression among Cambodian immigrants in New Zealand. Moreover, they identi"ed lack of acculturation, feelings of discrimination, and poor language skills as risk factors for mental disorders.

Chung and Kagawa-Singer (1993) examined predictors of psychological distress among Southeast Asian refugees. Even "ve years after arrival in the United States, premi-gration stressors, such as number of years in the refugee camp, number of traumatic events, and loss of family members, signi"cantly predicted depression. Apart from cultural changes, living conditions for immigrants are often below average, especially for refugees from Third World countries.

Here, postmigration factors (e.g., income, work situation, language skills) also played a role in the development of mental health problems (e.g., Hyman, Vu, & Beiser, 2000). Lipson (1993) reviewed studies on Afghan refugees* mental health. Afghan refugees residing in California displayed high levels of depression and psychosomatic symptoms of stress. This is assumed to be due to family role changes and the resulting con"ict in the American society. Furthermore, loneliness as well as isolation among the elderly have been linked to psychiatric morbidity.

One of the rare studies on the physical health of refugees comes from Hondius, van Willigen, Kleijn, and van der Ploeg (2000), who investigated health problems of Latin American and Middle Eastern refugees in the Netherlands, with special focus on traumatic experience and ongoing stress. Study participants, who had experienced torture, reported medical complaints. Surprisingly, PTSD was identi"ed among few of the respondents. However, not only traumatic experience prior to migration, but also worries about current legal status, duration of stay, and family problems contributed to ill health.

These studies underline the common assumption that acute as well as chronic stressors in the larger context of migration contribute to poorer physical as well as mental health. Various factors, such as acculturation styles, education, income, or social networks moderate the relationship between migration and health. Future research should support programs tailored culturally and individually that help immigrants to recover from their traumatic experiences, restore a normal life, and "nd their place in the new society.

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