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Clinical Psychology Review, Vol. 17, No. 4, pp. 359-374, 1997

Copyright 0 1997 Elsevier Science Ltd
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PSYCHOLOGICAL FACTORS
AFFECTING HEALTH AFTER
TOXICOLOGICAL DISASTERS
Johan M. Havenaar
University Hospital Utrecht
Wim van den Brink
University of Amsterdam
ABSTRACT. Exposure to toxic substances in the environment is an eoer more common event,
that may cause physical as well as psychological harm. When an entire community is exposed, the
term toxicological disaster is used. The mere threat of such an event may be a source of stress,
associated with changes in mental health, physical health, and changes in health-related
behaviors, A review is presented of the literature about the effects of the stressful experience of
toxicoEogica1 disasters on health and health-related behaviors. Three questions are examined: (a)
do toxicological disasters represent a specific type of stressor; different from other stressors?; (b)
which stress-mediated health effects have been observed in the aftermath of toxicological disasters?
and (c) is there evio!encefw a higher vulnerability in certain identifiable risk groups? On the basis
of the available literature, it is concluded that toxicological disasters may have profound effects
on subjective health, especially on symptom reporting, and on a number of psychophysiological
parameters. Evidence for a substantial impact of disaster-related stress on either physical or
psychiatric morbidity remains inconclusive. I n this respect toxicological disasters do not appear to
differ from other stressors. There is some evidence that toxicological disasters may have a more
pronounced effect on health-related behaviors, especially on r+roductive behavior (number of
births and abortions). Women, and especially those who have young children to care fo7; appear
to be more at risk for the observed health effects. The evidence for a higher vulnerability in other
risk groups (e.g., former psychiatric patients remains inconclusive).0 1997 Elsevier Science Ltd
Correspondence should be addressed to Johan M. Havenaar, Department of Psychiatry, Uni-
versity Hospital Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands.
359
360 J. M. Havenaar and W van den Brink
THE EXPOSURE of large numbers of people to hazardous substances, whether
caused by chemical accidents, deliberate dumping or other events, is an ever-more
common occurrence both in developed and developing countries. The list of sources
of exposure seems inexhaustible: warfare (Hiroshima), industrial accidents (Bhopal,
Seveso), occupational exposure (asbestos), and contamination of food (mercury
poisoned fish in Minimata, Japan; toxic oil syndrome in Spain). Several reports have
described the physical consequences of such events (e.g., Grisham, 1986; Logue,
Melick, & Hansen, 1981). In addition, increasingly the importance of psychological
consequences is being recognized. At times these may even overshadow the direct
physical effects (Baum, Fleming, & Davidson, 1983; Cormie & Howell, 1988; Lechat,
1990).
In the aftermath of a toxicological disaster, three groups of illness determinants play
a role: the biological effects of the exposure itself, the stressful experience of the
population and the response measures (Bertazzi, 1989).1 The following review deals
with the health effects that are determined by the stressful experience of the exposure
itself, or by the ensuing response measures, such as evacuation. These health effects
may manifest themselves directly as changes in the mental or physical health status of
the population, or more indirectly through changes in health-related behaviors. In the
review, outcome variables from each of these domains are taken into consideration.
The following three questions are addressed: (a) do toxicological disasters represent
a specific type of stressor, different from other stressors? (b) which stress-mediated
health effects have been observed in the aftermath of toxicological disasters, and (c)
is there evidence for a higher vulnerability for stress-mediated health effects in
identifiable risk groups?
The review is based on publications found after a computer-search (Medline),
supplemented with the reference lists of other review articles about the effects of
disasters, especially Bromet and Dew (1995), Green (1982, 1991), Green, Lindy, and
Grace (1994)) Lechat (1990)) Logue, Melick, and Hansen (1981)) and Rubonis and
Bickman (1991). It differs from these reviews in the fact that it focuses exclusively on
toxicological disasters. Many authors have claimed that the psychological response to
this type of disaster has specific features, which warrant separate discussion (e.g.,
Baum & Fleming, 1993; Green, Lindy, & Grace, 1994). Also, in this review the full
range of possible health outcomes is covered, whereas previous reviews have focussed
almost exclusively on mental health problems. Finally, the review includes a number
of studies by Eastern European authors, which have not been readily accessible thus
far. Before examining the three questions described above, a phenomenological
description of the stressful experience of toxicological disasters will be presented,
portraying the stressors that are involved in this type of event.
