RESEARCH
Trauma Signature Analysis of the Great East Japan
Disaster: Guidance for Psychological Consequences
James M. Shultz, MS, PhD, David Forbes, PhD, David Wald, PhD, Fiona Kelly, PhD,
Helena M. Solo-Gabriele, PhD, PE, Alexa Rosen, MPH, Zelde Espinel, MD, MA, MPH,
Andrew McLean, MD, MPH, Oscar Bernal, MD, PhD, and Yuval Neria, PhD
ABSTRACT
Objectives: On March 11, 2011, Japan experienced the largest earthquake in its history. The undersea
earthquake launched a tsunami that inundated much of Japan’s eastern coastline and damaged
nuclear power plants, precipitating multiple reactor meltdowns. We examined open-source disaster
situation reports, news accounts, and disaster-monitoring websites to gather event-specific data to
conduct a trauma signature analysis of the event.
Methods: The trauma signature analysis included a review of disaster situation reports; the construction
of a hazard profile for the earthquake, tsunami, and radiation threats; enumeration of disaster stressors
by disaster phase; identification of salient evidence-based psychological risk factors; summation of the
trauma signature based on exposure to hazards, loss, and change; and review of the mental health and
psychosocial support responses in relation to the analysis.
Results: Exposure to this triple-hazard event resulted in extensive damage, significant loss of life, and
massive population displacement. Many citizens were exposed to multiple hazards. The extremity of
these exposures was partially mitigated by Japan’s timely, expert-coordinated, and unified activation of
an evidence-based mental health response.
Conclusions: The eastern Japan disaster was notable for its unique constellation of compounding
exposures. Examination of the trauma signature of this event provided insights and guidance regarding
optimal mental health and psychosocial responses. Japan orchestrated a model response that
reinforced community resilience. (Disaster Med Public Health Preparedness. 2013;0:1-14)
Key Words: trauma, disaster, trauma signature analysis, TSIG, disaster mental health, psychosocial,
resilience, evidence-based intervention
E
arly on the afternoon of March 11, 2011, the
east coast of Honshu, Japan’s main island, was
the scene of a triple assault. Intense ground
shaking from an offshore underwater earthquake was
followed within minutes by the high-velocity on-shore
run-up of powerful tsunami waves.1,2 The tsunami
overtopped the protective seawalls surrounding the
Fukushima Dai-ichi nuclear power plant, precipitating
multiple reactor meltdowns; radiation was released over
a period of weeks. This complex emergency, variously
labeled ‘‘The Great East Japan Earthquake,’’ ‘‘The
Tohoku Earthquake,’’ or ‘‘3/11,’’ was a hybrid disaster3,4
in 3 acts: earthquake, tsunami, and radiation hazards.
Positioned along the Pacific Ocean’s seismicallyactive Ring of Fire, Japan’s history has been
punctuated by powerful and deadly earthquakes and
tsunamis. Although well prepared for these eventualities, on 3/11, Japan was subjected to the forces of the
largest earthquake in its national history, a tsunami of
the highest intensity on the Japanese meteorological
agency’s rating scale, and a nuclear crisis that evolved
over several weeks to be ranked 7 (highest) on the
International Nuclear Events Scale.
This disaster provided a multiple-impact case study
for examining the psychological consequences of the
affected population using trauma signature (TSIG)
analysis.5-7 TSIG examines the extent to which disaster
survivors were exposed to empirically-documented risk
factors for psychological distress and mental health
disorders.8-11 Based on the disaster ecology model,12,13
the premise of TSIG is that each disaster exposes the
affected population to a novel pattern of traumatizing
hazards, loss, and change. This singular ‘‘signature’’ of
exposure risks is a predictor of the psychosocial and
mental health consequences.
