© COPYRIGHT 2006 PHYSICIANS POSTGRADUATE PRESS, I NC. © COPYRIGHT 2006 PHYSICIANS POSTGRADUATE PRESS, I NC. Mental Health Problems After Disaster 15 J Clin Psychiatry 2006;67 (suppl 2) Symptomatology and Psychopathology of Mental Health Problems After Disaster Edna B. Foa, Ph.D.; Dan J. Stein, M.D., Ph.D.; and Alexander C. McFarlane, M.D. A variety of reactions are observed after a major trauma. In the majority of cases these resolve without any long-term consequences. In a significant proportion of individuals, however, recovery may be impaired, leading to long-term pathological disturbances. The most common of these is post- traumatic stress disorder (PTSD), which is characterized by symptoms of reexperiencing the trauma, avoidance and numbing, and hyperarousal. A range of other disorders may also be seen after trauma, and there is considerable overlap between PTSD symptoms and several other psychiatric conditions. Risk factors for PTSD include severe exposure to the trauma, female sex, low socioeconomic status, and a history of psychiatric illness. Although PTSD may resolve in the majority of cases, in some cases risk factors outweigh protective factors, and symptoms may persist for many years. PTSD often coexists with other psychiatric disorders, such as depression, anxiety disorders, and substance abuse, and with physical (somatization) symptoms. There is growing evidence that PTSD does not merely represent a normal response to stress, but rather is mediated by specific neurobiological dysfunctions. (J Clin Psychiatry 2006;67[suppl 2]:15–25) From the Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia (Dr. Foa); the Department of Psychiatry, University of Cape Town, Cape Town, South Africa (Dr. Stein); and the University of Adelaide, Department of Psychiatry, Queen Elizabeth Hospital, Woodville, Australia (Dr. McFarlane). Presented at the symposium “After the Tsunami: Mental Health Challenges to the Community for Today and Tomorrow,” which was held February 2–3, 2005, in Bangkok, Thailand, and supported by an educational grant from Pfizer Inc. Corresponding author and reprints: Edna B. Foa, Ph.D., Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania, 3535 Market Street, 6th Floor, Philadelphia, PA (e-mail: foa@mail.med.upenn.edu). cute stress reactions are a normal and expected re- sponse to a traumatic event, seen in the majority of A cases. Nevertheless, pathologic persistence of symptoms, or posttraumatic stress disorder (PTSD), is seen in a minor- ity of cases. The development of PTSD depends on com- plex interrelationships between the nature of the trauma itself, the characteristics of the victim, and the social cir- cumstances and support networks available to the victim. In each case, however, a central feature is the formation of a traumatic memory of the event. 1,2 The challenges there- fore are to understand the defining features of the event that form the basis of this traumatic memory and the factors that influence how the traumatic memory is subsequently manifested as acute and chronic illnesses. This article reviews the symptomatology and psycho- pathology of major trauma experienced by disaster victims. POSTTRAUMATIC PSYCHOPATHOLOGY A variety of reactions may be observed after a major trauma. The precise combination of reactions that is observed depends on numerous factors, including the se- verity and intensity of the initial trauma, the duration of exposure, and the individual characteristics and social cir- cumstances of the survivor. These predictors will be dis- cussed in more detail (see The Sequential Etiological Pro- cess Leading to PTSD and Its Predictors). In a review of 160 studies of disaster victims, Norris et al. 3 identified 6 discrete groups of outcomes following major trauma: specific psychological disorders such as PTSD, depression, or anxiety; nonspecific distress; health problems; chronic problems in living; resource loss; and problems specific to youth (Table 1). Overall, 77% of the studies identified specific psychological disorders such as PTSD, major depressive disorder (MDD), or anxiety, in- cluding generalized anxiety disorder (GAD) and panic dis- order. PTSD was the most commonly observed disorder, being identified in 68% of studies, followed by depression in 36% and anxiety in 20%. In addition, health-related problems such as somatic complaints, sleep disturbances, and substance abuse were reported in 23% of studies. Initial psychological reactions to trauma may include feelings of fear, horror, or helplessness (symptoms essen- tial for the diagnosis of PTSD; see Symptoms of PTSD). Sometimes, individuals struggle to find the language to express the overwhelming emotion that is experienced and will use words such as “shock,” “unbelievable,” or “im-