Mental health advisory for health professionals providing care for survivors of the 2010 Haitian earthquake

Updated March 2, 2010

In the aftermath of disasters, many survivors will show acute reactions to stress. Reactions to stress may appear immediately after traumatic events or days and even weeks later. Although many reactions to stress may also be symptoms of psychiatric disorders if they persist, reactions to stress are expected responses to traumatic events in the context of disasters. Reactions to stress may be confusing and frightening, and some may view their reactions as signs of weakness or mental illness. Providing reassurance that it is very natural to have physical and emotional responses after a disaster can help to reduce distress and promote better functioning. Common reactions include:

Physical Reactions: rapid heart rate, trembling hands, unexplained somatic symptoms (e.g., headaches, backaches, chest or abdominal pain), dizziness, blurry vision, sweating/trembling/shaking for no reason, sleep problems, loss of appetite, feeling choked or smothered
Cognitive Reactions: problems concentrating or remembering things, confusion, disorientation
Emotional Reactions: feeling tense and nervous, excessive fatigue, crying often or easily, feeling numb, being angry or irritable, feeling nervous or anxious around reminders of the earthquake, and nightmares/intrusive memories/mental images related to the earthquake
Interpersonal Reactions: problems in relationships with family or friends, conflict, withdrawal, isolation

In evaluating patients, clinicians should keep in mind that some patients may present with signs and symptoms that appear to be reactions to stress but may also be manifestations of medical illness. Adverse reactions to medications or having recently stopped taking medications are other potential causes of physical or mental status changes that should be considered as part of a clinical evaluation. Clinicians should also keep in mind that herbal medications are commonly used in Haitian culture, and like other medications they can cause adverse reactions.

Grief – Grief is normal and to be expected given the extensive loss of life that occurred after the earthquake; however sometimes grief can become so severe or persistent as to interfere with daily function to a degree that warrants clinical attention.

Long-Term Psychological Responses: The majority of people who experience reactions to stress after disasters and emergencies show resilience and do not go on to develop long-term psychopathology. However, in some survivors, the symptoms do not resolve. Posttraumatic Stress Disorder (PTSD), anxiety disorders, major depression, or other psychiatric disorders may develop. Such illnesses may be serious, even fatal, and warrant prompt follow up.

Depending on the severity of symptoms, level of function, potential risks, clinical questions, and/or other factors, referral to a mental health professional (and/or another health professional) may be warranted even in the absence of a psychiatric disorder.

Suicidal or homicidal ideation may occur in a variety of psychiatric disorders, and warrant immediate attention.

Alcohol and substance use may also increase suicide risk, as well as the risk of motor vehicle crashes and violence. Alcohol and substance use may increase following natural disasters.

Some examples of symptoms that may be indicative of PTSD include: dissociation (e.g., feeling unreal or outside oneself, having "blank" periods of time that one cannot remember); intrusive re-experiencing (e.g., disturbing memories, nightmares, or flashbacks); avoidance of reminders of the disaster (e.g., avoiding activities that remind one of the earthquake, withdrawing from other people); emotional numbing (e.g., unable to feel emotion, as if empty); hyper-arousal (e.g., startle responses, rage, extreme irritability, intense agitation). Diagnostic criteria for PTSD and other psychiatric disorders are included in the most recent edition of the DSM IV (American Psychiatric Association, 2000).

Risk Factors: People who have experienced any of the following are more likely to experience long-term difficulties and may be at higher risk for developing psychopathology:

Direct and indirect exposure to the earthquake and its impact, e.g., being injured in the earthquake, seeing injured or dead people, hearing people screaming
Loss of loved ones or friends
Exposure to prior traumas (e.g., disasters, sexual abuse, motor vehicle crashes, combat)
Pre-existing mental health issues such as depression or anxiety disorders
Social isolation
Multiple relocations and displacements
Loss of home, valued possessions, neighborhood, or community
Recent or subsequent major life stressors or emotional strain (e.g., intense emotional demands, searching for survivors, interacting with bereaved family members)
Extreme fatigue, weather exposure, hunger, or sleep deprivation

Cross-Cultural Issues: Clinicians should be aware that in Haitian culture, there is stigma associated with experiencing or disclosing behaviors associated with mental illness, and there are different culturally appropriate ways of expressing grief, pain, and loss. Haitian patients may be reluctant to discuss or admit to mental health problems, or may refer to stress and psychiatric symptoms in culturally-specific ways, e.g., referring to saisissement (rapid heartbeat and cool blood, due to trauma), and supernatural causes of symptoms, e.g., voudou and hexes. Any discussions of mental health or reactions to stress should be explained in culturally sensitive, supportive, and non-stigmatizing ways.

Children: Children’s immature abilities to understand and process the immediate and long-term effects of emergencies make them among the most vulnerable members of affected communities. Because of stigma in Haitian culture around mental illness, many children may be reluctant to discuss or admit to mental health problems. Likewise, prior caregivers in Haiti may not have fully explored such issues, even prior to the earthquake. Clinicians should consider potential mental health and developmental issues. Reactions to stress differ depending on developmental level and are generally marked by changes in typical behavior for the specific child or adolescent. Some children will warrant referral to a mental health professional.

Acknowledging Psychological Distress: Clinicians should be aware that many patients may be reluctant to acknowledge psychiatric symptoms or distress. Earthquake survivors may fear being stigmatized within their community or denied entrance to the United States, and aid workers and military personnel may fear being penalized professionally if they have psychiatric diagnoses noted on their medical records. Whenever mental health referrals are warranted, added care should be taken to explain and arrange such referrals to the patient and his/her caregivers in a culturally sensitive, supportive, and non-stigmatizing way.

Potential for Misattribution of Symptoms of Non-Psychiatric Medical Conditions to Psychological Distress – In the aftermath of the earthquake, some patients may experience symptoms of head injury, cardiovascular disease, infection, or other undiagnosed medical conditions which may present themselves through mental status changes. Health care providers examining patients who have survived the earthquake need to be alert to that possibility.

Additional resources may be found at CDC Earthquakes Mental Health Web page. Other organizations that may be able to provide relevant resources include the Substance Abuse and Mental Health Services Administration, the National Center for PTSD, and the Center for the Study of Traumatic Stress.

Emergency Preparedness and Response

Emergency Preparedness & Response

Mental health advisory for health professionals providing care for survivors of the 2010 Haitian earthquake

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