Acute Stress Response: Psychological Impact of Trauma on Older Adults

On February 25, at an afternoon symposium, 3 speakers addressed implications of the September 11th tragedy on the elderly population, along with response strategies in the event of future bioterrorist attacks.

Older New Yorkers and the Aftermath of 11 September 2001

“In the days immediately following the September 11th event, AAGP was careful not to ‘pathologize’ a person’s reaction to what was understandably a traumatic event, but to portray these reactions as the normal responses individuals have when coping with stressful situations,” said Gary Kennedy, MD, professor of psychiatry, Albert Einstein College of Medicine, Bronx, New York; president, AAGP.

Findings from a national phone survey concerning post-September 11th stress responses indicate that certain population groups appeared more vulnerable following this tragedy. Attributes of stress response include: admission of distress when reminded about the September 11th event, intrusive memories, disturbing thoughts or dreams, problems concentrating and sleeping, irritability, and incidence of angry outbursts.

Survey results suggest that women and Hispanics in particular, were more likely to experience post-September 11th stress responses, though these differences may be attributable to greater willingness among these groups to verbalize their feelings. Not surprisingly, individuals with prior mental health needs, and those who lived within 100 miles of Ground Zero also appeared significantly more vulnerable. Presence of family members at or near Ground Zero provided a “connection” to the tragedy that increased the likelihood of personal stress response, even for individuals living beyond the 100-mile zone.

“What’s lacking from the existing data is a real estimate of stress disorders and co-morbid mental illness,” said Dr. Kennedy. Emerging data from a New York Academy of Medicine study of post-tragedy reactions of 1000 New Yorkers will provide information on the relationship of stress reaction to depressive disorders. Results from a follow-up study, conducted on the six-month anniversary of September 11th will yield additional information on post-traumatic stress disorders related to this tragedy.

Other considerations for future research include: the effect of major stress on existing medical conditions, the impact of stress-mitigating factors such as social support and religious affiliation, and rates of spontaneous recovery (i.e., people who experience stress but heal themselves through their social network).

Associated rates of mortality and morbidity (i.e., the number of individuals who were unable to carry on with their work and family responsibilities following the tragedy) should also be studied. Consideration of possible transmissible effects of this event on future generations may also prove valuable (as demonstrated by Holocaust survival literature).

Additional research is also needed to gain a more complete understanding of how the effects of aging contribute to stress response. “We need data about the contribution of poor health and disability, as well as social isolation, to really understand who’s most vulnerable for stress, and to identify individuals for whom we would want to take a more preventive approach when an event like this occurs,” said Dr. Kennedy. Despite the availability of a wide network of social support services in New York City, Dr. Kennedy hypothesized that older, more isolated New Yorkers, and veterans of prior wars, were especially vulnerable following the September 11th tragedy. Some elderly New Yorkers, particularly the economically disadvantaged, may have been at greater risk for stress disorders (versus less serious stress reactions) in part because a high degree of ethnic diversity among this population makes it difficult to customize social service programs to meet their individual needs.

Dr. Kennedy postulated that other factors may actually protect some older New Yorkers from post-tragedy stress. Some elderly New Yorkers may be “hardened off” to tragedy based on historical and life experiences such as world wars, the Holocaust, and racial discrimination. “These individuals have had difficult experiences and they’ve lived through them; they know they can get through it again. As bad as it was, they know there’s a tomorrow,” said Dr. Kennedy.

Psychological Impact of the 9/11 Tragedy on Older Adults — Lessons Learned form Older Adults in New York City’s
Chinese American Community

“I want to stress the resilience of most of the older people in our community after September 11,” said Teddy Chen, MSSW, director, Mental Health Bridge Program, Charles B. Wang Community Health Center, New York City. “What we learned about the human face of tragedy from these elders living in the shadow of Ground Zero will help our future work,” said Mr. Chen.

Mr. Chen and colleagues developed a screening questionnaire to locate individuals (including senior citizens) in New York City’s Chinese American community who were in need of post-tragedy assistance (Table 1). Responses from interviews yielded information that helped dimensionalize the impact of the tragedy on this community.

