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Aftermath of a disaster

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Title:
Aftermath of a disaster psychological response to the Indianapolis Ramada jet crash
Series Title:
Quick response research report ;
Physical Description:
19, 11 p. : ill. ; 28 cm.
Language:
English
Creator:
Smith, Elizabeth Mary
North, Carol S
University of Colorado, Boulder -- Natural Hazards Research and Applications Information Center
University of Colorado, Boulder -- Institute of Behavioral Science
Publisher:
Natural Hazards Research and Applications Information Center, University of Colorado
Place of Publication:
Boulder, Colo
Publication Date:

Subjects

Subjects / Keywords:
Aircraft accidents -- Psychological aspects -- Indiana -- Indianapolis   ( lcsh )
Aircraft accident victims -- Mental health -- Indiana -- Indianapolis   ( lcsh )
Genre:
government publication (state, provincial, terriorial, dependent)   ( marcgt )
bibliography   ( marcgt )
non-fiction   ( marcgt )

Notes

Bibliography:
Includes bibliographical references (p. 19).
Additional Physical Form:
Also issued online as part of a joint project with the Louis de la Parte Florida Mental Health Institute (FMHI) Research Library's disaster mental health initiative.
Statement of Responsibility:
Elizabeth M. Smith, Carol S. North.
General Note:
Cover title.
General Note:
"Institute of Behavioral Science #6."

Record Information

Source Institution:
University of South Florida Library
Holding Location:
University of South Florida
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
aleph - 001985189
oclc - 39119316
usfldc doi - F57-00037
usfldc handle - f57.37
System ID:
SFS0001118:00001


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Aftermath of a disaster :
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NaturalHazardsResearchandApplicationsInformationCenterCampusBox482UniversityofColoradoBoulder,Colorado 80309-0482 AFTERMATHOFADISASTER:PSYCHOLOGICALRESPONSETOTHEINDIANAPOLISRAMADAJETCRASHElizabethM.SmithCarolS.North1988QuickResponse Research Report#23This publication is partofthe Natural Hazards &Applications Information Center's ongoing QUick Response Research Report Series. http://www.colorado.edu/hazardsInstituteofBehavioralScience#6 (303) 492-6818

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AFTERMATHOFADISASTER:PSYCHOLOGICALRESPONSETOTHEINDIANAPOLISRAMADAJETCRASHDESCRIPTIONOFTHEDISASTEREVENTAtapproximately 9:20A.M.onOctober 20,1987anAir Forcejetfightercrashed into thelobbyof theRamadaInnin Indianapolis.Theeventwascompletely unexpectedandoccurred without warning. Although the hotelhadbeenfullyoccupied the previous night,mostof the guestshadalready checkedout;the majority of those presentwerehotel employees. Therewerenine immediatefatalities,allhotel employees.Theremaining22employeesweresafelyevacuated immediatelyafterthe crash, exceptforonehospitalized with burninjuries.Therewasonenon-employeefatality,a salesmanwhohadstoppedtouse a hotel phone,andwhodied ofburninjuriesapproximatelyoneweekafterthe crash. Thisdisasterwasmarkedbya considerable degree of horrorandterror.Survivorstoldstoriesof looking out apicturewindowto see the planeflyingtowardthem;shrapnelfromthe plane blasting through walls fivefloorsaway;trapped victims cryingandscreaming for helpandbeatingonthe walls as they died; bodies charredbeyondrecognitionandblownto pieces;andamanwhocamerunning out of the hotel in flames.(Seenewspaperaccounts in appendix.)Uponemergingtosafetyoutside the burninghotel,the immediate impulseformanyvictimswastogobackintorescue thosestilltrappedinside.Severaltried,butwereimmediately turnedback by intense heatandsmoke,onlytostandhelplessly,listeningwith horror totheirco-workers' screamsfrominsideasthey perished.Thescene outsidewaschaos, with thefirstarrivalsof the100emergencyandfirevehicles,swarmsofnewspaperandtelevisionreporters,andcrowdsof onlookersandworriedrelatives.Thesecrowdshamperedfrustratedvictims intheirfrenzy to locatetheirloved ones.

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2RedCross rescue workerssetupa waitingroomfor victimsandtheirfamiliesata hotel a blockaway.Withthe help of the victims, workersbegancompiling alistof the missing. Early estimates offatalitieswerereported as highas50.By4 P.M., about17peoplewerestillunaccountedfor.Throughout the day, theemployeeswaited together,huggingeachother,andsharing photosfromtheirwalletsandcrying together.TheRamadaemployees described themselvesasaclose-knitgroup,likea family.Somehadworkedtogetherformanyyears. After the crash they pulledevenclosertogether,providing support for each other in awaythatnooneelsecould.By10P.M. all but afewof the victims' bodieshadbeenidentified,andthe remaining victimsandfamilieswenthome.Allhadlostfriendsandco-workers;somehadlostcloserelatives.Therewasapromptresponsebythe National OrganizationforVictims' Assistance(NOVA),andgroupcounselingwasprovided to all employees with1n afewdays of the crash.Asaresultof the accident the hotelwasclosedforwhathasproved tobeanindefiniteperiod; thusmostemployeessuffered a secondary loss ofemployment.Withthesuddenlack ofincome,somewereunable topayrentandwereforced tomove.TheAir Force remunerated victimsforlosses oftheirpossessions and, insomecases, fortheirloss ofincome.However,thisassistancewasreportedlyirregularandindefinite.A temporaryofficewassetupbyRamadaInnmanagementandthisenabled the employees to maintain contact witheachother.However,thiswasmademoredifficultdueto uncertainty about the future of thehotel,manyindividualsbegantolookfor other jobs.METHODSWelearned of the plane crashaswewerepreparing the quick response grant application for study of the psychological impact of various types of