The stress paradigm has been widely criticized because of its inherent circularity and its lack
of specificity and clarity in operational definitions. Attempts have been made to formulate more
neutral generic concepts to describe the complicated relationship between the individual, the
environment and the clinical disorder, that is, through the introduction of the category of
psychological factors affecting physical condition, used in the DSM-ZZZ and DSM-Nclassifica-
tion systems (APA, 1987, 1994). This concept, also alluded to in the tide of this paper, has thus
far not gained wide acceptance in the field (Stoudemire & Hales, 1991).
Psychological Factors of Toxicological Disasters 361
THE STRESSFUL EXPERIENCE OF TOXICOLOGICAL DISASTERS
Bertazzi (1989), in a review of industrial disasters and epidemiology, identified the
following five major elements of the stressful experience, which determine the stress
response following a toxicological disaster:
1. Uncertainty. It usually takes a while before the contaminant is identified and
exact information concerning levels and risks are made public. As long as
people are not aware of the exposure, no stress response occurs. Once people
are notified, however, uncertainty about the possible health effects caused by
the exposure to a toxic substance evokes a massive reaction in the population.
A striking example of this has been described following the nuclear incident in
Goiania in central Brazil (Petterson, 1988). Here children found 100 grams of
Cesium-137 and painted themselves and their neighbors with this luminescent
carnival glitter. No stress reaction occurred until exposed individuals became
sick. Eventually, four people died from acute radiation syndrome and 249
suspected cases of contamination were identified, 50 of whom needed hospital-
ization. After this became known, panic spread over the whole state and more
than 125,000 people underwent a voluntary check-up for external radiation.
A contributing factor to the uncertainty is the lack of undisputed knowledge
about the effects of the exposure. During the initial period after the event
researchers and practitioners in the field often lack adequate technology to
assess the physical and psychological consequences. In the long run this uncer-
tainty tends to remain, because of the low biodegradability of many toxic
substances, for example, radionuclides or dioxins, and the long period of
latency of some of the health effects, which may become manifest only in future
generations. Because of this protracted nature of the threat, toxicological
disasters have been called diluted disasters (Bertazzi, 1989).
2. Housing and job insecurity. Evacuation from the contaminated site and fear of
contamination of homes and premises are important sources of stress. The
incident with the nuclear power plant at Three Mile Island near Harrisburg
(TMI) provides a classic example of this (Hartsough & Savitski, 1984). In
response to a minute release of radiation and an impending loss of control at
the plant, the governor of Pennsylvania issued an evacuation advisory directed
at pregnant women and preschool children living within a 5-mile radius of the
endangered plant. As a result 144,000 people fled from the area.
The housing and job insecurity following toxicological disasters is related to
both the actual and the perceived danger of the situation. More often than not
there are considerable controversies between experts and laymen about this.
There have been heated debates about safe dose-limits in areas contaminated by
fall-out from Chernobyl, even between experts. After the disintegration of the
Soviet Union in 1992, this finally resulted in different dose-limits being set in
each independent republic. This aggravated the confusion and distrust in the
exposed populations. Similar debates about whether or not to evacuate oc-
curred in Love Canal, where housing lots were built on a chemical waste site
(Gibbs, 1983). Here evacuation was initially advised only for women and young
children living in one street immediately adjacent to the canal, but this advice
was revised and expanded several times, until it finally resulted in the perma-
362 J. M. Hauenaar and W van ah Brink
3.
nent relocation of 300 entire families (Fowlkes & Miller, 1982). Loss of value of
property may be an additional stress-factor, especially in western countries.
Public behavior is much more likely to be determined by the public percep
tion of risks and hazards, than by the opinion of experts. Petterson (1988)
described how, in the weeks that followed the Goiania incident, value of prod-
ucts from the entire region dropped by 50%, hotel occupancy by 40%, and
public sales by 30%, because of changes in consumer behavior. In the Gomel
region (Belarus) not far from Chernobyl a steep decline in tourism and other
economical activities has been reported. These large scale social-psychological
phenomena produce secondary stressors by causing economical problems for
the exposed population (Havenaar, 1996).
Social rejection. Victims of toxicological disasters may suffer from discrimination,
as though they were carriers of some mysterious and noxious contagent. Lifton
(1967) described how survivors of the nuclear bombings of Hiroshima, the so
called Hibakusha, suffered from discrimination, for example as marriage
candidates. Social rejection and discrimination of evacuees and inhabitants
from contaminated regions has been reported following many toxicological
events, for example, after the Seveso accident (Bertazzi, 1989), the Love Canal
crisis (Edelstein & Wandersman; 1987; Fowlkes & Miller, 1992) and in victims
exposed to asbestos and pesticides (Cuthbertson & Nigg, 1987).