Disaster-specific analysis is important because, as
Kessler and team have documented across a spectrum
Disaster Medicine and Public Health Preparedness
Copyright 2013 Society for Disaster Medicine and Public Health, Inc. DOI: 10.1017/dmp.2013.21
1
Trauma Signature Analysis
of international disasters, ‘‘secondary stressors unique to a
particular disaster situation have more impact than the
disasters themselves’’ in determining the prevalence of
postdisaster mental disorders.14 Currently under development
with contributing investigators on 5 continents, TSIG is
intended to provide actionable guidance for mental health
and psychosocial support that is tailored, timed, and targeted
to the profile of the event. For each disaster case study, TSIG
analysis combines expertise from disaster sciences (in this
case, earthquake geophysics and environmental engineering),
disaster management, disaster public health, and disaster
mental health (including input from Japanese experts).
METHODS
The TSIG analysis reported here consisted of the following
components: (1) collection and synthesis of information
from real-time disaster situation reports (sitreps) issued in the
immediate aftermath; (2) collection of information from
international earthquake and tsunami monitoring systems
and consultation with subject matter experts; (3) construction of a multihazard profile for this triple-threat event;
(4) review of the scientific literature on evidence-based risk
factors for psychological distress and psychopathology for
persons exposed to earthquake, tsunami, and radiation
hazards; (5) enumeration of event-specific disaster stressors
and risk factors based on a review of sitreps and news
accounts, cross-referenced with the evidence-based literature;
(6) creation of a trauma signature summary for the disaster
based on the estimated psychological severity of exposures to
hazards, loss, and change; and (7) review of Japan’s disaster
mental health response.
Disaster Situation Reports
Beginning on March 11, 2011, TSIG investigators collected
and examined situation reports (sitreps; Table 1) as they
became available on ReliefWeb (http://reliefweb.int), a resource
that serves the disaster response community as the international
repository for late-breaking and archival information for major
disaster events. Within hours of the initial impact, the first
sitreps were posted on ReliefWeb as they were issued from
sources such as the Government of Japan, United Nations
Office for the Coordination of Humanitarian Assistance, and
US Agency for International Development.
Sitreps were issued almost daily during the first 3 weeks,
providing estimates of confirmed deaths; missing, displaced,
and injured persons; and numbers of households lacking
access to clean water and electrical power. Sitrep data have
served as proxies for disaster stressors and indicators of
exposure to hazards, loss, and change. Sitrep estimates were
examined to see how rapidly they attained equilibrium and
stability. As a reliability check, sitrep estimates produced
in the immediate postimpact period were compared with
the figures available 1 year postdisaster to gauge the data’s
utility and accuracy.
2
Disaster Medicine and Public Health Preparedness
Disaster Monitoring Systems and Expert Consultation
Scientific information was gathered from earthquake,
tsunami, and radiation-monitoring systems. Within the first
day, preliminary estimates of magnitude and cartographic
depictions of the earthquake shaking intensities throughout
Japan were characterized; the tsunami wave heights and wave
arrival times were mapped for the entire Pacific Ocean; and
early estimates of radiation exposure near the damaged power
plants were published. TSIG researchers consulted subject
matter experts from the physical sciences to assist in
accurately characterizing the exposure of the Japanese
population to the earthquake and tsunami hazards. One of
these experts is a geophysicist from the US Geological Survey
who created the Shake-Map technology for graphically
displaying (Figure 1) the geographic areas and the corresponding human populations that experience varying levels
of earthquake ground shaking (D.W.), and another is an
environmental engineer and dean of research specializing in
coastal flooding (H.S.-G.).
Construction of a Multi-Hazard Profile
Based on the review of sitreps and hazard-monitoring
websites, and with direct consultation from subject matter
experts, the TSIG team created a hazard profile with separate
descriptions for the earthquake, tsunami, and radiation
hazards (Table 2). TSIG hazard profiles use an epidemiologic
approach to disaster description (hazard, person, place, and
time). Type of disaster was based on disaster classification
schemes used by the Centre for Research on the Epidemiology of Disasters15 and the World Association for Disaster and
Emergency Medicine16; forces of harm were derived from the
Disaster Ecology Model;12,13 magnitude and severity were
based on hazard-specific rating systems (eg, moment magnitude and Modified Mercalli Index for earthquakes, International Nuclear Events Scale for radiation events); and
place and time descriptions were from the hazard-monitoring
websites. For added perspective on the exceptional nature of
each of the 3 hazards, Table 2 presents information on the
historical context.