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3disastersandincludeditin the proposal asoneof the eventstobestudied.Promptnotificationof funding allowedusto begin our researcheffortswithin ten daysafterthedisaster.Theinitialcontactwaswith the Disaster Services Office of theAmericanRedCross in Indianapolis. This yielded valuable information regarding thedisasteraswellaslinkinguswith theownerof theRamadaInn. Aphonecallto theownerindicating ourinterestin studying the psychologicaleffectsofthisevent broughtanimmediate responsefromhisassistant.Bothheandtheownerhadbeenscheduledtobein the hotel in the lobby areawheremostof thefatalitiesoccurredonthemorningof the crash.However,oneforgot tosethis alarmandoverslept;the otherwasdelayedbyanother meeting. Therewereinfactanumberof individualswhoweresupposedtobetherethatdaybutwerenot because of a cancelled meeting, changing schedules, adoctor'sappointment,cartrouble,etc.Conversely, therewereotherswhoshould nothavebeenthere,likethe local salesmanwhowaskilled.Althoughwehadoriginallyplanned to study individuals (employeesandguests)whowerepresentatthe time of thedisaster,mostof the hotel guestshaddepartedandhotel records oftheirregistrationsdestroyed in thefire;thus they could notbereadilylocated. Insteaditwaselected to interview asmanyof the61survivingemployeesaspossible. Since thecommunityof hotel employeeswassoclose-knit,itwasexpectedthateventhose not presentatthe time of the crash mighthaveexperienced psychological sequelae. This unusual arrangement of the occurrence of a severedisasterin a circumscribedcommunityof co-workerswasidealforanepidemiological study ofthistype.Itprovided arareopportunity to studyanentirepopulation ofdisastervictims, systematically, in the acute phase following the event.Theinclusion ofoff-siteemployeesalso allowed the unique opportunitytotest

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4the hypothesisof'adose-response relationshipbetween of exposuretothedisasteranddegree of emotional upset. Lettersweresent to the61surviving hotelemployeesexplaining the studyandinvitingthemtoparticipatebyresponding via enclosedselfaddressed postcards orbytelephone.Ifnoresponsewasreceived, theinvestigatorsfollowedupwith a telephonecall.SampleAtotalof46individualswereinterviewed. Seventeen(37%)of these on-siteatthe hotelatthe time of the crash.Ofnote,onenon-' employee, a hotel guest,wasincluded in the count ofoff-siteindividuals,,sincehehadbeenstaying the hotelonbusiness for several months,andwasgenerally consideredbytheemployeestobea valuedmemberoftheir"community of co-workersattheRamada.Sevensubjects refusedtobeinterviewed(19%on-siteand9%off-site)foranoverall refusalrateof13%.Nineindividuals(14%)could notbelocated'duetocomplications of thedisaster(destroyed records;newlyunemployedvictims havingtomoveforfinancialreasons).Onlyoneof the unlocated subjectswasin theon-sitegroup.Thetotalcompletionratewas74%,fairlyevenly dividedbetweentheon-site(77%)andoff-site(72%)groups.Mostpersons interviewed agreed toparticipatebecause theywantedtobeof help in a researcheffortwhichthey thoughtmightbenefit others in thefuture.Othersfeltaneedtotalkabouttheirexperience orsawitasanopportunity to obtain help Amongtheon-siteindividualswhorefused, several indicatedthatthey believeditwouldbetoo upsettingtotalkabout thedisasterexperienceandonehadbeenadvisedbya lawyertosign nothingandtalktonoone. Other respondents reportedthatthese onsiterefuserswereamongthose they consideredtobethemost In

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5contrast,therefusalsin theoff-sitegroupseemedtobeprimarlyduetoa lackofinvolvement'or impact of thedisaster.Mostof the unlocatedindividualswerecontractworkerswhohadlimited contact with therestoftheclose-knitcommunityof employees. Instruments Subjectswereinterviewed abouttheirpsychiatricandsocialstatususing a modified version of the Diagnostic Interview Schedule/Disaster Supplement(DIS/OS)(RobinsandSmith1983). This interviewwas desi9ned fortheECAHazards study fundedbyNIMH(Smithetal.1986)andhasbeenusedbyinvestigatorsin several recentdisasterstudies.Itelicitsinformation aboutthedisasterexperienceandtheindividuals'perceptions of the event, use of formalandinformal support systems, behavioral responsetothe traumatic event,and15DSM-IIIdiagnoses selectedfortheirpotentialrelevancetothedisasterexperience.Inthisstudy only the followingdiagnosticcategorieswereincluded: post-traumaticstressdisorder,depression, somatizationdisorder,generalized anxietydisorder,panicdisorder,phobicdisorders,antisocialpersonalitydisorder(adultcomponent), alcohol abuse/dependence,anddrug abuse/dependence. For eachdisorderthatwasascertained tohaveoccurred,ageof onsetandageatlastsymptomwereobtained, thus providinglifetimeaswell ascurrentpsychiatricstatus.Onsetandrecencyforeachpositivesymptomof therelevantdiagnoseswerealso obtained.Thusinformationwasavailableastothepresenceorabsence of eachsymptomduring theintervalbetween thedisasterandthe interview,andpriortothedisaster.Thedisasterinterview also contained anumberofothermeasuresthatmightbesensitivetochanges in mentalhealth.These included use of healthservicesandpsychoactive drugs, healthanddisabilitystatus,rolefunction,

