Lars Weisaeth

Bereavement and Mental Health after Sudden and Violent Losses: A Review

Abstract This paper reviews the literature on the psychological consequences of sudden and violent losses, including disaster and military losses. It also reviews risk and resilience factors for grief and mental health and describes the effects and possible benefit of psychosocial interventions. The review shows gaps in the literature on grief and bereavement after sudden and violent deaths. Still, some preliminary conclusions can be made. Several studies show that a sudden and violent loss of a loved one can adversely affect mental health and grief in a substantial number of the bereaved. The prevalence of mental disorders such as post-traumatic stress disorder (PTSD), major depressive disorder (MDD), and prolonged grief disorder (PGD, also termed complicated grief) varies widely, however, from study to study. Also, mental health disorders are more elevated after sudden and violent losses than losses following natural deaths, and the trajectory of recovery seems to be slower. Several factors related to the circumstances of the loss may put the bereaved at heightened risk for mental distress. These factors may be differentially related to different outcomes; some increase the risk for PTSD, others for PGD. Given the special circumstances, bereavement following sudden and violent death may require different interventions than for loss from natural death. Recommendations for future research and clinical implications are discussed.

Textbook of disaster psychiatry

Those of us living in developed countries tend to see ourselves as being fairly immune to the effects of disaster and large-scale trauma. Events such as the Chernobyl disaster, Hurricane Katrina, the 2004 Tsunami and the September 11 attacks remind us that no community is unaffected by such events. When they do occur, disasters have profound effects on the communities exposed to them and these effects are often felt many miles away. The serious study of the effects of disaster really began in the 1970s with epidemiological studies such as that undertaken after a flood at Buffalo Creek. Since then a large body of research has amassed on the effects of disaster and in the identification and description of appropriate forms of response. This wideranging textbook, with contributions from leading scholars in the field provides an impressive and comprehensive synthesis of the literature to date. Part one provides an overview of the mental health effects of disaster on individuals and communities, exploring risk and protective factors and emphasising that disasters are a primary cause of mental health need. Themes of resilience continue throughout the book. Part two discusses the foundations of disaster psychiatry, with a detailed critique of the epidemiological research on the effects of disaster on mental health for adults and children, a chapter on the neurobiology of disaster exposure and a thought provoking chapter on disaster ecology. This chapter elucidates the complex interrelationships and interdependence of the social, psychological, geographic, anthropological and economic contexts surrounding disasters and describes an ecological framework to aid understanding of potential avenues of prevention, mitigation and recovery for mental health responders. Part three looks at various aspects of clinical care with a review of the available research on early intervention and description of expert consensus recommendations and treatment considerations for those with ongoing traumatic stress reactions. The following two chapters focus specifically on medical-surgical and inpatient assessment, management and service delivery considerations. The final chapter in this section looks at the role of nongovernmental organisations (NGOs) and consideration of some of the challenges to work in less-developed countries, often with scarce or non-existent mental health infrastructures and healing practices which may be very different from Western models of health care. Part four explores special topics. The chapter on traumatic death and terrorism and disasters focuses on the effects of exposure to death for emergency service personnel, recovery workers and those who are likely to experience repeated exposure to death. A cognitive and emotional processing model is presented which considers a range of stressors for disaster workers including high levels of sensory stimulation and having to deal with personal effects. Amongst other things, the Psychology, Health & Medicine Vol. 14, No. 5, October 2009, 629–630Part I. Introduction: 1. Individual and community responses to disasters Robert J. Ursano, Carol S. Fullerton, Lars Weisaeth and Beverley Raphael Part II. Foundations of Disaster Psychiatry: 2. Epidemiology of disaster mental health Carol S. North 3. Children and disasters: public mental health approaches Robert Pynoos, Alan M. Steinberg and Melissa J. Brymer 4. Disaster ecology: implications for disaster psychiatry James Shultz, Zelda Espinel, Sandro Galea and Dori B Reissman 5. Neurobiology of disaster exposure: fear, anxiety, trauma and resilience Rebecca P. Smith, Craig L. Katz, Dennis S. Charney and Steven Southwick Part III. Clinical Care and Interventions: 6. Early intervention for trauma-related problems following mass trauma Patricia J. Watson 7. Acute stress disorder and posttraumatic stress disorder in the disaster environment David M. Benedek 8. Assessment and management of medical-surgical disaster casualties James R. Rundell 9. Interventions for acutely injured survivors of individual and mass trauma Douglas Zatzick 10. Non governmental organizations and the role of the mental health professional Joop de Jong Part IV. Special Topics: 11. Traumatic death in terrorism and disasters Robert J. Ursano, James McCarroll and Carol S. Fullerton 12. Weapons of mass destruction and pandemics: global disasters with mass destruction and mass disruption Robert J. Ursano, Carol S. Fullerton, Ann E. Norwood and Harry Holloway 13. Workplace disaster preparedness and response Nancy T. Vineburgh, Robert Gifford, Robert J. Ursano, Carol S. Fullerton and David M. Benedek 14. Health care systems planning Brian Flynn Part V. Public Health and Disaster Psychiatry: 15. Public health and disaster mental health: preparing, responding, and recovering Robert J. Ursano, Carol S. Fullerton, Lars Weisaeth and Beverley Raphael.