Evidence-Based Literature on Psychological
Risk Factors for Earthquake, Tsunami, and
Radiation Hazards
The disaster mental health literature on human population
exposure to earthquake, tsunami, and radiation hazards was
searched to expand the TSIG database and identify evidencebased risk factors that were incorporated into the construction of
the disaster stressor matrix.
Event-Specific Disaster Stressors and Risk Factors
For weeks following impact, TSIG investigators continuously
perused print and media news accounts, accumulating
photographic and video documentation of the disaster. Based
on a review of sitreps and news accounts, cross-referenced
with the evidence-based scientific literature, a table was
constructed of disaster stressors experienced by Japanese
VOL. 00/NO. 00
1 400 000 in 14 prefectures
1 400 000
1 400 000
1 600 000
2 500 000
1 800 000 (4.4 million)
938 000 (2.3 million)
938 000 (2.3 million)
1 million (2.4 million)
875 000 (2 million)
760 000
660 000
490 000
372 000 (913 000)
260 000
No estimate
1 million
citizens during the impact and postimpact phases (Table 3).
The resulting stressor matrix provided an event- and hazardspecific delineation of evidence-based risk factors for
psychological consequences that were prominent and specific
to this disaster. Development of the disaster stressor
matrix was an important step for understanding how this
disaster’s unique pattern of harmful physical forces was likely
to cause concomitant psychological reactions, distress, and
psychopathology.
Trauma Signature Summary
c
b
Including 210 000 within 20-km radius of Fukishima plant.
(national media reporting ,15,000 missing/unaccounted for)
Number dropped significantly due to double counting in Fukishima prefecture.
The TSIG team created a composite trauma signature
summary table listing the most prominent disaster exposures
conferring psychological risk (Table 4). Within the disaster
ecology model,12,13 exposure to the forces of harm is
subcategorized into exposures to hazards, loss, and change.
The major evidence-based risk factors were categorized under
these headings by disaster phase along with information
specific to this Japanese disaster.
a
1419
1990
1885
2043
2285
No estimate
2611
2611
2644
2644
2644
2766
2766
2766
No estimate
1600
1647
3100
3676
5178
6400
7197
8199
8649
9079
9408
10066
10091
11257
,11600
March 13
March 14
March 15
March 16
March 17
March 18
March 19
March 20
March 21
March 22
March 23
March 25
March 28
March 30
April 4
,10 000
,10 000
3118b
7845
8913
10 000
10 905
12 722
13 262
12 782
14 716
17 443
17 649
16 343
16 450
380 000 in 2050 sheltersa
371 800
550 00
530 000
430 000
390 000
376 907
367 141
341 589
318 213
261 000
244 000
250 000
173 200c
170 500
4 million buildings near Tokyo; no gas or electriciity in Sendai
4 400 000 in Tohoku
1 200 000 in Kanto
2 600 000 (3.2 million)
1 250 000; limited gas for 3.2 million people
843 000; limited gas for 3.2 million people
634 465
451 786
373 748 (.1 million)
289 000 (713 000)
289 000 (713 000)
244 000 (601 000)
216 977 (533 763)
216 164 (531 763)
210 000 (516 600)
200 000
190 000 (492 000) No gas for 330 000 households (936 000)
180 000 No gas for 340 000 households
No estimate
No estimate
No estimate
215 000
No estimate
171
19
464
March 11
March 12
Evacuated to Shelters
Reported as Missing
Confirmed Deaths
Date
2011 Great East Japan Disaster: Disaster Situation Report Summary
TABLE 1
Injured Persons
Households (Persons) Without Electrical Power
Households (Persons) Without Water
Trauma Signature Analysis
To our knowledge, this TSIG is the first case study to classify
the exposure severity of the major psychological risks factors.