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6andsocial support.Inaddition to these questions,allofwhichwerepartof theECAinterview, thedisastersection explored thedisasterexperienceanditsmeaningfor the respondents.Allparticipantswereaskedtoevaluatenewscoverage of thedisaster,onwhomtheyblamedthedisaster,andwhetherotherstressfullifeeventshadoccurred in thelastyear. Subjectswerealso asked to completetwoself-administered forms: theImpact.of Events Scale (Horowitzetal.1979), a 1S-item questionnairewhichmeasures current subjectivedistressrelated to experiencing astressfullifeevent;andthe Tridimensional Personality Questionnaire (Cloninger 1986).Themajority of interviewswereconducted in-personandwerecompletedatfourtosixweeksafterthedisasterevent.Forvarious reasons, afewinterviews could notbescheduled in personandwerecompletedbytelephone. Interviewswereconductedbythe authors,twofourth-yearpsychiatryresidents,anda researchassistant.Allsubjectswereoffered $10.00forparticipating.Theinterview tookonaverage approximately ninety minutestoadminister.DataAnalysis.Forthe purposes ofanalysis,the subject groupwasdivided into three categories: IIhit" oron-site(N=17) IInear-hitll(N=12),andIImissll(N=17).TheIInear-hitll included thosewhohadoriginallybeenscheduled tobeatworkatthe time of the crash, but foronereason or anotherwerenot theree.g.,oversleeping,illness,cancelled meeting.The"miss"group consisted of thoseemployeeswhowerenoton-siteandwhowerenot scheduledtobeworkingthatday,--e.g.,nighttime bartenderandentertainment employees.Becauseof the limitedsizeof thestUdysample,testsof significancewerenot performed.Theresultswillbepresented in adescriptivefashion.

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7RESULTS.DemographicInformation.Thesamplewastwo-thirds femaleandmostly Caucasian, with ameanageof 29.2.Sexratios,race,andageweresimilarinallsUbgroups(Table1).Thesamplecontained a sizablenumberof part-timeandunskilled workers,whichmayhelp to explain therelativelyyoungageof the group.Giventhischaracteristic,ratesof pre-existing psychopathology mightbelower than expected, sincemanysubjectswouldnothaveyetreached theageofriskformanypsychiatric disorders. On-site victimsweremoreoften married thaneitherof theoff-sitegroups.Mostof the subjectshadcompleted high school orhadobtained a G.E.D.,andthe "near-hit" grouphadthe highest frequency of individualswhohadfinished high schoolandattendedcollege.Thismayreflectthefactthata meeting of the better-educatedmanagementemployeeswascancelledatthelastminute,andallthese individualswouldhavelikelybeenkilledin the meetingroomwhichwaslocated near the point of thejet'simpact. SUbjectivedistressandattributionofblame.Respondentswereaskedhowupset theyhadbeenafterthe plane crash,andhowmuchtheyfelttheyhadbeenharmed.Perceived degree of upset (Table2Jwasscored high ("very upset")bymostrespondents.Itwasnot surprisingthat100%of thoseon-sitereportedthattheywerevery upset.The"missIIgroupcontained thesma11estproportion of "very upset" subjects,reflectinga dose-related responsepattern.Overseventy percent of thoseon-siteandatleastonehalfofthe.respondents in thetwooff-sitegroups believedthatthedisasterhadcaused agreatdeal ofharm.Onlyone-fourth of sUbjectsfeltthattheyhadcompletely recovered,andtheon-sitevictimswerelesslikelythaneitherof theoffsitegroups to reportfullorpartialrecovery.

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8Respondentswerealso askedifthey thought thedisasterwasjustanactofGodor nature, or whether they thought the victims oranyotherindividuals,industries,orgovernmentagencieswereinanywaytoblameforthe degree ofdamage.While100%ofon-sitevictimsfeltthedisasterreflectedjustanactofGodor nature,manyof theoff-sitesubjectsblamedthe victims.Abouttwo-thirdsatleastpartiallyblamedother individuals or agencies withlittlevariationacross the subgroups. Various respondentsblamedthe Air Force for not maintainingitsjetbetter;afewblamedthepilotfor bringing a disabledjetintosucha populated area;manyblamedtheairtrafficcontrollersfor not communicating properly with thepilot.Rarely,airportpersonnelwereblamedfornotcallingthefiredepartmenttoinformthemthattherehadbeennoexplosivesonthe plane,whichthey believedwouldhaveallowed the rescue workerstoenterthe burning hotelmorequicklyandsavemorelives.Othersblamedthe PresidentandtheGovernorfor notcallingtoexpresstheirsympathy,andfor not declaring the area a nationaldisastersite.Forthosewhoblamedtheirfellow victims, theblamewasoften ascribedtothosewhodied because theyhadgonebackinside the burning hoteltorescuetheirbelongingsratherthan escapingtosafetywhentheymighthave.Someblamedthemselvesfornot being abletorescue evenwhenthey recognizedthatthe rescuewasnot physically possible. Psychiatric Impact.Asshownin Table 3, one-third of thesampledeveloped anewdiagnosis [including post-traumaticstressdisorder(PTSD)byDSM-IIIcriteria,alcohol abuse/dependency, major depression,andgeneralized anxiety disorder] following thedisaster, i.e., incident cases.Thesenewdisorders appeared in a very apparentdoseresponse fashion, with over half of theon-sitesubjects developing anewdisorder, diminishing to only12%in the "miss" group.