Not surprisingly, the events of September 11th generated feelings of loss for many community residents, either directly (in human or economic terms), or indirectly (e.g., in terms of loss of innocent strangers and a community landmark). Many residents personally related to the Twin Towers, which they referred to as “the sister towers.” They recalled the towers being built, and harbored precious memories of family moments that included these buildings. Moreover, many Chinatown seniors viewed the Towers as a nearby symbol of academic and professional success.

Yet, study results indicate that many Chinatown seniors exhibited a high degree of coping skills and an ability to bounce back and resume their lives after the tragedy. Several said that drawing upon past life experiences gave them the strength needed to survive this crisis. “When you talk to them they will tell you that they’ve seen before that life has a lot of things you cannot expect,” said Mr. Chen.

Post-tragedy fear, worry and withdrawal were sometimes associated with specific age-related or cultural vulnerabilities. Physical weaknesses, impaired sensory functioning (e.g., poor vision) and language barriers contributed to initial confusion among some residents, who were forced to rely on other channels (e.g., relatives or friends) to gather information about what had happened. An inability to speak or read English resulted in increased anxiety for some residents who were unsure whether they would be adequately informed during and after the event.

Close multi-generational connections also influenced the post-tragedy experience for many elders in the community. Several seniors (who typically retain leadership roles in their extended families) expressed concern for the economic futures of their families, given the post-disaster drop in Chinatown tourism and a decline in the local garment industry.

Many seniors may have been particularly vulnerable to post-tragedy stress based on other losses and loneliness in their lives at the time. In some cases, trauma from this event stirred up unresolved, residual fear, anxiety and depression from previous traumatic experiences, such as the Vietnam War.

Several respondents shied away from community counseling programs, based on a belief that post-September 11th stress and depression was a “life problem” versus a mental health issue worthy of counseling. (This dovetails with prior research that demonstrates a common tendency among the elderly to fail to recognize underlying mental health problems, but rather, to present symptoms via a range of physical complaints.) “They think, I lost a son, it’s a family problem, a life problem. They don’t think, it’s a mental health issue, I may have depression, anxiety, or PTSD,” said Mr. Chen.

Community mental health challenges include the ability to help Chinatown seniors translate what they view as routine family and life problems and vague somatic complaints into mental health terms, and to ultimately provide effective mental health services to those in need.

Table 1. The Screening Questionnaire

1. Were you worried, anxious, or nervous most of the time?
2. Were you unable to control your worries or focus on what you are doing?
3. Were you emotionally or physically upset by reminders of the 9/11 event?
4. Were you unable to have sad or loving feelings or feeling numb?
5. Did you easily get annoyed or have outbursts of anger?
6. Were you jumpy or easily startled?
7. Did you feel sad, low or depressed most of the time?
8. Did you lose interest and pleasure in doing things?
9. Did you often feel tired or exhausted, or have headaches or bodily pains?

Trauma and Response in a New Era of Bioterrorism

“Following traumatic stress, most persons will experience acute symptoms that will dissipate over time. I don’t think that’s any different for biological terrorism, we just don’t know the extent of it,” said Commander Robert DeMartino MD, assistant professor, Department of Psychiatry, F. Edward Herbert School of Medicine Uniform Services, University of Health Sciences; director, Program in Trauma and Terrorism, Center for Mental Health Services, U.S. Public Health Service, Rockville, MD.

Historical information regarding public response to bioterrorism is scarce, making it difficult to find parallel events from which to draw conclusions and formulate government emergency response guidelines. Public behavior in the aftermath of other types of traumatic events (including epidemics and natural disasters) provides some clues to assess how people might react to social, economic, and psychological consequences of a bioterrorist attack. “We don’t have the luxury of waiting a decade to obtain information; we need to develop comprehensive and effective plans now,” said Dr. DeMartino.

Bioterrorist events are similar in impact to natural disasters, but differ across several dimensions, including timing, visible damage, perception of control, and extent and persistence of effects. Bioterrorism has a high potential for casualties (into the hundreds of thousands), depending on the agent and means of dispersal. Symptoms may mimic those of common ailments (e.g, the flu) and can therefore generate mass confusion. Uncertainty over the availability and effectiveness of treatments may exist (as during the recent anthrax scare). If a contagious agent is involved, there may be widespread dispersion of casualties to other geographic areas. “Bioterrorism is a new and unfamiliar threat. It’s invisible, odorless, and colorless,” said Dr. DeMartino.