The exposure severity ratings, developed by the disaster
epidemiologists on the TSIG team, used order-of-magnitude
(10-fold) differences between adjacent categories. Based on
112 years of data from the Centre for Research on the
Epidemiology of Disasters,15 ratings of ‘‘Extreme’’ for a
specific measure have been reserved for disasters that produce
consequences at that order of magnitude only several times
per century. ‘‘Very Severe’’ ratings reflect the order of
magnitude threshold reached with a frequency of 1 or several
times within a 10- to 20-year period, while ‘‘Severe’’ ratings
occur 1 or several times within a 3- to 5-year period. This
classification approach will soon be scrutinized and refined by
an international group of disaster mental health professionals
using a web-based Delphi process. The Japanese disaster was
of sufficient magnitude to be rated Very Severe or Extreme on
most of the psychological risk factors appearing in Table 4.
The Disaster Mental Health Response
Japan mounted an immediate and multifaceted disaster
mental health response.17 This response was examined from
the vantage point of the findings from the TSIG analysis.
RESULTS
Situation Report Overview
Results are presented according to the sequence of steps in
the TSIG analysis and summarized in a series of detailed
tables. Table 1 combines information from 2 complete sets of
sitreps produced by the United Nations Office for the
Coordination of Humanitarian Assistance and the Center of
Excellence for Disaster Management and Humanitarian
Assistance. Because many persons who were engulfed in the
tsunami waves disappeared, the number of fatalities was
estimated from a combination of confirmed deaths and
Disaster Medicine and Public Health Preparedness
3
Trauma Signature Analysis
FIGURE 1
Earthquake Shaking Map: M 9.0, Near the East Coast of Honshu, Japan.
M 9.0, NEAR THE EAST COAST OF HONSHU, JAPAN
PAGER
Version 15
Origin Time: Fri 2011-03-11 05:46:24 UTC (14:46:24 local)
o
o
Location: 38.30 N 142.37 E Depth: 29 km
FOR TSUNAMI INFORMATION, SEE: tsunami.noaa.gov
Estimated Fatalities
Created: 22 weeks, 6 days after earthquake
Red alert for shaking-related fatalities and
economic losses. High casualties and
extensive damage are probable and the
disaster is likely widespread. Past red alerts
have required a national or international
response.
Estimated Economic Losses
Estimated economic losses are 0-1% GDP
of Japan.
Estimated Population Exposed to Earthquake Shaking
ESTIMATED POPULATION
EXPOSURE (k = x1000)
ESTIMATED MODIFIED
MERCALLI INTENSITY
- -*
PERCEIVED SHAKING
Not felt
Weak
Light
Moderate
none
none
none
V. Light
none
none
none
Light
POTENTIAL
DAMAGE
Resistant
Structures
Vulnerable
Structures
13,803k* 21,142k* 8,416k*
9,464k*
34,740k*
5,816k*
257k
0
Strong
Very Strong
Severe
Violent
Extreme
Light
Moderate
Moderate/Heavy
Heavy
V. Heavy
Moderate
Moderate/Heavy
Heavy
V. Heavy
V. Heavy
*Estimated exposure only includes population within the map area.
Population Exposure
population per ~1 sq. km from Landscan
Structures:
Overall, the population in this region resides
in structures that are resistant to earthquake
shaking, though some vulnerable structures
exist. The predominant vulnerable building
types are non-ductile reinforced concrete
frame and heavy wood frame construction.
Historical Earthquakes (with MMI levels):
Date
Dist. Mag.