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9Overhalfthesamplemetcriteriafor a psychiatric diagnosis (prevalence) following thedisaster,andunlike the incidenceratesthe prevalenceratedid not varybydegree of exposure. Separating thesetworatesof disease occurrence carves out those incident caseswhichwerespecificallyassociated with the occurrence of thedisaster.SymptomsofPTSOwereamongthemostcommonofsymptomsexperiencedbydisastersurvivorsandthese did not vary in frequencybysexdistribution.Three-quarters of thesamplereported havingatleastoneof the nine possibleOSM-IIIsymptomsofPTSO,averaging 4.17symptomsper subject (Table 4).Numberof subjects reportingsymptomsvaried in a dose-response fashion, with100%of theon-sitevictims experiencingoneormorePTSOsymptoms.This group alsohadthe highestmeannumberofsymptomsper SUbject.The"miss" group, with the lowestnumberofsymptomsper subject,stillscoredatleastonepositivesymptomin over half of subjects.Thesymptomwith the highest frequency of endorsementwasrecurring dreams/intrusiverecollections,reportedbyalmost three quarters of subjectsand94%ofon-sitevictims.Inthe "miss"group, insomniawasthemostcommonsymptom,acknowledgedbyabouthalfTwenty-twopercent ofallvictimsmetfullOSM-IIIcriteriaforPTSOafterthedisaster,with amilddose-responserelationship(Table 5). Although the interviewwasnot designed tomakeOSM-IIIRdiagnoses, reportedsymptomswerefitascloselyaspossible intoOSM-IIIRcriteria,andthe datawerere-analyzed.Whileitisrecognizedthatthisisnot aperfectlymatchedcomparisonduetothetwodifferentmethodologies,itmakesforatleastaroughcomparison ofOSM-IIIandOSM-IIIRcriteriaforPTSOin thesamepopulation.Theoverall prevalence ofpost-disasterPTSOrosefrom22%to33%whenOSM-IIIRcriteria were used. Thisislargelydueto thefactthatthe

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10DSM-IIIRcriteria"donot require the presence ofnumbnessandthatthenewcriteriadonot include the presence of survivorgUilt.Numbnessandsurvivor gUiltwerethetwoDSM-IIIsymptomsleastfrequently endorsedbythesubjects.Mostcases ofpost-disasterPTSDwerecasesthatarosedenovo,i.e.withoutanypriorhistory of thePTSDsyndrome.Allcases ofPTSDin onsitevictims appeareddenovofollowing thedisaster;thispatternwasnot seen in theoff-sitesubjectswhosePTSDrepresented a recurrence of a previousPTSDepisodeasfrequentlyasitrepresented development of adenovodisorder.Ofinterest,noneof theon-sitevictims recalledanypriorhistoryof aPTSDepisode, but 14% of theoff-sitegrouprecalled apriorepisode. This suggeststhatthe high frequencyandseverity ofpost-disasterPTSDsyndromesin theon-sitevictimsmayhaveblotted outtheirmemoriesofpriorepisodes ofPTSDthattheoff-sitevictimswereable torecall.Alternatively,perhaps theoff-sitevictimsmayhavevolunteered pastPTSDsymptomstocompensatefortheirlack of currentPTSDsymptoms.Twentypercent of the respondentswereabusing or dependentonalcoholpriortothedisaster(not shown),andabout halfthisnumberof subjectswasactivelyabusing alcoholafterthedisaster(Table6).Thoseabusing alcohol following thedisasterwerenot necessarily thesameones having ahistoryofprioralcohol abuse.Thetwosubjects developing alcohol abuseforthefirsttimeafterthedisasterwereboth in theon-sitegroup.Abouthalfof the alcohol abuse cases alsomet for dependence.Post-disasteralcohol diagnoses did not vary in frequencybetweenon-siteandoff-sitegroups. Approximatelyone-fifthof the respondentsmetcriteriafora previous episode of depression (not shown),andon-sitevictims recalledsomewhatlessin thewayof past depressions thaneitherthe "near-hit" or "miss"groups.