4. Media siege. The media play an important role, not only in transmitting the news
about a toxicological event, but also in shaping the issues of debate and in
determining public perception of the event (Mazur, 1981). After the TM1 crisis,
journalist swarmed in as the inhabitants of the area fled from the area. The
victims of the accident will be followed-up by the media for months and years.
More often than not, media coverage tends to focus on information supporting
the public fear that something terrible has happened and that the worst is yet
to come. With Chernobyl, this has certainly been the case. Up to this very day,
newspaper articles or television programs appear at regular intervals depicting
children suffering from congenital malformations or leukemia, allegedly caused
by the disaster. In Seveso similar media attention has been reported (Bertazzi,
1989).
5. Cultural fwessure. People become the target of conflicting public pressure and
messages about how to behave, what to believe and what to expect. One
important aspect having direct implications for health is the discussion that
often arises about the advisability for pregnant women to have an abortion.
Another issue that has played an important role in the aftermath of Chernobyl,
was the discussion about whether not to implement iodine-prophylaxis in chil-
dren, to prevent the uptake of radioactive iodine in the thyroid gland in areas
with endemic iodine deficiency. According to oral reports, the authorities,
postponed or even prevented iodine prophylaxis in some regions for psycho-
hygienic reasons, that is, to prevent stress in the population. This may perhaps
be seen as one of the most paradoxical examples of a psychological factor, in this
case anticipatory anxiety for a stress-response, influencing the health outcome
of a toxicological disaster.
Psychological Factors of Toxicological Disasters 363
DO TOXICOLOGICAL DISASTERS DIFFER FROM OTHER STRESSORS?
The question whether toxicological disasters represent a specific type of stressor may
be divided in two: (a) are there specific features of the stressor and the type of
psychological mechanisms they set in motion? and (b) do they differ from other
stressors with respect to outcome, either in form, magnitude or duration.
Specificity of Event Characteristics and Etiological Mechanisms
Many authors have argued that manmade (technological) disasters are phenomeno-
logically and etiologically different from natural disasters (Baum & Fleming, 1993;
Couch & Kroll-Smith, 1985; Cuthbertson & Nigg, 1987; Green, Lindy, & Grace, 1994;
Hodgkinson, 1989; Logue, Melick, & Hansen, 1981). They have pointed out several
distinct features of technological disasters, which are summarized in Table 1.
Most of these are related to distinct qualities of the stressor, (e.g.. its suddenness and
its the duration). Others pertain to mediating factors, such as sense of control
perceived by the victims, or modifying characteristics, such as effect on social support.
Each of these characteristics may theoretically have a differential effect on outcome,
for example, the fact that toxicological disasters often lack a high-impact phase, has
been described as one of the reasons why posttraumatic stress disorder (PTSD) is a less
likely outcome after such events.
Another typical phenomenon in case of toxicological disasters, is the central role
that is played by information. In most cases people exclusively know about the toxic
threat through risk messages, such as official announcements, media coverage, or
personal networks (Green et al., 1994; Kasperson et al., 1988; Rumyantzeva 8c Marty-
ushov, 1992). A complicating factor in this respect is the confusion raised by contra-
dictory messages about the seriousness of the situation. More often than not, experts
and laymen disagree in their perception (appraisal) of the incurred risk (Lee, 1986;
Slavic, 1987). Giel (1991) has pointed out the signal potential of a disaster like the
Chernobyl disaster (i.e., its propensity to induce a significant medical or political
response). Events that many people perceive as harbingers of further catastrophic
mishap have a high signal potential. Erikson (1990) perhaps caught the essence of
peoples perception of such events by stating that toxic exposure is associated with
dread, whereas natural disaster causes fear. Related to this sense of dread is the
breakdown of meaning in victims lives, commonly observed in the victims of
toxicological disasters (Gibbs, 1989). Such a breakdown of meaning has been de-
scribed vividly in survivors of the atomic bomb in Japan by Lifton (1967). In his study
about the Hiroshima survivors 17 years after the bomb fell, this author described a
vast breakdown of faith in the human matrix supporting each individual life and
therefore a loss of faith (or trust) in the structure of existence (p. 487).