Max
Shaking
(UTC)
(km)
MMI(#)
Deaths
1998-06-14 363 5.7 VII(428k)
0
1994-12-28 263 7.7 VII(132k)
3
1983-05-26 369 7.7 VII(174k)
104
Recent earthquakes in this area have caused
secondary hazards such as tsunamis,
landslides, and fires that might have
contributed to losses.
Selected City Exposure
from GeoNames.org
MMI City
IX Iwanuma
IX Furukawa
IX Hitachi
IX Takahagi
VIII Karasuyama
VIII Shiogama
VII Yokohama
VII Tokyo
IV Nagoya
IV Kobe
III Osaka
PAGER content is automatically generated, and only considers losses due to structural damage.
Limitations of input data, shaking estimates, and loss models may add uncertainty.
http://earthquake.usgs.gov/pager
bold cities appear on map
Population
42k
76k
186k
34k
18k
60k
3,574k
8,337k
2,191k
1,528k
2,592k
(k = x1000)
Event ID: usc0001xgp
From the United States Geological Survey.24
4
Disaster Medicine and Public Health Preparedness
VOL. 00/NO. 00
TABLE 2
2011 Great East Japan Earthquake: Hazard Profilea
Disaster Type
Disaster Components
Earthquake
Tsunami
NPP Radiation Emergency
Forces of harm
Megathrust faulting along tectonic plate boundary
Subduction of Pacific plate beneath Japan
Very strong-violent ground shaking experienced by
41 million persons
Large tsunami waves (maximum run-up height reported:
40.5 m/133 ft) along hundreds of miles of coastline
in Iwate and Miyagi prefectures
Multiple-wave sequence
Inundation zone: 561 km2
300 000 persons/108 000 households
Damage to Fukushima Dai-ichi NPP:
14-m tsunami waves overtopped 5.7-m seawalls
Plant blackout with loss of power, controls, and
instrumentation
3 reactor units overheated and damage to nuclear
fuel caused explosions and reactor meltdowns
Radiological contamination spread into
environment
Magnitude/severity
Mainshock moment magnitude (Mw) 9.0:
First 2 weeks: 726 strong aftershocks in first 12 d
Modified Mercalli intensity (MMI): 41 million persons
experienced MMI 7 (very strong), 8 (severe) or
9 (violent) shaking levels
Tsunami magnitude: Mt 9.1 (consistent with Mw 9.0
earthquake)
‘‘Major’’ tsunami on Japan Meteorological Agency rating scale
Highest level tsunami warning issued
International Nuclear Event Scale (INES): level
7 (highest)
Historical context
Most powerful earthquake in Japanese history
5 Largest earthquakes since 1900:
4th deadliest tsunami in Japanese history:
Second-worst NPP or civilian nuclear/ radiation
event after Chernobyl NPP (also rated INES 7).
9.5
9.2
9.1
9.0
9.0
Valdivia, Chile, 5/22/1960
Prince William Sound, Alaska 3/27/1964
Indian Ocean, 12/26/2004
Kamchatka, Russia, 11/4/1952
Tohoku, Japan, 3/11/2011
Place dimension
Epicenter: 120 km from Sendai
Hypocenter: 32 km below the surface
Built environment: strong, resistant structures,
limited damage
Major impact along 561 km2 of Honshu (Japan’s main island)
coastline
25 million tons of tsunami debris
Evacuation mandated within 20-km radius of
Fukushima Dai-ichi NPP
Stay indoors with shutters closed; movement
restrictions within 20- to 30 km perimeter
Time dimension
Strong foreshocks
Initial earthquake mainshock:
March 11, 2011 at 14:46 (05:46 GMT)
Frequency: series of hundreds of strong aftershocks of
gradually decreasing frequency and intensity during
several weeks (262 aftershocks $Mw5.0 in first
2 weeks)
Time before impact of tsunami along Japan’s coast: 20-60 min
Duration of acute life/health risk: weeks
Duration of disruption: years
Duration of life/health risk: months
Duration of disruption: years
a
Technical event description: Hybrid disaster with natural (geophysical: earthquake/tsunami) and human-generated (nuclear power plant [NPP] radiation hazard) components and complex humanitarian