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11Depressionwasthemostcommonpost-disasterdiagnosis, with overtwo-fifthsof sUbjects meetingcriteria(Table 6).Althoughnotshownonthetable,maleswereslightlyover-represented in depressive cases.Intheon-sitegroup,newordenovodepression occurred in one-fourth of the sample,andthisfrequency decreased to halfthatamountin the m iss" group. Impressively,100%ofallindividuals with apriordepressionhada recurrence following thedisasterinallsubgroups (notshown).Thus,pre-existingdepressive history appearstostrongly predict relapse or persistence followingdisasterinthissample. On-site victimshadtwice the prevalencerateofpost-disastergeneralized anxiety disorderasoff-sitevictims with arateof approximatelyoneinfivefor theentiresample(Table6)..Frequency did not varybysex. Anxiety disorders inon-sitesubjects appeareddenovofollowing thedisasterabout as often as they represented a recurrence. Therewerenonew-onset anxiety disorders in the "m iss" group. Therewasconsiderable overlap in the occurrence of thethreemostprevalent diagnoses: depression,PTSD,andgeneralized anxiety disorder (Table 7).Overhalf of the subjectsmetcriteriaforatleastoneof these three diagnoses,andathirdof thesamplehadtwoormorediagnoses. Thirty percent of subjectsmetcriteriaforoneof these three diagnoses,35%metcriteriafor two,and7%metcriteriafor three (notshown).PTSDoccurred four timesmorefrequently in conjunction withoneof the othertwodiagnoses thanitdid alone. Generalized anxiety disorder occurred in conjunction with another diagnosis eight timesmorefrequently thanitdid alone. .Whenthe tabulationwasexpandedandrepeatedtoinclude dataonalcohol disorders (theleastfrequent of diagnoses),itwasfoundthatthose abusing alcohol usuallymetcriteriaforatleastoneother non-alcohol diagnosis.

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12Single-diagnosis cases of alcohol disorders,PTSO,andgeneralized anxiety disorder did notaddmuchtothe overall prevalencerateofpsychiatricdisorders.Thediagnosis of depressionwasthemostlikelyof these four disorderstooccur in the absence of another. Since the majority of thesamplereported feelingsomewhatupset or very upset about thedisaster,thisvariable did not provide a usefulcorrelationwithmoreobjective measures.However,SUbjectsgavemoreheterogenous responses to questions about subjective perceptions ofharm,andthisSUbjective measurewasobjectively supportedbythe finding of higher frequencies of psychiatric diagnoses occurring in SUbjects expressing thegreatestperceivedharm(Table8).A psychiatric diagnosiswaspresent inallsubjectswhoreportedthatthey'hadnot recovered. Surprisingly, almost one fourth of those withatleastonediagnosisfeltfullyrecovered despitetheirdiagnosable psychopathology. This unusual subset averaged 2.00 diagnoses persubject;themostcommondiagnosiswasdepression infiveof thesix(not shown). Predictors ofpost-disasterpsychiatricstatus.Forty-three percent of subjectsgaveapre-disasterhistory ofoneof the following fourpsychiatricdiagnoses:PTSD,major depression, alcohol abuse/dependence,andgeneralized anxiety disorder (notshown).Theproportion having apre-disasterpsychiatricdiagnosiswashighest in the "miss"group(47%)andlowestamongtheon-sitevictims(35%).Inthe EpidemiologicCatchment Area project,a survey accessing the prevalence of mental disorders in the general population (Robinsetal.1984),itwasfoundthat29-38%of thesamplehadexperiencedatleastoneof thefifteenOSM-IIIdisorders.Theserates,whichinclude other diagnoses besides the four diagnosesexaminedinthisanalysis, aremuchsmaller than the43%

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13pre-disasterprevalencerateinthispopulation (Table9).Ofinterest,whenthe analysiswasexpandedto includepost-disasterdisordersaswell, therateroseto54%.Tenout of eleven sUbjects with a previouspsychiatricdiagnosis experienced diagnosablepost-disasterpsychopathology, whilelessthanhalfof those without experiencedpost-disasterpsychopathology.Onlytwo(9%)of 22subjectswith apre-disasterdiagnosiswerefreeofpsychiatricdisorder following thedisaster,andthesetwosubjectswerein the "miss" group.Manyindividuals without apriordiagnosis developedoneafterthedisaster,butmorefrequently they remainedfreeof psychiatricdisorder,andthisheldforallSUbgroups Otherstudieshaveshownthatvictims ofdisastermayhavespecialcharacteristics(e.g.,lowsocioeconomicstatus)thatpredisposethemtoexperiencing adisaster,thesamecharacteristicsthatpredisposetopsychiatricdisorders (FergussonandHorwood1987). Unlike otherstudiesof low-income individualswhowereathigherriskof experiencing adisaster(e.g.,duetolivingon a flood plainwherelandischeaper, or residing intrailerswhichare vulnerable to tornadodamage)(Smithetal.1986),characteristicsof the population inthisstudy did not putthematriskforexperiencingthisdisaster.Theplane crash into the hotel lobbyseemedtobeamorerandomevent,anditwasonlybychancethattheemployees"got in the way".Aboutone-fifthof theentire sample hadpreviously receivedpsychiatrictreatment,andone-third of these subjectshadrequiredhospitalization(Table 10). History ofpsychiatrictreatmentwasequally frequentamongon-siteandoff-sitevictims, with the highest frequency(29%)in the "miss" group and lowest(8%)the "near-hit" group.