Specificity of Stress-Mediated Health Outcomes of Toxicological Disasters
In the following section the empirical evidence to consider man-made disasters as
different from natural disasters is reviewed. Rubonis and Bickman (1991) in a meta-
analytic review about mental health outcomes and disasters, examined relationships
among four sets of variables (a) characteristics of the victim population, (b) charac-
teristics of the disaster, (c) study methodology and (d) type of psychopathology. These
authors found no evidence for a differential effect of toxicological or other techno-
logical disasters; in fact the strongest predictor of psychopathology appeared to be a
364 J . M. Havenaar and W van den Brink
TABLE 1. Summary of Characteristics of Natural Disasters
and Technological Catastrophes
Course of events
Natural Disasters
Sudden
Usually, there is an identifi-
able clear low point. Condi-
tions tend to improve with
passage of time
Technological Catastrophes
Sudden or diluted
There may be a clear low
point, but particularly in
toxic disasters, this is not
so. Conditions do not neces-
sarily improve in foreseeable
time
Visible damage
Predictability
Perception of control
Extent of events
Persistence of effects
Effects on community
Usually causes disfigure-
ment of environment. May
destroy homes, businesses,
disrupt power, sanitation,
and the availability of drink-
ing water
Though point of impact
cannot always be specified,
some predictability can be
obtained because: (a) occur-
rence rates for an area can
be obtained from past expe-
rience and (b) forecasts can
provide some warning
Natural disasters not gener-
ally viewed as controllable.
Their occurrence highlights
a lack of control over the
elements
Usually limited to victims of
the disaster
Effects appear to be rela-
tively short-lived. Loss of
property or loved ones,
however, may be associated
with more chronic effects
Tendency to form a thera-
peutic community (low
conflict; consensus about
causative agents, level of
damage, priorities of reme-
dial action)
Some (e.g., dam breaks)
involve visible destruction.
Others (e.g., TMI, Love Ca-
nal) do not. May cause in-
visible damage manifested
as health problems caused
by the exposure
Not predictable; failures are
usually sudden and leave
little time for evacuation
Technology is normally un-
der human control. There-
fore, mishaps are likely to
be perceived as loss of con-
tl-01
Loss of confidence and
credibility may engender
effects in people not di-
rectly victimized
May be either acute or
chronic, but appear to be
likely to cause long-term
consequences for many. this
is particularly true when
toxic substances are in-
volved
Tendency to form a non-
therapeutic community
(high conflict, uncertainty
about causative agents, level
of damage, future risks and
necessary countermeasures)
Adapted from Baum, A., Fleming, R., and Davidson, L.M. (1983).
Psychological Factms of Toxicological Disasters 365
high immediate death toll, which tends to be higher in natural disasters. Also a study
by Dew, Bromet, and Schulberg (1987), which is not included in Rubonis and
Bickmans review, does not support the notion that toxicological disasters cause more
severe, or different psychopathology. These authors compared the psychological
impact of the TM1 incident to the impact of husbands lay-off from work in two
samples of women and found similar degrees of psychopathology for several years
following the stressors onset.
Two studies compared the self-reported physical health of victims exposed to floods,
dioxin contamination or both with victims of natural disaster or unexposed controls
(Smith, Robins, Pryzbeck, Goldring, & Solomon, 1986; Solomon & Canino, 1990).
Victims of dioxin exposure reported more deterioration of physical health in the year
after the disaster than victims of floods or unexposed controls.
STRESS-MEDIATED HEALTH EFFECTS OF TOXICOLOGICAL DISASTERS
Below, an overview is given of studies that have investigated the epidemiology of
stress-mediated health effects in toxicological disasters. The purpose of this overview
is to document the current state of knowledge about this subject and to identify any
gaps in the studies that have been conducted thus far, keeping in mind the broad
range of possible manifestations of the effects of stress on health.
For our overview, we have applied the following selection criteria to the articles
found in the computer-search: (a) the study should report on a health outcome that
cannot be attributed to the toxic exposure; (b) the study should give at least minimal
information about samples and study methods; and (c) the study should include some
reference data or control group. In total 56 studies were identified that meet the above
criteria. A complete overview of these studies, including a description of their meth-
odologies and full references has been published elsewhere (Havenaar, 1996).
