PTSD: National Center for PTSD

Risk and Resilience Factors After Disaster and Mass Violence

Millions of people have been directly affected by disaster and mass violence, yet the vast majority of them recover from any stress reactions they experience. At the same time, some survivors will develop psychological disorders such as major depression, generalized anxiety, and posttraumatic stress disorder (PTSD). Many more experience non-specific distress, somatic complaints and other medical health conditions. Risk and resilience (or protective) factors influence the impact of a disaster or mass violence on affected individuals.

Risk Factors

Severity of exposure to the event (especially injury, threat to life, and extreme loss) and post-event adversities consistently and most strongly influence the likelihood of serious or lasting psychological problems following disaster and mass violence. Individual, social, and community-level risk factors also can play a role in how survivors will fare after these events.

Severity of exposure

The amount and nature of exposure to the event is highly related to risk of future mental health problems, such that injury and life threat as well as proximity to the disaster or violence are most predictive of likelihood of distress, difficulty functioning, and potential psychological impairment, even up to 10 years after the event (1-15).

Those who directly experience the event will feel a more lasting impact, followed by those in close contact with immediate survivors. In one review of literature, for example, in the first year after a disaster, prevalence of PTSD ranged between 30% and 40% among direct victims, while between 10% and 20% of rescue workers and 5 to 10% of the general population were similarly affected (16). Type of disaster also impacts long term adjustment in research samples, with mass violence samples being more likely to report severe impact than technological or natural disasters samples (17).

Where significant displacement occurs, separation from home and family has been noted as a risk factor for anxiety and depression in some individuals (2,18-23).

Perception of health risk in chemical and radiological disasters increases risk for long-term anxiety and somatic symptoms, even in unexposed populations (24-27).

Post-event adversity

Post-event stress and adversity along with weak or deteriorating psychosocial resources have consistently been shown to be significant risk factors for long-term adjustment problems and psychopathology (e.g., 2,10,28-32). These can include factors such as loss of employment, financial constraints, and relationship difficulties (31,33). For instance, in a study conducted five years after bushfires, life stressors—many of which were related to ongoing social and economic disruption caused by the fires—contributed the most to delayed onset or lingering PTSD, depression, and distress (34).

Individual factors

Demographic risk factors for adjustment problems and psychopathology following disaster and mass violence include female gender, ethnic minority group membership, poverty or low socioeconomic status, little previous experience in coping with these types of events, prior exposures to highly stressful experiences, prior history of mental disorders, and being aged 40 to 60. Risks also increase among those over 65 who are sick, economically disadvantaged, impacted by evacuation procedures, or frail (3,9-10,13-15,17,30).

There are a number of cognitive factors that are related to increased risk following disaster and mass violence, including negative coping strategies, such as rumination and self-blame (e.g., 35,36), negative appraisals (about the event, personal role in the event, reactions, and potential future risk; e.g., 37), avoidance coping (30), negative religious appraisals (e.g., viewing the event as punishment; 5,38), and assignment of blame (e.g., 39-41).

Two personality traits have been linked to depression following disaster and mass violence. Those with higher neuroticism—a tendency to experience sadness, anger, and fear, and a susceptibility to the effects of stress on mood—are more at risk for depression. Extraversion—a tendency to experience positive emotions and to be engaged with others—also plays a role. People with lower extraversion are similarly at risk for depression (42).

Specific to mass shootings, guilt and resentment, insecurity, anxiety sensitivity, beliefs that events are random and uncontrollable, pre-existing lack of social support, ruminative and avoidant coping styles, and punitive attitudes toward crime have all been found to increase risk for PTSD, depression, and anxiety disorders following these events (43-47).

Social factors

Though perhaps high in the immediate aftermath of disaster or mass violence, social support can deteriorate over time. Continuing post-disaster stress and the need for survivors to rebuild their own lives may make it difficult for them to offer positive support to others. Following mass trauma, previous in group-out group divisions—racial, religious, ethnic, social, or tribal—may become apparent as people try to gain access to much needed resources. This may be true even if those divisions previously seemed resolved (48-50).

Lack of social support—or perceived barriers to it—has been shown to be related to worse recovery following disasters (1,32,51-53). And receiving negative social support, in which members of one's social circle minimize survivors' problems or needs, harbor unrealistic expectations regarding their recovery, or downplay their pain, is a strong correlate to long-term post-trauma distress.

Specific to the aftermath of mass shootings, unique social factors have also been reported to increase risk for anxiety, distress, and poor functioning. These include factors such as perceived pressure to participate in events designed to promote community unity, such as memorials and community meetings, a sense of guilt that the community didn't prevent the shooting, or shame that one's community is now identified with the shooting, differences in readiness to "move on" or to become involved in legal matters, or viewing perceived outsiders with distrust (23,54-57).

Social factors within the family have also been reported to increase risk of long term distress following disasters and mass violence. For instance, the presence of children in the home increases the stressfulness of disaster recovery among their parents. The presence of a severely distressed family member, interpersonal conflict, and lack of support in the home are risk factors for more severe post-traumatic reactions (17). Conflicts may arise because differing exposure levels among family members can result in differing courses of post-trauma recovery. Finally, family members may serve as distressing reminders to each other of the circumstances surrounding the event.

Community-level factors

Community-level factors have been shown to create additional risk for individuals (51,58,59). For instance, displacement and low community social cohesion have been associated with worse mental health outcomes above and beyond individual-level characteristics (2,20,21,60).

Protective Factors

In addition to identifying risk factors, disaster and mass violence research also describes protective factors (or resilience) at the individual, social, and community level (7,8,10,30).

Individual factors

A number of demographic factors have been reported to confer reduced risk for psychopathology and prolonged distress. These include male gender, greater education levels, and older age (for those with no reported mobility issues or illness) (10,30). Additionally, certain personality factors foster resilience. These include having a greater capacity for hope or optimism, being generally less negative and more emotionally stable, being agreeable, and having perceived coping self-efficacy or the specific sense that one can cope with what has happened (61-63).

There are a number of adaptive skills that have been shown to be protective following disasters and mass violence, such as having an ability to reframe what has happened in a more positive, energizing, or helpful way; the ability to use distraction when appropriate to reduce distress; the capacity to fit coping strategies to the context in a flexible way; the ability to make meaning of the situation based on personal values; the use of positive religious strategies; and the capacity to seek support from others when needed (e.g., 38,64-66). Interventions such as Skills for Psychological Recovery focus on fostering many of these adaptive skills.

Social factors

Social support is one of the key ingredients to recovery following disasters and mass violence. It has been shown to facilitate well-being and limit psychological distress. Social connectedness increases opportunities for knowledge essential to recovery from the event. It also provides opportunities for a range of social support activities, including practical problem-solving, emotional understanding and acceptance, sharing of traumatic experiences, normalization of reactions and experiences, and mutual instruction about coping (9,10,53,59,65,67-71).

Community-level factors

A socially cohesive and well-resourced community has been shown to be better positioned to identify and assist those in need, disseminate information across the community, and advocate for outside aid following disasters and mass violence (72-74).

Conclusion

Because of the findings regarding multiple risk and protective factors, and the fact that many people are able to handle the demands placed upon them by disasters and mass violence, knowledge of the unique combination of risk and protective factors is an important step in response to these events.

Many researchers suggest assessing pre-existing, event-related, and post-event risk factors, as well as existing strengths, resources, and abilities. Rather than offering global interventions, which may undermine natural coping abilities, support can then be tailored as needed, with a focus on fostering protective factors (41,75-77).

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