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14History of previous psychiatric treatment predicted development ofoneormorepost-disasterpsychiatric diagnoses in 60% of victims. while 52% of individuals withoutpriorpsychiatric treatment developed apost-disasterdiagnosis. suggestingthathistory of psychiatric consultationwasnot apredictorof development ofpost-disasterpsychopathology. Thismaywellbeduetothe high frequency of psychiatric disorders.Abouttwo-thirds of theentiresampletook advantage of ,the group counseling offeredbyNOVAafterthedisaster.with thoseon-siteatthe timeofthe crashmoreoftenparticipating.Mostcounselingparticipantsfeltthatithadbeenveryhelpful.andmanystatedthattheywouldhavelikedmoresessions.especiallyindividual sessions.Mostof thosewhowantedfurthercounseling said theydidn'tgetitbecause they affordit.Seventeen percent of the victims did seek professional help(psychiatristorother mental health professional) in thewakeof thedisaster(Table 10); however. these individuals did notalwaysrepresent thesameindividualswhohadsoughtpsychiatrictreatment in thepast.Treatment-seekerswerefairlyevenly dividedamongthosewhosought treatment before thedisaster.afterthedisaster.andboth beforeandafter.Coping. Informationoncopingwasobtainedfromsubjectswhoreportedfeelingupsetafterthedisaster.Anoverwhelmingmajority of survivors reportedthattheydependedonfamily or friends to helpthemcopewiththeirfeelings.Butfor most.thiswasnotenough.andthey turned elsewhereforadditionalassistance.Aboutone-fourth turnedtooneof each of the followingmethodsto cope: medication. alcohol. or a health professional (Table 11).Almosttwo-thirdscopedbyutilizingmedication. alcohol.orthe services of a physician or counselor (notshown).Ofthe 28% whoadmittedtousing alcohol tocopewiththeirfeelings about thedisaster.two-thirdsmet

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15lifetimecriteria"foralcohol abuse,andhalfwereactivelyabusing alcoholafterthedisaster(notshown).Allbutoneof these alcohol abusersmetcriteriafordependence,eithercurrently or in thepast;halfwerecurrentlydependent.Femalesrepresented almost half of those using alcohol to cope, but only one-third ofallthose abusing alcohol (notshown).Respondents generallyfeltthatwhathelpedmorethan anythingwasthe support they receivedfromfamilyandfriends.Mostfeltthattalkingabouttheirexperiences helpedthemresolvetheirfeelings.Manyreportedthatsharingtheirexperiencesandfeelings with fellow co-workerswhohadbeenthrough thesamethingwasinvaluable,andthatotherswhohadn'tbeentherecouldn'tunderstand or provide support in thewaythattheircomradescould.Theyoftenreportedthattheirfamiliesandfriendsdidn'twanttolistentothem,andtheywelcomedthe opportunitytotalkto alisteningearaspartofparticipatinginthisresearchproject.A minority did notwanttotalkabout thedisasteratall,statingtheyfeltthattheycopedbestbytryingtoforget aboutitandgettingonwiththeirlives.Several individualscopedbyfocusingtheirenergies 6n helpingtosupporttheirfellow victims.Manystoriesof altruismcametolightin these interviews,andsomesubjects reportedthattheydrewstrengthfromhelpingothers.Theydeveloped telephone support networksamongthemselves,andhelped each other find jobsandhousing.Manyreportedthattheirexperiencehadstrengthened or "proved"theirreligiousfaith.Subjectscommonlyreportedthattheyhadexperienced a"sharpchangeintheirvalues since thedisaster:they appreciated eachdayintheirlivesin a way'that they hadn't before; they placedmorevalueontheirfamiliesandlessonmaterialthings.Forexample, subjects said theynowmadea point oftellingtheirspouses frequentlythatthey lovedthem,andthey could not leave forworkunless they

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16hadkissedalltheirchildren.Manyweremakingeveryefforttospendasmuchtime as possible withtheirfamil iesandto"not takethemfor grantedIIanymore.CONCLUSIONSThefindings of our preliminary data analysis suggestthatafteradisasterwith strong elements ofterrorandhorror, survivors experience highratesof subjective upset correlated with objective evidence of psycho pathology, often in a dose-responsepattern.Onefourth of the victimshaddeveloped a disorderthattheyhadnever experiencedpriortothedisaster;thisfrequencywashighest (over half) in theon-sitegroup,andlowest in theoff-sitegroup. Clearly, propensity to develop a diagnosablepsychiatricconditionwasdose-related accordingtodegree ofdirectexposuretothedisasterexperience.ForPTSDandgeneralized anxiety disorder, degree ofpsychiatricimpact appearedtobedose-relatedtothe victims' degree of exposuretothedisaster.Otherfactorsunrelated to exposure appearedtoplayamoreprominentrolein thepost-disasterexperience of depressionandalcohol abuse/dependence.Theapparent dose-responserelationshipofPTSDandgeneralized anxiety disorderwouldtend to support a hypothesisthatthe occurrence of these disordersmaybecloselytiedto the elements ofterrorandhorror,whichmaybeimportant contributorstothe severity of a traumaticdisaster.Depressive disorders are perhapsmorecloselytiedtootherrelatedfactorssuchas bereavement over loss of lovedoneswhodied in thedisaster,or gUilt over having survived.Fordepression, pre-existing cases predicted recurrence orpersistence,withallpriorepisodes recurringafterthedisaster.CasesofPTSDtendedtoarisedenovoafterthedisasterwithout apre-disasterhistory,especiallyin