Effects on Physical Health
Several physiological manifestations of the stress response have been described, for
example, changes in blood pressure, catecholamine excretion in urine and changes in
immune competence (Davidson & Baum, 1992; McRinnon, Weisse, Reynolds, Bowles,
& Baum, 1989; Zaicev, Balakleevskaja, & Petrenko, 1992). The clinical significance of
these changes is, however, uncertain. Only one study (Bertazzi, 1989) reported an
increased mortality from cardiac disease in victims of the Seveso accident.
Subjective changes in physical health are a constant finding in the wake of toxico-
logical disasters. Following the TM1 incident, several authors have found that the
affected population reported more physical symptoms on self-report questionnaires,
such as the somatic subscale of the SCL-90 (Bromet, 1989; Davidson & Baum, 1992;
Prince-Embury & Rooney, 1988). Smith et al. (1986) reported significantly higher
rates of people who experienced a deterioration of health after exposure to dioxin
and/ or flood. Most changes were perceived by those exposed only to dioxin. Mothers
living in the vicinity of TM1 rated their childrens health as worse than mothers in a
control area (Houts, Tokuhata, Bratz, Bartholomew, & Sheffer, 1991).
Elevated rates of physical complaints, vegetative disregulation and chronic
somatic diseases have been reported following the Chernobyl accident. Unfortu-
nately, most of these studies lack a careful description of samples and applied
methodology. In some of the articles that do meet the minimal criteria for inclusion
in this review, especially those by Russian authors, the physical problems are attributed
366 J. M. Hauenaar and W van den Brink
to biological effects of radiation (e.g., Niagu, Noshchenko, & Loganovski, 1992).
Shigematzu (1991) on the basis of findings from the International Chernobyl Project,
conducted under the auspices of the World Health Organization and the Interna-
tional Atomic Energy Agency, reported high levels of somatic complaints, especially
fatigue and headache, in contaminated areas. Since, with the exception of an increase
of malignant thyroid disease in young children, no somatic effects of the radiation
released after the incident have been firmly established so far, it seems likely that some
or all of these effects are stress-mediated (van den Bout, Havenaar, & Meijler-Iljina,
1995; Williams, 1994).
Mental Health Outcomes
Increased levels of psychological distress as measured with a variety of self-report
instruments are a common finding in most of the studies reviewed, especially on the
psychosomatic subscale of the SCL90. In one of the TMI-studies elevated levels of
distress could be measured, even more than 6 years after the event (Davidson & Baum,
1992). Diminished performance on cognitive tasks, such as proof reading and a puzzle
(towers of Hanoi), were demonstrable for an even longer period of time. The
clinical significance of these findings is unclear, as findings were within normal ranges.
Also after the Chernobyl disaster, long-term effects on psychopathology have been
observed using the GHQ (Viinamiki et al., 1995; Havenaar et al., 1996).
Elevated rates of the symptoms of depression, posttraumatic stress and other anxiety
disorders in exposed subjects have been found by all authors using a clinical interview
method (Breton, Valla, 8c Lamber, 1993; Bromet & Schulberg, 1986, Robins, Fisch-
bath, Smith, Cottler, Solomon, & Goldring, 1986; Smith et al., 1986). In only two
studies, however, did these symptoms reach threshold levels for clinical diagnosis.
Bromet and Schulberg (1986) reported significantly higher incidence and prevalence
of affective disorders in TM1 mothers (but not in other subjects) 12 months after the
incident. Smith et al. (1986), using the DIS, found a significant increase in the
incidence and prevalence of PTSD and other psychiatric syndromes, and higher rates
of new and persisting clinical psychiatric disorders in subjects exposed to floods
and/ or toxins. In contrast three other studies, including a carefully designed prospec-
tive study which was conducted in the framework of the Epidemiological Catchment
Area study in the US (Robins et al., 1986), failed to find a significant increase in the
incidence and prevalence of psychiatric disorders. Studies on PTSD using the Diag-
nostic Interview Schedule (DIS; Robins, Helzer, Croughan, & Ratcliff, 1981) have
however been criticized, because the DIS diagnosis of PTSD requires that the subject
links his or her symptoms to the event, which may induce false negative results on this
test (Kulka, Schlenger, Fairbank, Jordan, Hough, Marmar, & Weiss, 1991; Solomon &
Canino, 1990). Also the lack of a high impact phase may lead to the absence of
intrusive memories (Green, 1991).