Stress reactions in police officers after a disaster rescue operation.

This study intended to determine the prevalence of posttraumatic stress disorder symptoms and to report subjective well-being, general distress, and social functioning among police officers 18 months after a rescue operation during a fire at a discotheque. Emotional responses, including self-reported reactions, recorded during and after the fire were analysed. Forty-one police officers participated in the study. They completed a questionnaire and a battery of self-report measures. Psychological distress was recorded using the PTSS-10, IES-R, and GHQ-28. The three scales had a high internal consistency. The police officers were not unaffected by their experiences, and a few officers were still under stress. One police officer had IES-R intrusion and an avoidance score greater than 20, suggesting a stress reaction of clinical significance. When compared with the PTSS-10 scale, two (5%) officers showed a high level of psychological distress. Measured with the GHQ-28, three officers (7%) still had a high level of psychological distress. On one of the four different subscales most of the officers show various degrees of reduced social functioning. Debriefing was carried out by the police department after the fire, and 75% thought debriefing was positive. Eighteen months after the disaster a few police officers are still under stress.

Psychiatric disorders and functional impairment among disaster victims after exposure to a natural disaster: A population based study

OBJECTIVE We aimed to examine psychiatric morbidity and functional impairment after a natural disaster. METHOD Norwegian tourists who survived the 2004 tsunami in Khao Lak (n = 63), a severely affected area in Thailand, were interviewed in person 2.5 years after the disaster. The examination included the Mini International Neuropsychiatric Interview, the PTSD module of the Structured Clinical Interview for DSM-IV Axis I disorders, the Work and Social Adjustment Scale (WSAS), the Global Assessment of Functioning function score (GAF-F), and questions covering background characteristics and disaster exposure. RESULTS The most prevalent disorders were specific phobia (30.2%), agoraphobia (17.5%), social anxiety disorder (11.1%), PTSD (11.1%), major depressive disorder (MDD, 11.1%), and dysthymic disorder (DD, 11.1%). In 24 of the 40 respondents with a current psychiatric disorder, symptoms had originated after the tsunami. The post-tsunami 2.5 year incidence of PTSD and MDD was 36.5% and 28.6%, respectively. Multivariable regression analysis showed that the depressive disorders (MDD and DD) and PTSD were associated with self-reported functional impairment (WSAS), and the depressive disorders were associated with clinician assessed functional impairment (GAF-F). LIMITATIONS Small sample size and high education may limit the generalizability of the results. CONCLUSIONS Depression and anxiety disorders were common among disaster victims 2.5 years after the 2004 tsunami. Psychiatric disorders other than PTSD, especially depressive disorders, are of clinical importance when considering long-term mental health effect of disasters.

Early trauma-focused cognitive-behavioural therapy to prevent chronic post-traumatic stress disorder and related symptoms: A systematic review and meta-analysis

BackgroundEarly trauma-focused cognitive-behavioural therapy (TFCBT) holds promise as a preventive intervention for people at risk of developing chronic post-traumatic stress disorder (PTSD). The aim of this review was to provide an updated evaluation of the effectiveness of early TFCBT on the prevention of PTSD in high risk populations.MethodsWe performed a systematic literature search in international electronic databases (MEDLINE, EMBASE, PsycINFO, CENTRAL, CINAHL, ISI and PILOTS) and included randomised controlled trials comparing TFCBT delivered within 3 months of trauma, to alternative interventions. All included studies were critically appraised using a standardised checklist. Two independent reviewers selected studies for inclusion and assessed study quality. Data extraction was performed by one reviewer and controlled by another. Where appropriate, we entered study results into meta-analyses.ResultsSeven articles reporting the results of five RCTs were included. All compared TFCBT to supportive counselling (SC). The study population was patients with acute stress disorder (ASD) in four trials, and with a PTSD diagnosis disregarding the duration criterion in the fifth trial. The overall relative risk (RR) for a PTSD diagnosis was 0.56 (95% CI 0.42 to 0.76), 1.09 (95% CI 0.46 to 2.61) and 0.73 (95% CI 0.51 to 1.04) at 3–6 months, 9 months and 3–4 years post treatment, respectively. A subgroup analysis of the four ASD studies only resulted in RR = 0.36 (95% CI 0.17 to 0.78) for PTSD at 3–6 months. Anxiety and depression scores were generally lower in the TFCBT groups than in the SC groups.ConclusionThere is evidence for the effectiveness of TFCBT compared to SC in preventing chronic PTSD in patients with an initial ASD diagnosis. As this evidence originates from one research team replications are necessary to assess generalisability. The evidence about the effectiveness of TFCBT in traumatised populations without an ASD diagnosis is insufficient.