Dr. DeMartino hypothesized that a “best case” bioterrorism scenario might include: advance public warning, rapid public awareness as the attack unfolded, quick-acting symptoms, rapid identification of the agent, and use of a non-communicable agent. A “worst case” scenario could involve: no advance warning, delayed symptoms that are difficult to track, an unknown communicable agent, and several repeat incidents over an extended time.

Military studies and data from groups at risk for terror-related sequelae (e.g., bombing victims) indicate a range of possible public responses to a bioterrorist attack, including: fear, stress, or acute stress disorder; feelings of loss, grief, depression, and PTSD; extended vigilance; self-quarantine; feelings of denial and fatalism; and excessive concern with decontamination. Other likely reactions are the hoarding of protective equipment and fear-induced panic and flight. Impact on the health care system could include over-burdening of medical facilities and dereliction of responsibilities among medical personnel.

Risk perception is a likely driver of behavioral responses during a bioterrorist event. The media and governments play a key role in controlling public expectation of perceived risk. Inappropriate media messages, or the loss of credibility in government authorities could lead to greater perceptions of risk and fear-induced panic. Individuals need credible information to make informed decisions, particularly given the possibility of a brief, time-limited window of opportunity for escape from the threat. Informers must strike a balance between panic and absence of worry. “If you don’t control people’s expectations about events, you are destined for them to base their response on a worst case scenario,” said Dr. DeMartino.

Evidence from other health-related catastrophes (e.g., Love Canal and Three Mile Island) indicates that devastating, long-lasting community ramifications could potentially result from a bioterrorist attack. The risk of permanent community decimation likely increases when people are forcibly displaced. Government and local institutions need to bear the responsibility for making a community “clean” again.

Potential for economic loss as a result of bioterrorism is also enormous. “We need to look at how economies would be affected since we know that’s tied to people’s long-term psychological health. There is a need to raise consciousness of these types of issues among politicians and agencies,” said Dr. DeMartino.

Dr. DeMartino noted that magnitude of a trauma (i.e., the type and degree of exposure to a traumatic event) is the best predictor of the overall psychological impact on any one individual. Evidence from the terrorist bombing in Oklahoma City five years ago indicates that persistent psychological wounds may affect the day-to-day lives of residents for years. “In terrorist events, the number of psychological casualties will always be many times more numerous than the physical casualties, and they have the greater potential for a more severe and longer-lasting behavioral and psychological sequelae than natural disasters,” said Dr. DeMartino.

Actual evidence is scarce regarding the likelihood of short - or long-term psychological disorders stemming from bioterrorist events. After the Tokyo sarin attacks, some people experienced post-traumatic stress disorder and other depressive disorders, but unique circumstances make it difficult to trans-
late impact from one event to another. “We’re assuming that the more intense the experience, the greater the opportunities for traumatic stress,” said Dr. DeMartino.

Behavioral casualties of bioterror remain vaguely defined. The recent anthrax scares in NYC and Washington, DC, though relatively mild, had a serious impact on some people’s behavior, particularly for those who sought treatment despite rational indications that drugs were unnecessary.

Geriatric populations may be at increased risk, both medically and psychologically, in the event of a bioterrorist attack. A weakened physical state (especially for those with chronic illness) may place them at greater risk from the direct effects of chemical and biological agents (including possible neuropsychiatric sequelae), as well as treatments. Moreover, reduced access to information and social support may delay treatment. In addition, compromised mobility and economic hardship can restrict their treatment and flight options, raise their sense of risk, and make forced displacement particularly traumatic.

On the other hand, senior citizen status may be an advantage during a bioterrorist attack. Physical isolation may be protective in the event of a contagious agent, while stress may be lessened due to the absence of direct childcare responsibilities. Moreover, the ability to place events into the context of an entire lifetime may add perspective and reduce anxiety.