Hypochondriasis and other forms of somatization may be other psychopathological
outcomes (Bromet & Dew, 1995). Roht, Vernon, Weir, Pier, Sullivan, and Reed (1995)
studied two communities living near toxic waste dumps, which were considered safe
by experts, and a third unexposed community. Exposed communities scored more
symptoms on a self-report scale, but these scores correlated highly with hypochon-
driasis items in the questionnaire and with questions about the respondents beliefs
about the extent of the danger. On the basis of these results the authors conclude that
high levels of symptoms in exposed population may be best explained by reporting
Psychological Factars of Toxicological Disasters 367
bias related to hypochondriasis. Whether this is indeed the case is open to debate,
because hypochondriasis scales inadvertently show substantial overlap with complaint
questionnaires (Gatchel & Newberry, 1991). Perhaps the value of Rohts observation
lies in the fact that it points toward an increased awareness of physical symptoms and
higher inclination to report them as a possible mechanism explaining higher scores
on symptom-scales.
The massive fear that arises in a population after exposure to radioactive radiation
has by some others been referred to as radiophobia or as a mass psychosis
(Mitchell, 1984; Oberhofer, 1989; Pretre, 1989). The concept of radiophobia has been
strongly criticized by Drottz-Sjbberg and Persson (1993)) who points out that public
anxiety caused by nuclear disasters shows little resemblance to clinical disorders such
as phobia or psychosis.
The course of clinical psychopathology following disaster, if at all present, is
probably relatively brief and self-limiting in most individuals. The increased preva-
lence and incidence found by Bromet and Schulberg (1986) and Smith et al. (1986)
could be demonstrated up to 12 months after the event; after that, rates dropped to
usual levels. For psychological distress, subclinical pathology and psychological im-
pairment a far longer persistence of symptoms has been reported, even as long as 6
years after the TM1 incident (Davidson & Baum, 1992).
Changes in Health-Related Behaviors
Several authors reported changes in health-related behavior, including illness behav-
ior following toxicological disaster. Most of these studies report on changes in repro-
ductive behaviors. Rachmatulin, Karamova, Dumkina, and Girfanova (1992) reported
a 240% increase in induced abortions in factory workers in an area, partly contami-
nated by fall-out from Chernobyl. Bertollini, Di Lallo, Mastroiacovo, and Perucci
(1990) reported a reduction of births in Italy 9 to 12 months after the Chernobyl
disaster, followed by a catch-up increase in the ensuing months. In some Italian
regions there was an increase of induced abortions in the first 3 months following the
disaster. Lower pregnancy rates and a rise in the number of induced abortions in the
year following the disaster was observed in the Scandinavian countries (Ericson &
K&aum;llen, 1994; Irgens et al., 1991; Knudson, 1991). Knudson (1991) concluded on
the basis of these data that the fear of radiation from the Chernobyl disaster probably
caused more fetal deaths than the released radioactivity itself.
Three papers describe the effects of toxicological disasters on other health-related
behaviors. Mileti, Hartsough, Madson, and Hufnagel (1984) reported a clear rise in
alcohol sales after the TM1 crisis, which lasted for several days. Only minor changes
were observed in the number of committed crimes, traffic accidents, suicides, and
psychiatric admissions, all falling within the range of normal fluctuations. Rachmatu-
lin et al. (1992) reported an increase in sick-leave in factory workers near Chernobyl
in the years following this accident, mostly related to psychological and psychosomatic
problems. Lebedev (1992) found that in the first year following the Chernobyl disaster
help seeking for psychological and psychiatric problems decreased. A similar finding
has also been reported after natural disasters (Yates, Axsom, Bickman & Howe, 1989).
Two other papers, not meeting the inclusion criteria for our review because of their
anecdotal nature, reported more serious changes in illness behavior. Giel (1991) has
described how a nuclear disaster changed medical survey-utilization and thus influ-
enced official health statistics. After the Chernobyl disaster, 20% of the visitors to a
368 J . M. Hauenaar and W van den Brink
Red Cross center were referred for a radiological check-up for complaints, such as
dizziness, headache, hypertension, and other nonspecific complaints. Local hospital-
based health statistics showed a rise in the prevalence of a wide score of diseases,
ranging from diabetes and cardiovascular disease to diseases of the nervous system. As
a relationship of these diseases with irradiation is considered improbable, it seems
likely these changes in morbidity rates were related to changes in illness behavior, and
to changes in diagnostic practice (see also Ginzburg, 1993). McLeod (1982) reported
an increase of 113% in the number of persons using sleeping pills and 88% of those
using tranquilizer during the week following the TM1 crisis, while 14% according to
this report used more alcohol and 30% smoked more cigarettes.
