Disasters and Mental Health
http://www.100md.com
《新英格兰医药杂志》
The response by Rudolph Giuliani, then New York City's mayor, to the question of just how many had died on September 11, 2001 — "more than we can bear" — is a pithy comment on the far-reaching impact of the catastrophic. It points to that which cannot be properly quantified but which can linger long after the critical events have passed. Disasters are as old as humankind and, in some ways, have partly defined it; from them, human beings have long sought to rescue those who were spared, to nurse the wounded, and to make sense of it all. More modern, perhaps, is the notion that damage need not be only physical, that risk may go beyond life and limb. Descriptions of "soldier's heart" during the Civil War and of "war neurosis" during World War I provided conceptual antecedents to and set the stage for post-traumatic stress disorder (PTSD), which was codified into the psychiatric nosology of the Diagnostic and Statistical Manual of Mental Disorders in the wake of the Vietnam War.
PTSD is not the sole mental health outcome of trauma (depression, substance abuse, and psychosomatic disorders have all been linked to trauma), nor is it an invariable or enduring outcome. For example, among randomly selected residents living in close proximity to the World Trade Center in New York City at the time of the September 11 attacks, only 8 percent met the diagnostic criteria of PTSD in the immediate aftermath of the attacks — and this decreased to 2 percent six months later. And yet, PTSD is useful for understanding the impact of a collectively tragic event on an individual person.
PTSD is not a normative buffer against external assaults; it is, rather, a distinctly abnormal, maladaptive response. Blunted cortisol responses to stress and heightened hypothalamic–pituitary activity develop, counterproductively, in PTSD in an effort to restore homeostasis. Decreased hippocampal volume seems to be an antecedent rather than a consequence of chronic PTSD, and this appears to be partly responsible for the neuroendocrinologic abnormalities. Such a finding, if consistently replicated, would suggest that we may be moving from the merely descriptive (sex, age, proximity to the event) to the biologic underpinnings of PTSD and potential target loci for therapeutic intervention.
Disasters disrupt the lives of all involved but cause a maladaptive traumatic response in only a minority. For this reason, mental health professionals are most helpful when they reserve their specialized interventions for those persons who cannot adapt to disaster. Disasters and Mental Health describes the responses of a dozen different countries to their own tragedies. Although each is ultimately unique, such worldwide experiences have underlying themes, with four types of disasters addressed here: natural disasters (earthquakes in Japan, Turkey, and Greece), terrorist attacks (bombing of the U.S. Embassy in Nairobi and the 9/11 attacks), industrial accidents (Chernobyl, in the former Soviet Union, and Bhopal, India), and internecine fighting (in the former Yugoslavia, the Middle East, and Latin America).
Commonalities across such a varied set of events can be further distilled. First, disasters disproportionately affect poor regions of the world and, in a vicious cycle, further contribute to their underdevelopment. Second, disasters are often put to political use, for settling festering social struggles (scapegoating is a case in point). Third, to do no harm is still a useful dictum in this context: a deluge of unsolicited and poorly coordinated help occurs frequently enough after a disaster to have earned the label "second disaster." Finally, a disaster requires concerted responses at both the logistic and psychological levels, or at the communal and individual levels, so as to contain the disrupted relations between inner and outer realities. As stated in the first chapter, by Juan José López-Ibor, disaster provides "an empirical falsification of human action," rudely reminding us of the incorrectness of our orderly conceptions regarding nature and culture.
Giuliani's words humanized the unimaginable, lifting it above the anonymously numerical. But his sentiment was inaccurate in the end: as a species we have learned time and again that we can bear much more than we care to imagine. This timely book will help us maximize what we are summoned to bear when disaster inevitably strikes next.
Andrés Martin, M.D., M.P.H.
Yale Child Study Center
New Haven, CT 06520
andres.martin@yale.edu(Edited by Juan José López)
PTSD is not the sole mental health outcome of trauma (depression, substance abuse, and psychosomatic disorders have all been linked to trauma), nor is it an invariable or enduring outcome. For example, among randomly selected residents living in close proximity to the World Trade Center in New York City at the time of the September 11 attacks, only 8 percent met the diagnostic criteria of PTSD in the immediate aftermath of the attacks — and this decreased to 2 percent six months later. And yet, PTSD is useful for understanding the impact of a collectively tragic event on an individual person.
PTSD is not a normative buffer against external assaults; it is, rather, a distinctly abnormal, maladaptive response. Blunted cortisol responses to stress and heightened hypothalamic–pituitary activity develop, counterproductively, in PTSD in an effort to restore homeostasis. Decreased hippocampal volume seems to be an antecedent rather than a consequence of chronic PTSD, and this appears to be partly responsible for the neuroendocrinologic abnormalities. Such a finding, if consistently replicated, would suggest that we may be moving from the merely descriptive (sex, age, proximity to the event) to the biologic underpinnings of PTSD and potential target loci for therapeutic intervention.
Disasters disrupt the lives of all involved but cause a maladaptive traumatic response in only a minority. For this reason, mental health professionals are most helpful when they reserve their specialized interventions for those persons who cannot adapt to disaster. Disasters and Mental Health describes the responses of a dozen different countries to their own tragedies. Although each is ultimately unique, such worldwide experiences have underlying themes, with four types of disasters addressed here: natural disasters (earthquakes in Japan, Turkey, and Greece), terrorist attacks (bombing of the U.S. Embassy in Nairobi and the 9/11 attacks), industrial accidents (Chernobyl, in the former Soviet Union, and Bhopal, India), and internecine fighting (in the former Yugoslavia, the Middle East, and Latin America).
Commonalities across such a varied set of events can be further distilled. First, disasters disproportionately affect poor regions of the world and, in a vicious cycle, further contribute to their underdevelopment. Second, disasters are often put to political use, for settling festering social struggles (scapegoating is a case in point). Third, to do no harm is still a useful dictum in this context: a deluge of unsolicited and poorly coordinated help occurs frequently enough after a disaster to have earned the label "second disaster." Finally, a disaster requires concerted responses at both the logistic and psychological levels, or at the communal and individual levels, so as to contain the disrupted relations between inner and outer realities. As stated in the first chapter, by Juan José López-Ibor, disaster provides "an empirical falsification of human action," rudely reminding us of the incorrectness of our orderly conceptions regarding nature and culture.
Giuliani's words humanized the unimaginable, lifting it above the anonymously numerical. But his sentiment was inaccurate in the end: as a species we have learned time and again that we can bear much more than we care to imagine. This timely book will help us maximize what we are summoned to bear when disaster inevitably strikes next.
Andrés Martin, M.D., M.P.H.
Yale Child Study Center
New Haven, CT 06520
andres.martin@yale.edu(Edited by Juan José López)