PTSD: National Center for PTSD

Phases of Traumatic Stress Reactions Following Disaster and Mass Violence

The impact of disaster and mass violence is often widespread with many people who directly experience the event and many more who witness or are indirectly affected. It is common for people to react with behavioral and emotional stress reactions and readjustment problems. Prior research has shown that needs and reactions of individuals and communities change over time and can vary widely depending on the type of event.

Responses and interventions appropriate for one stage might be of little use—or even potentially harmful—at another phase. The post-event period can be divided into four phases: impact, immediate, intermediate, and long-term.

Phase 1: Impact

This phase encompasses the hours, days or weeks following a disaster or mass violence event, depending on the size and scope of the event. The impact phase tends to be longer for events that destroys people's homes and create a housing crisis, like a hurricane, earthquake, flood, or fire. Events like a mass shooting, large-scale accident, or technological disaster, may have a shorter impact phase because the survivors—though deeply affected—at least have a place to go home to.

Several stressors may occur during impact, including threat to life and encounters with injury and death; loss (of loved ones, home, workplace, possessions), dislocation (i.e., separation from loved ones, home, familiar settings, neighborhood, community); or, grappling with disasters that are caused by human error, neglect, or malevolence. Worry and confusion about family members and friends who might have been involved in the disaster or mass violence event amplify distress, as do uncertainty, chaos, disruptions to communication, and confusion about the true scope and nature of the event.

During the impact phase, affected individuals and communities experience a sense of threat, shock, fear, helplessness or powerlessness, guilt, and anxiety. Some people respond in a way that is disorganized and stunned, which may be transient or may extend into the post-disaster period. This may be manifested by people standing in harm's way, or wandering aimlessly, seemingly out of touch with their surroundings. Conversely, others may be energized and activated to help others and to respond in a focused, efficient manner.

During this phase, people often reach out in concerted efforts to support each other and prevent loss of life and property. Most people react to protect their own lives and the lives of others. After the fact, however, people may judge their actions during the disaster as not having fulfilled their own or others' expectations of them.

Phase 2: Immediate - Rescue

This is the phase in the days and weeks following disaster and mass violence in which there is a reckoning with what has happened. During this phase, people are beginning to assess the extent of damage to home and community. They may be trying to locate survivors while still reeling from the shock of what just happened. At this time, they are only beginning the process of dealing with the physical, emotional, and social impact of injury, loss, and exposure to traumatic stress engendered by the event. The focus is often on survival needs and the restoration of safety and some semblance of order.

While people are getting their lives in order, there may be a delay in emotional reactions, which may only appear after a certain level of stability has been achieved. Reactions in the immediate phase are expected to be changeable and usually depend on the individual's history, perceptions, and exposure to the disaster. A full range of negative emotional, mental, social, and physical reactions may occur, but they may not be predictive of long-term outcomes. Reactions may include:

• Numbness
• Denial or shock
• Confusion
• Feeling stunned or overwhelmed
• Anxiety
• Grief reactions to loss
• Flashbacks and nightmares
• Anger
• Despair
• Sadness
• Hopelessness

Conversely, positive reactions in all of these dimensions are also possible, such as inspiration to help others and to rebuild, relief, and gratitude.

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Phase 3: Intermediate - Recovery

The intermediate phase may last from weeks to months, depending on the size and scope of the event.

This phase is the prolonged period of adjustment or return to equilibrium. It begins as rescue is completed and individuals and communities face returning to fulfilling routine tasks and roles. Much of what happens in this phase will depend on the extent of devastation that has occurred, as well as injuries, exposure to traumatic stress, and lives lost (1).

During the impact and immediate phases of response, most people's priority is basic safety and survival. Once that need is secured, and the intermediate phase begins, other psychosocial needs emerge that had been previously frustrated and unfulfilled. Additionally, ongoing adversities are common in this phase and complicate recovery.

The sub-phases of this period have been described as:

• Altruism: There is an outpouring of support, services, and supplies. People may feel grateful, inspired by the altruism of others, and relieved to receive support. A heightened sense of solidarity among survivors can transcend prior conflicts and barriers within a community. This has been identified as "altruistic or therapeutic community" or "post-disaster Utopia" (2). People may be hesitant to express distress, concern, or dissatisfaction, because they feel they should be grateful for the aid given, or because they have suffered less than others have.
• Disillusionment: In this period, which usually follows the altruistic phase, there may be disappointment in the disaster response, and hopeful expectations may give way to resentment. This disillusionment can also occur when outside relief workers leave and affected individuals realize that they are "on their own" with a lot of work left to be done. This aspect of the recovery process has been called the "second disaster" because it presents new adversity, loss, conflict, and potential trauma. Tensions and inequities existing prior to the event can re-emerge and be stronger than before, particularly when marginalized communities are perceived to be the least aided (3,4).