An interesting observation, open to several interpretations, was made by Hatch,
Wallenstein, Beyea, Nieves, and Susser (1991). These authors reported a modest
post-accident rise in cancer rates in the proximity of the TM1 plant three and four
years after the incident followed later by a decline. Radiation emissions did not
account for the observed increase, therefore the rise could be related either to a
biological effect of stress on cancer growth, or, alternatively, to changes in help-
seeking behavior and diagnostic practice rising from post-accident concern.
RISK FACTORS
Several studies have investigated risk factors for stress-mediated health effects of
toxicological disasters. Gibbs (1986), Horowitz and Stefanko (1989) and Viinamiki
and colleagues (1995) have observed more psychopathology in women than in men
in the aftermath of toxicological disasters. According to Shore, Tatum, and Volmer
(1986)) this finding may be partly caused by the fact that post-disaster studies usually
focus on anxiety and depression, both of which are more prevalent in women. Gibbs
(1983) found no sex differences in her review of post-disaster studies that take into
account typical male expressions of psychological dysfunctions, such as substance
abuse and aggressive behavior. Whether observed sex difference can be fully ex-
plained by these methodological factors remains to be seen. Interestingly, similar sex
differences have been reported for perception of risk from nuclear accidents (Mard-
berg, Carlstedt, Stalberg-Carlstedt, & Shalit, 1987; Sjijberg & Drottz, 1987; Weisaeth,
1991).
Especially women with preschool children are at risk, which is probably related to
the threat toxicological disasters carry for themselves and their young children
(Bromet 8c Schulberg, 1986; Havenaar et al., 1996). In this risk group, higher rates of
subclinical distress as well as of psychiatric disorders have been observed, especially
anxiety disorders. Children themselves also appear to be at risk, and may show a wide
range of internalizing and externalizing symptoms ranging from anxiety and depres-
sion to behavioral and school problems (Breton et al., 1993; Bromet, Hough &
Connel, 1984; Cornely & Bromet, 1986; Sorenson, Soderstrom, Copenhaver, Carnes,
& Bolin, 1987). Havenaar et al. (1996) also found that people who had been evacuated
after the Chernobyl disaster had a significantly increased risk for psychological distress
as well as for psychiatric disorders in terms of DSM-I I I -R (APA, 1987). Persons who
participated in rescue or clean up work following this nuclear disasters did not have
a higher risk of psychopathology.
Nuclear workers working at the damaged nuclear power plant at TM1 did not have
an increased risk for psychopathology in all studies. Bromet and Schulberg (1986)
found no difference in mental health of TM1 workers and workers of another nuclear
Psychological Factors of Toxicological Disasters 369
plant. Chisholm and colleagues (1981) found differences between workers from the
damaged plant at TM1 and those from an undamaged plant, but TM1 employees had
lower scores on the hostility and distrust dimensions of their questionnaires than
other residents. Somewhat surprisingly, Goldsteen, Schorr, and Goldsteen (1989)
found no evidence that living in closer proximity to the disaster site at TM1 was
associated with an increased risk for distress.
Social class may play a role. Higher social class (usually measured by education and
income) is usually associated with better mental health outcomes. However, this
connection may be an indirect one, because lower class individuals are probably more
prone to be hit by a disaster and more susceptible to the disasters physical and
economical impact. Social class may also be confounded with pre-disaster psychopa-
thology (Gibbs, 1989).
Pre-existing psychopathology was not found to be associated with and increased
vulnerability across studies. Bromet (1989)) for example, found no discernible differ-
ences between psychological reactions of mental patients and other inhabitants living
near the endangered nuclear power plant at Three Mile Island. Robins et al. (1986)
found no higher rates of relapse or persistence of preexisting disorder in respondents
who had previously been diagnosed as being mentally ill. Research in this area is
difficult, as willingness to admit to past and present psychological problems might be
a confounding factor leading to a spurious inflation of the relationship between pre-
and post-disaster psychopathology, especially in studies using retrospective designs.