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17the high-exposure'group.Evenin those individualswhodid notmeetcriteriaforanyof the four majorpsychiatricdisorders, evidence ofstresswasapparent intheirhigh frequencies ofsymptomreporting(e.g.,ameanof fourPTSDsymptomsper sUbject),andthesymptomsappeared in a dose-responserelationshiptolevel of exposure.Theapparentunmetneeds of thedisastersurvivors in thesamplewereexpressed intheiruniformly highrateof turningtoexternalmethodsof copingbeyondwhatfamilyandfriends could provide--i.e.,theutilizationof medications, alcohol, or services of a health professionalby63%.Half of those using alcohol tocopemetcriteriafor current alcohol abuse,andhalfof thesewerephysically dependentonit.Respondents generally thatdisastercounselingwasuseful,andmanyfeltinneedoffurtherhelp but could not affordit.IMPLICATIONSFORFUTURERESEARCHThefindings here are notanend-point; they represent astartingpointforfutureresearch. Although the findingthatpost-disasterpsychopathology occurs inrelativelyhigh frequencyandin a dose-responserelationshipisimportant,furtherfollow-up studies tracing the course ofsymptomsandthe process of recovery over time willbeequally important.Andalthough the discoverythatperceivedharmbythedisasterandpre-existingpsychopathology are importantpredictorsofpost-disasteroutcomein the acute phaseisalso important,furtherfollOW-Upstudiesshowingpredictors of long-termoutcomewillbeof considerable usefulness.Workerswhodesign future intervention programs willneedthisinformation in ordertotailortheirprogramstothespecificneeds of thoseathighestrisk.Since100%ofpre-disasterdepressionandalmosthalfof pre-existing alcohol disorders tend to recur orpersist,perhapsdisasterworkers couldtargetvictims withsuchahistoryto

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18focustheir resources onthoseathighestrisk.Infact,almost two-thirds of survivorswhowillhaveanacutepost-disasterpsychiatric disorder canbepredictedbyidentifying thosewhohadapre-disasterpsychiatrichistory.Atfollow-upitwillbepossible to ascertainwhichformsof interventionhavebeenassociated with the best outcomes. Since systematicdisasterresearchisstillin theearlystages,manyquestions remain about the bestwaytogoabout designing researchstudies.A crucial issueisthatof timing of interviews.Toomuchdelay ingettingintothefieldinitiallymaymisssymptomsthatoccur in theearlyphases following adisaster;also,victimsmaybelessinclined to discusstheirexperiencesandfeelingsastime goes by.Itisnotclearwhenisthe best time to returntothefieldfor follow-up interviews, sincefewsystematic studieshaveutilizedperiodic reassessment. Frequent re-interviews of thesamesubjectswouldcreateadditionalproblemsin the methodologybycontaminatingsubjects'recollectionof eventsandsymptomsandreducingtheircooperation.Ideally,a systematic,largerscaleeffortneedstobemadewhichwouldallow re-interview of portions of thesampleatstaggeredintervals.Thiswouldestablishoptimumintervalsfor researchers to followuptheirsubjects..Inthe end,suchimprovementsin research methodology will increase understanding of the psychological consequences of adisasterandillustratethe course of recovery.

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19REFERENCESCloningerCR.(1986)Tridimensional Personality Questionnaire.St.Louis,MO:WashingtonUniversitySchoolofMedicineFergussonDMandHorwoodLS.(1987)VulnerabilitytoLife Events Exposure 17: 739-749. HorowitzM,WilnerN,andAlvarezW.(1979)Impactof Events Scale: A measure of subjectivedistress.Psychosomatic Medicine41(3): 209-218.RobinsLNandSmithEM.(1983)TheDiagnostic Interview Schedule/Disaster Supplement.St.Louis,MO.:WashingtonUniversitySchoolof Medicine.RobinsLN,etal.(1984)Lifetime Prevalence of Specific Psychiatric Disorders in ThreeSites,ArchGenPsych,41:949-958.SmithEM,RobinsLN,PrzybeckTR,.etal.(1986)Psychosocial consequences of adisaster.InJ.H.Shore(Ed.), Disaster Stress Studies:NewMethodsandFindings (pp. 50-76). Washington, D.C.:AmericanPsychiatric Press, Inc.

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Table 1.DemographicsSexMaleFemaleRaceWhiteBlackAgegroups<2525-4445-64Meanage(years) Marita1Status Married Divorced/ Separated SingleWidowedEducationHSgrad orGEDSomecollegeMean(Years) On-site(N=17)5(29%)12(71%)16(94%)1(6%)5(29%)10(59%)2(12%)30.113(76%)o4(24%)o11(65%)1(6%)11.6 Near-hit(N=12)5(42%)7(58%)10(83%)2(17%)3(25%)7(58%)2 (17%) 29.73(25%)3(25%)6(50%)o10(83%)5(42%)12.8Miss(N=17)7(41%)10(59%)16(94%)1( 6%) 8(47%)6(35%)3(18%)28.1 4(24%)3(18%)9(53%)1(6%)9(53%)4(24%)11.5All(N=46)17(37%)29(63%)42(91%)4(9%)16(35%)23(50%)7(15%)29.220(43%)6 (13%)" 19(41%)1(2%)30(65%)10(22%)11.8

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Table 2. Perceived upset.harm.anddegree of recovery On-site Near-hitMissAll(N=l7)(N=12)(N=17)(N=46)UpsetVery17(100%)11(92%)10(59%)38(83%)Somewhat0 0 4(24%)4(9%)Notvery 0 0 2(12%)2(4%)Noinfo. 0 1(8%)1(6%)2(4%)HarmGreat deal12(71%)6(50%)9(53%)27(59%)Notmuch5(29%)6(50%)8(47%)19(41%)RecoveryFull 2(12%)3(25%) -7 (41%)12(26%)Partial8(47%)7(58%)9(53%)24(52%)None7(41%)2(17%)1 (6%)" 10(22%)

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*Table 3. Subjects withoneormorepsychiatric diagnosesafterthe disaster (prevalence versus incidence) SUbjects withoneor mote On-SiteNearhitMissAlldiagnosis(N"'l7) (N=12) (N=l7)(N=46)Allcasesafterdisaster10 (59%) 7 (58%) 8 (47%) 25 (54%) (prevalence)Newcases 9 (53%) 4 (33%) 2 (12%) 15 (33%) sincedisaster(incidence)*IncludesPTSO(byOSM-IIIcriteria),alcohol abuse/dependence, depression,and anxiety disorder.