Psychosocial needs may be intense in the intermediate phase, particularly for those who have been severely affected. Reactions that were prevalent in the immediate phase will carry over to this phase. Physical symptoms, such as sleep disturbance, indigestion, and fatigue may also emerge. Stress reactions can also express themselves socially in relationship or work difficulties.

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Phase 4: Long-Term - Reconstruction

This phase may last several months or years, as communities rebuild and individuals deal with their post-event problems. On the one hand, there may be opportunities for positive social consequences if communities collectively respond and rebuild. However, if the community is unable to pull together and overcome fragmentation, there may be increased risk for ongoing stress reactions across the community.

The ongoing daily impact from the disaster may be complicated by socioeconomic, cultural, racial, and political factors associated with the disaster response. Additionally, concerns for the future and what it might hold can result in fear, resentment, and depression.

The perception of the event and the meaning assigned to it may also affect long-term psychosocial adjustment. Ongoing media coverage of aspects related to mass violence (i.e., coverage of the event itself, subsequent coverage of courtroom events) may create triggers for those who view the coverage, particularly those most close to the event (5-9).

While the majority of affected individuals will see a lessening of distress over time in the long-term phase, vulnerable populations such as those with injury, severe disaster exposure or ongoing adversities, may continue to suffer for years after a large-scale disaster or mass violence event.

See: Treatment Interventions Following Disaster and Mass Violence

Summary

As the needs of individuals and communities change over time following disaster and mass violence, response efforts can be tailored to best support the current phase of recovery. The phases of disaster reaction described here highlight the need for a stepped (phased) public health response of disaster psychosocial intervention.

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References

• Raphael, B., & Wilson, J. P. (1993). Theoretical and intervention considerations in working with victims of disaster. In J. P. Wilson & B. Raphael (Eds.) International handbook of traumatic stress syndromes (pp. 105-117). New York, NY: Springer US.
• Hobfoll, S. (2014). Resource caravans and resource caravan passageways: a new paradigm for trauma responding. Intervention, 12, 21-32. doi:10.1097/WTF.0000000000000067
• Hartman, C., & Squires, G. D. (2006). Pre-Katrina, post-Katrina. In G. Squires & C. Hartman (Eds.) There is no such thing as a natural disaster: Race, class, and Hurricane Katrina (pp. 1-12). New York, NY: Routlege.
• Halpern, J., & Tramontin, M. (2007). Disaster mental health: Theory and practice. Belmont, CA: Thomson Brooks/Cole.
• Ahern, J., Galea, S., Resnick, H., & Valhov, D. (2004). Television images and probable posttraumatic stress disorder after September 11: The role of background characteristics, event exposures, and preievent panic. The Journal of Nervous and Mental Disease, 192, 217-226. doi:10.1097/01.nmd.0000116465.99830.ca
• Nishi, D., Koido, Y., Nakaya, N., Sone, T., Noguchi, H., Hamazaki, K., Hamazaki, T., & Matsuoka, Y. (2012). Peritraumatic distress, watching television, and posttraumatic stress symptoms among rescue workers after the Great East Japan earthquake. PLoS One, 7, e35248. doi:10.1371/journal.pone.0035248
• Silver, R. C., Holman, E. A., Andersen, J. P., Poulin, M., McIntosh, D. N., & Gil-Rivas, V. (2013). Mental- and physical-health effects of acute exposure to media images of the September 11, 2001, attacks and the Iraq War. Psychological Science, 24, 1623-1634. doi:10.1177/0956797612460406
• Holman, E. A., Garfin, D. R., & Silver, R. C. (2014). Media's role in broadcasting acute stress following the Boston Marathon bombings. Proceedings of the National Academy of Sciences of the United States of America, 111, 93-98. doi:10.1073/pnas.1316265110
• Pfefferbaum, B., Newman, E., Nelson, S. D., Nitiéma, P., Pfefferbaum, R. L., & Rahman, A. (2014). Disaster media coverage and psychological outcomes: Descriptive findings in the extant research. Current Psychiatry Reports, 16, 464-470. doi:10.1007/s11920-014-0464-x

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