Personality factors are a group of factors that may act as modifiers in relation to
outcome. Several authors (Davidson, Baum, & Collins, 1982; Gibbs, 1989; Prince
Embury, 1992) found more external locus of control in affected groups than in
control groups. Locus of control correlated significantly with psychopathological
measures (Baum & Fleming, 1993; Prince-Embury, & Rooney, 1988). Coping styles
also appear to mitigate the effects of stress in the individual. In the case of TMI,
emotional management, based on reappraisal of the incident in more positive terms,
appeared to be more effective than denial or problem-oriented coping in reducing
distress. Amount of trust in the available information and in experts and authorities
(Prince-Embury & Rooney, 1987, 1992, 1995; Goldsteen et al., 1989), religious belief,
and social support are other important modifiers of outcome, as is perception of
threat (Sorenson et al., 1987). The latter finding is on the verge of being circular as
the concepts of perception of threat and anxiety about its potential harm are closely
intertwined.
DISCUSSION
A growing literature about the role of stress in health outcomes in toxicological
disasters has emerged, especially during the past 10 years. It should be noted, that
disasters that have been studied best, so far, have been relatively small in scale in
comparison to major toxicological disasters, such as Bhopal or Chernobyl, a majority
of which appears to take place in second and third world countries (Baum, 1987;
Lechat, 1990; Bromet 8c Dew, 1995). In these countries, the necessary experience and
infrastructure to conduct ep\ demiological surveys is often lacking. Therefore, findings
of the studies reviewed above cannot be generalized to different cultural settings too
readily, although some universality appears to be present in the outcomes of nuclear
incidents in countries as remote as Japan, the United States, Brazil and the former
Soviet Union.
370 J M. Havenaar and K van den Brink
Elevated levels of distress, as measured through self-report symptom questionnaires
and changes in biological markers, such as heart rate, blood pressure, catecholamine
metabolism, and immune parameters have been observed in exposed populations
consistently. Anxiety symptoms are reported most often. Posttraumatic stress seems to
be a relatively uncommon consequence after toxicological disaster. Partly this may be
the result of a methodological artifact typical for the situation after toxicological
disasters, because the absence of a high-impact phase in these disasters may lead to
false negative diagnoses. Somatic symptoms are also reported consistently and may be
a manifestation of hypochondriasis induced by disaster. Early life cycle families and
people who are relocated as a result of such disasters appear to be especially at risk.
Despite the unequivocal findings when symptom scales or biological markers are
used to measure outcome, there are only a few reports in which the deviations in these
assessments reach the level of clinical significance. In this respect, the studies on
toxicological disasters are consistent with the literature on the psychological impact of
disaster (Rubonis & Bickman, 1991) and on stress and health in general (Watson &
Pennebaker, 1989). Only one study reported higher mortality in an exposed popula-
tion. An increased incidence and prevalence of clinical psychiatric disorders has been
observed in mothers with young children and in evacuees, but not in other members
of exposed populations. Apparently, stress accompanying toxicological disasters leads
mainly to subclinical changes. It has been hypothesized that increased symptom-
reporting should be interpreted as a form of illness behavior. This interpretation
generates interesting testable hypotheses, which may also be relevant to the study of
a number of related conditions, such as multiple chemical sensitivity syndrome and
sick building syndrome, in which unexplained nonspecific symptoms arise after
presumed exposure to low doses of toxic substances (Terr, 1994).
In contrast to the large number of studies about psychophysiological changes and
mental health effects, there is a relative lack of studies about health-related behaviors
following toxicological disasters. Studies that have investigated these phenomena
provide provocative evidence for a significant increase in the use of alcohol, drugs,
and medication and in the number of legal abortions. There is also evidence for
changes in illness behavior, be it more of an anecdotal nature. Most often this
concerns requests for a physical check-up following possible contamination, but
evidence suggests that other manifestations of illness behavior, such as sick-leave and
help-seeking behavior may be included as well. An opposite tendency (i.e., decreased
help-seeking) has been observed for psychological problems, a finding that should
lead to a reconsideration of services set up to support disaster victims.
In conclusion, it may be said that toxicological disasters may be associated with a
considerable loss of well-being in the affected population, which may last for pro-
tracted periods of time. At this moment there is only evidence for a significant impact
on clinical morbidity in certain risk groups, especially anxiety disorders in mothers
with young children and evacuees. Long-term follow-up will be needed to assess the
possibility of increased physical morbidity and mortality over time. Further study is
also needed in second and third world countries, where toxicological accidents are
I
increasingly common. Finally, further studies are needed on health-related behaviors
after toxicological disasters.
Psychological Factors of Toxicological Disasters 371
Acknowledgements - The authors wish to thank R. Giel, G. Glas en J. Ormel for their valuable
comments on earlier versions of this paper, and L.I. Meyler-Iljina and H. Mozhaeva for
preparing excerpts of Russian texts.
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