A disaster is defined not only by material, but also by psychosocial criteria: a) it causes psychic suffering, b) it brings unhappiness, c) it causes perturbations in the human environment, and d) it strikes the society's functions, such as production-distribution-use of energy and water, circulation of persons and merchandises, etc. Thus, in a disaster, each victim, witness or rescuer, is wounded not only in his/her personal ego, but also in his/her communal ego. Therefore, we must take in consideration not only the individual but also the collective reactions and behaviours. The mental health intervention must be adapted to these distinctions and to the three phases of the disaster psychology: a) the immediate phase (first hours), b) the post-immediate phase (first days, first weeks), and c) the chronic phase (after one month).
The immediate reaction to disasters is usually the normal adaptive biophysio- psychological reaction of stress. It is useful, life-saving, focusing attention, mobilizing the mental and physiological capacities and prompting to decision making. But, it is accompanied by disturbing neurovegetative symptoms and, if it is too intense, too long or too repeated, it exhausts the energetic reserves and becomes overwhelming stress, in one of its four modalities: stuporous inhibition, uncontrolled agitation, individual panic flight, and automatic behaviour (acting by reflex or blind imitation, without consciousness or recall of the action). In predisposed individuals, we can also observe neurotic (anxious or hysterical) or psychotic (confusional, manic, delusional or schizophreniclike) reactions (1).
The post-immediate reaction can be the progressive extinction of stress symptoms, or a short-delayed emotional or neurovegetative reaction, or the variable persistence of neurotic or psychotic states. But it can be also the beginning (latency period) of a durable or chronic psychotraumatic syndrome, the so-called 'post-traumatic stress disorder' (PTSD). The latency period is not completely silent clinically: we can observe perplexity, sadness, abnormal euphoria, and insomnia.
The psychotraumatic syndrome is well known to clinicians. It covers a large range of cases, more or less severe and durable, corresponding to complete PTSD or elements of PTSD, and associate anxious, depressive, psychosomatic or personality pathology. Its main symptoms are the reviviscences of the event, the increased arousal and alertness, with insomnia, the avoidance of everything that recalls the trauma, and withdrawal from the world and from others (2). The ICD-10 has introduced the category of 'modifications of personality after an experience of catastrophe', emphasizing the marked change of the whole victim's personality.
Collective behaviour is different from the arithmetic sum of the individual behaviours which seem to compose it. It depends on the collective mind of the people, and eventually on the collective soul of the crowd, and it has its own psychological characteristics. Collective behaviours can be adjusted or maladjusted (1). Adjusted behaviours accomplish learned adaptive actions: evacuating in order, helping others, etc. They are characterized by three aspects: a) group structure is maintained, b) leadership is maintained, and c) mutual help is offered. Maladjusted behaviours include collective stupor (people remain without initiative or evacuate the damaged zone in a slow centrifugal stuporous exodus), collective panic (distracted flight, pitilessly overthrowing and trampling all that obstructs it) (3), discharge of violence, identifying scapegoats, and regressive desire of being perpetually assisted (4). Maladjusted behaviours are characterized by three elements: a) group structure is destroyed, b) leadership disappears, and c) crowd mentality prevails, without solidarity.
In the immediate phase (first hours), the early, immediate, mental health intervention is a moral obligation. Experience shows that victims who receive an early medical/psychological help have less severe sequelae. The mental health intervention must include: a) medical/psychological care provided by medical specialized teams, and b) psychological support provided by psychologists and mental health personnel (helped by para-professional workers). In France, the official network of the 'medico-psychological emergency cells' provides immediate intervention on the ground, with teams (psychiatrists, psychologists and nurses) integrated into the network of the medical emergency teams. Their mission is: a) to give care to mentally wounded people and to treat the disturbing symptoms of stress, b) to ensure the triage and the evacuation of the above people (5). They work in close collaboration with teams of psychosocial support, who provide help to the other victims. In this immediate phase, care includes not only the administration of anxiolytic or antidepressant medication, but mainly listening to the victims expressing their stress or trauma experience, and providing information about the reactions, the symptoms and their evolution. This early medical/psychological care and support is called 'defusing'.
In the post-immediate period, not only the medical/psychological follow- up of the hospitalized victims must be assured, but 'debriefing' (individual or in groups) must be proposed to victims and rescuers who need it. Experience shows that debriefing for rescuers must be conducted according to cognitive and narrative principles, while debriefing for victims must be based on the expression of emotions (cathartic method) (2).
In the chronic phase, the treatment of PTSD (complete or incomplete) and associated pathology (often misdiagnosed) must be ensured as soon as possible, because any delay facilitates the development of the morbid process. This treatment must be provided in a special setting (different from the ordinary psychiatric settings, because the victim of disaster does not consider himself/herself as a psychiatric patient), by psychiatrists and clinical psychologists specially trained in PTSD and disaster psychiatry.
Collective panic is difficult to deal with, and requires public order measures taken by the authorities. Other collective maladjusted behaviours (collective inhibition, collective dependence, scapegoating phenomena) require the intervention of mental health personnel. The help of paramedical personnel and institutions will be appreciated.
Prevention can be provided in the warning phase (giving exact information on the upcoming disaster and instructions on the appropriate reactions), but it is better to ensure longterm prevention. Long-term prevention, in countries frequently struck by natural disasters, includes four phases: a) information (on the risks and dangers), b) moral education (mutual help and solidarity), c) instructions (about means of protection and rescue) and d) training in exercises. Education of rescuers and leaders must be made available, dealing not only with the stress of the victims and its effects, but also with the stress of rescuers: how to recognize it and cope with it.
References
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