Acute Disaster Exposure and Mental Health Complaints of Norwegian Tsunami Survivors Six Months Post Disaster

The objective was to investigate the relationship between possible disaster stressors and subsequent health problems among tourists experiencing the 2004 South–East Asia tsunami. A cross–sectional study was performed as a postal survey concerning the experiences of the disaster exposure in retrospect and the presence of psychological symptoms (GHQ–28) in Norwegian tsunami victims 6 months post disaster. The strongest predictors of health complaints were danger of death, witness impressions, and bereavements. Aggravated outcomes were also seen in those who helped others in the acute phase or had sole responsibility for children when the tsunami struck. Having a family member or close friend who was injured was reversely associated with health problems. Women reported more psychological distress than men, but the difference disappeared with increasing degree of danger exposure. Dose–response relationships to psychological distress were found for single exposure factors as well as for the cumulative effects of being exposed to several exposure variables.

Psychiatric disorders among disaster bereaved: an interview study of individuals directly or not directly exposed to the 2004 tsunami

Background: Few studies have explored the long‐term mental health consequences of disaster losses in bereaved, either exposed to the disaster themselves or not. This study examined the prevalence and predictors of mental disorders and psychological distress in bereaved individuals either directly or not directly exposed to the 2004 tsunami disaster. Method: A cross‐sectional study of 111 bereaved Norwegians (32 directly and 79 not directly exposed) was conducted 2 years postdisaster. We used a face‐to‐face structured clinical interview to diagnose current posttraumatic stress disorder (PTSD) and depression (major depressive disorder, MDD) and a self‐report scale to measure prolonged grief disorder (PGD). Results: The prevalence of psychiatric disorders was twice as high among individuals directly exposed to the disaster compared to individuals who were not directly exposed (46.9 vs. 22.8 per 100). The prevalence of disorders among the directly exposed was PTSD (34.4%), MDD (25%), and PGD (23.3%), whereas the prevalence among the not directly exposed was PGD (14.3%), MDD (10.1%), and PTSD (5.2%). The co‐occurrence of disorders was higher among the directly exposed (21.9 vs. 5.2%). Low education and loss of a child predicted PGD, whereas direct exposure to the disaster predicted PTSD. All three disorders were independently associated with functional impairment. Conclusions: The dual burden of direct trauma and loss can inflict a complex set of long‐term reactions and mental health problems in bereaved individuals. The relationship between PGD and impaired functioning actualizes the incorporation of PGD in future diagnostic manuals of psychiatric disorders. Depression and Anxiety, 2009.

Work-related post-traumatic stress disorder

BACKGROUND Work-related post-traumatic stress disorder (PTSD) is an important condition encountered by many occupational health practitioners. AIMS To carry out an in-depth review of the research on occupational groups that are at particular risk of developing work-related PTSD. METHODS A literature search was conducted in the databases OVID MEDLINE, OVID Embase, Ovid PsycINFO, ISI Web of Science and CSA Health and Safety Science Abstracts. RESULTS Professionals such as police officers, firefighters and ambulance personnel often experience incidents that satisfy the stressor criterion for the PTSD diagnosis. Other professional groups such as health care professionals, train drivers, divers, journalists, sailors and employees in bank, post offices or in stores may also be subjected to work-related traumatic events. Work-related PTSD usually diminishes with time. CONCLUSIONS Mental health problems prior to the traumatic event and weak social support increase the risk of PTSD. Prevention of work-related PTSD includes a sound organizational and psychosocial work environment, systematic training of employees, social support from colleagues and managers and a proper follow-up of employees after a critical event.

Predictors of posttraumatic stress reactions in Norwegian U.N. peacekeepers 7 years after service

A sample of 1,624 Norwegian veterans from the UNIFIL (United Nations Interim Force in Lebanon) was investigated on average 6.6 years after service, completing a questionnaire focusing on stress exposure and posttraumatic stress reactions. The prevalence of posttraumatic stress disorder (measured by the Posttraumatic Symptom Scale [PTSS-10]) was 5% overall, but 16% in the subgroup of personnel having been prematurely repatriated from UNIFIL. Multiple regression analyses showed that the following variables made separate and significant contributions to the explained variance of the PTSS-10: Service stress exposure, perceived lack of meaningfulness with respect to the military mission, and stressful life-events in life after service. These factors explained 25% (overall sample) and 37% (repatriated sample) of the variation in the posttraumatic symptom score.

Longitudinal changes in recalled perceived life threat after a natural disaster

BACKGROUND Post-traumatic stress disorder (PTSD) diagnosis often depends on a retrospective, self-report of exposure to a life-threatening event. AIMS To examine the stability of recalled perceived life threat in a community sample exposed to a distinct stressful event. METHOD Five hundred and thirty-two Norwegian citizens who experienced the 2004 South-East Asia tsunami completed a self-report questionnaire 6 and 24 months post-disaster. The questionnaire measured perceived life-threat intensity, exposure, immediate stress response, psychopathology, personality dimensions, self-efficacy and social support. RESULTS Recalled threat intensity increased from 6 to 24 months (P<0.001). Recall amplification was associated with lack of PTSD symptom improvement (P<0.05), but not with degree of exposure, immediate stress response, mood or stress symptoms, personality, self-efficacy or social support. CONCLUSIONS Recall amplification of perceived life threat from a single stressful event occurs in the general population, it may hinder PTSD symptom improvement and it questions the diagnostic validity of PTSD.