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Table 4.PTSOSymptomsOn-site Near-hitMissAll(N=17)(N=12)(N=17)(N=46)PTSOSymptomdreams/16 (94%) 9(75%)8(47%)33 (72%) recollectionhappening again10 (59%) 4(33%)1( 6%) 15 (33%) numbness5 (29%) 3(25%)3 (18%) 11 (24%) jumpy 14(82%) 6(50%)3 (18%) 23 (50%) insomnia15 (88%) 6 (50%) 9 (53%) 30(65%)survivorguilt7(41%)2(17%)4 (24%) 13(28%)concentration10(59%)6 (50%) 6(35%)22(48%)avoid reminders11(65%)4(33%)8 (47%) 23(50%)remindersmake12(71%)7, (58%) 3(18%)22(48%)worsemeannumberofsymptoms5.88 3.92 2.65 4.17 sUbjects with17 (100%) 10 (83%) 9 (53%) 35 (76%) >1symptom

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Table5. Post-disaster rates ofPTSDdiagnosisby DSM-III versusDSM-IIIRcriteriaRates of On-site Near-hitMissAliPTSDDiagnosis(N=I?)(N=12)(N=I?)(N=46)ByDSM-III5(29%)2(17%)3(18%)10(22%)criteriaByDSM-IIIR9(53%)3(25%)3(18%)15(33%).criteria

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Table 6. RatesofPsychiatric DiagnosisAllcases sincedisaster(Prevalence) On-site Near-hitMissAllDiagnosis(N=l7)(N=12)(N=I?)(N=46)PTSD*5(29%)2(17%)3(18%)10(22%)Alcohol abuse/ 2(12%)2(17%)2(12%)6(13%)dependence Depression 7(41%)6(50%)6(35%)19(41%)Generalized 5(29%)2(17%)2(12%)9(20%)anxiety disorderNewCasesSince Disaster (Incidence) On-site Near-hitMissAll(N=I?)(N=12)(N=I?)(N=46)PTSD*5(29%)1(8%)1(6%)7(15%)Alcoholabuse/ 2(12%)0 0 2(4%)dependence Depression4(24%)3(33%)2(12%)9(20%)Generalized 3(18%)2(17%)0-5(11%)anxiety disorder Diagnosis Present BeforeandAfter Disaster (Persistence) On-site Near-hitMissAll(N=17)(N=12)(N=1?)(N=46)PTSD*01(8%)2(12%)3(7%)Alcoholabuse/ 0 2(17%)2(12%)4(9%)dependence Depression 3(18%)3-(25%)4(24%)10(22%)Generalized 2(12%)0 2(12%)4(9%)anxiety disorder*DiagnosismadebyDSM-IIIcriteria.

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Table7.Overlapof Post-disaster Disorders (Prevalence) ,/ I/I/ / GENERALIZEDANXIETYDISORDER18 //OEPRESSIONi/Subjectswerecountedas positive iftheyhadeitheranewonset of a recurrence of depression,PTSD, generalized anxiety disorder.*DiagnosismadewithDSM-IIIcriteria.

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Table 8.*Relationship ofnumberof post-disaster diagnoses to subjective reports ofharmandrecoveryHarm*Nodiagnosis Z1 diagnosisNotmuch11 (73%) 8 (26%) Great deal4 (27%) 23 (74%) Total15(100%)31(100%)Recovery*Nodiagnosis diagnosis Full5 (33%) 7 (23%) Partial10 (67%) 14 (45%) None010 (32%) Total15(100%)31(100%)*includesPTSD(byDSM-IIIcriteria), generalized anxiety disorder,andalcohol abuse/dependence.

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Table9.*Current psychiatric diagnoses versus prior psychiatric diagnoses*includesPTSO(byOSM-IIIcriteria),depression, generalized anxiety disorder,andalcohol abuse/dependence.

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Table10.Treatment Psychiatric On-site Near-hitMissAllTreatment(N=l7)(N=12)(N=l7)(N=46)Pre-disaster 4(24%)1(8%)5(29%)10(22%)treatment Pre-disaster 1(6%)a2(12%)3(7%)hospitalization Current*4(24%)a4(24%)8(17%)treatment*Refers to treatmentbypsychiatrist or othermenta1health

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Table11.CopingMethodof On-site Near-hitMissAllCoping(N=16) (N=10) (N=14)(N=40)Friends/Family16(100%)10(100%)9(64%)35(88%)Medication 6(38%)2(20%) 3(21%)11(28%)Alcohol6(38%)3(30%)2(14%)11(28%)*7(44%)(20%)Doctor/Counselor 2 1(7%)10(25%)Other16(100%)2(20%)6(43%)24(60%)*Doctorrefers tomedicaldoctor or other health professional or counselor.