Pergamon

Clinical Psychology Review, Vol. 17, No. 4, pp. 359-374, 1997 Copyright 0 1997 Elsevier Science Ltd Printed in the USA. All rights reserved 0272-7358/97 $17.00 + .oo

PII so272-7358(97)-00009-3

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. In 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, University Hospital Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands. 359

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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 and DSM-Nclassificapsychological factors affecting physical condition, used in the DSM-ZZZ 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).

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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 hospitalization. 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 uncertainty 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.

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 occurred 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-

Housing and job insecurity. Evacuation

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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 products 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).
3.

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). 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).
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 children, 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 psychohygienic 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. Media siege. The media play an important

Social rejection. Victims of toxicological

4.

5.

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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 phenomenologically 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 Martyushov, 1992). A complicating factor in this respect is the confusion raised by contradictory 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 described 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 metaanalytic review about mental health outcomes and disasters, examined relationships among four sets of variables (a) characteristics of the victim population, (b) characteristics of the disaster, (c) study methodology and (d) type of psychopathology. These authors found no evidence for a differential effect of toxicological or other technological disasters; in fact the strongest predictor of psychopathology appeared to be a

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TABLE

1. Summary of Characteristics of Natural Disasters and Technological Catastrophes Natural Disasters Technological Catastrophes

Course of events

Sudden Usually, there is an identifiable clear low point. Conditions tend to improve with passage of time

Sudden or diluted There may be a clear low point, but particularly in toxic disasters, this is not so. Conditions do not necessarily improve in foreseeable time Some (e.g., dam breaks) involve visible destruction. Others (e.g., TMI, Love Canal) do not. May cause invisible damage manifested as health problems caused by the exposure Not predictable; failures are usually sudden and leave little time for evacuation

Visible damage

Usually causes disfigurement of environment. May destroy homes, businesses, disrupt power, sanitation, and the availability of drinking water Though point of impact cannot always be specified, some predictability can be obtained because: (a) occurrence rates for an area can be obtained from past experience and (b) forecasts can provide some warning Natural disasters not generally viewed as controllable. Their occurrence highlights a lack of control over the elements Usually limited to victims of the disaster

Predictability

Perception

of control

Technology is normally under human control. Therefore, mishaps are likely to be perceived as loss of contl-01

Extent of events

Loss of confidence and credibility may engender effects in people not directly 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 involved Tendency to form a nontherapeutic community (high conflict, uncertainty about causative agents, level of damage, future risks and necessary countermeasures)

Persistence of effects

Effects appear to be relatively short-lived. Loss of property or loved ones, however, may be associated with more chronic effects

Effects on community

Tendency to form a therapeutic community (low conflict; consensus about causative agents, level of damage, priorities of remedial action)

Adapted from Baum, A., Fleming, R., and Davidson, L.M. (1983).

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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 methodologies 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 toxicological 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. Unfortunately, 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

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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 International 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, Fischbath, 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 prospective 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 Diagnostic 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 hypochondriasis 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

PsychologicalFactars of ToxicologicalDisasters

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 prevalence 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 impairment 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 behavior following toxicological disaster. Most of these studies report on changes in reproductive behaviors. Rachmatulin, Karamova, Dumkina, and Girfanova (1992) reported a 240% increase in induced abortions in factory workers in an area, partly contaminated 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. Rachmatulin 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 influenced official health statistics. After the Chernobyl disaster, 20% of the visitors to a

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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 hospitalbased 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 helpseeking 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 explained by these methodological factors remains to be seen. Interestingly, similar sex differences have been reported for perception of risk from nuclear accidents (Mardberg, 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 depression 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-III-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

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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 psychopathology (Gibbs, 1989). Pre-existing psychopathology was not found to be associated with and increased vulnerability across studies. Bromet (1989)) for example, found no discernible differences 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 preand 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.

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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 population. 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 symptomreporting 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 protracted 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, whereI toxicological accidents are increasingly common. Finally, further studies are needed on health-related behaviors after toxicological disasters.

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- 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. Acknowledgements

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