emergency.3,4,15,16
Trauma Signature Analysis
Disaster Medicine and Public Health Preparedness
1)
2)
3)
4)
5)
1) 30 000-40 000 deaths
Meio Nankaido, 9/20/1498
2) 30 000 deaths
Hoei Nankaido, 10/28/1707
3) 27 000 deaths 1 earthquake
Sanriko, 6/15/1896
4) 19 000 deaths 1 earthquake
Tohoku, 3/11/2011
5
6
Trauma Signature Analysis
Disaster Medicine and Public Health Preparedness
TABLE 3a
2011 Great East Japan Disaster: Disaster Stressors - Impact phase
Stressors
Earthquake
Tsunami
Nuclear Power Plant (NPP) Radiation Emergency
Hazard
Earthquake early warnings
widely distributed
Exposure to physical forces:
> Strong foreshocks
> Mainshock ground shaking
> Immediate very strong
aftershocks
> Hundreds of strong
aftershocks for months
Physical injury
Limited warning period
Exposure to physical forces
> Powerful tsunami waves
> Tsunami run-up far above
sea level
> Floating debris
> Rapid flooding
Perceived threat of harm
> Panicked evacuation
> Fear of physical harm
> Fear of death
Hundreds of structure fires
Mass casualties
Personal physical harm
> Physical injury
> Near drowning
> Entrapment under debris
Witnessing injury to others
Witnessing death of others
Exposure to grotesque scenes
> Bodies in flood waters
> Bodies washing ashore
Exposure to snow, cold, harsh
conditions during rescue
Limited warning period/delay in
warning
Severe radiation exposure of NPP
employees/responders
Fire and explosions at nuclear plants
Contamination of crops
Contamination of water supply
Radiation hazard
Possible short-term and long-term health risks
due to radiation
Fears of invisible radiation hazard
Uncertainty regarding risks (a major stressor)
Loss
Mortality due to earthquake
structural collapse
Mass mortality
> Death of loved ones
> Death of friends
> Death of community leaders
Separation from loved ones
> Desperate searching
> Digging through debris
Loss of homes
> Displacement
> Loss of possessions
Community-wide destruction:
Loss of utilities (power, water)
Loss of survival necessities
Loss of community services
Loss of businesses
Impact on coastal industries (fishing,
tourism)
Loss of schools
Saltwater contamination of coastal
areas affecting soils
Loss of access to home sites and
communities
Contamination of area
Damage to crops
Contamination of water supplies
Loss of power, utilities, services in
areas served by damaged NPPs
Economic losses
Closure of businesses and schools
Loss of sense of community
Loss of access to services (health, mental health)
Loss of freedom of movement
Loss of utilities (power, water)
Immediate loss of necessities
Immediate loss of possessions
Lack of security
Perceived loss of control
Evacuation from home
Displacement
Stranding of survivors; out of reach
of help for days/weeks
Living in shelters
Fear of indoor environments
Community-wide destruction
Massive property damage
Extensive tsunami debris
Lack of security
Lack of power
Lack of clean water
Mandated evacuation from home
within 20 km of damaged NPPs
Other communities required to stay
indoors for weeks
Displacement
Living in shelters
Fear of radiation hazard
Community-wide disruption
Fear of contamination of food, water
Lack of power
Exposure to freezing temperatures
Lack of clean water
Stigmatization and discrimination of
communities
Distrust of government information
Change
VOL. 00/NO. 00
TABLE 3b
2011 Great East Japan Disaster: Disaster Stressors - Post-impact phase
Stressors
Earthquake
Tsunami
Nuclear Power Plant (NPP) Radiation Emergency
Hundreds of moderate to very
strong aftershocks extending
for months
Environmental hazards from
earthquake damage
Massive landslides
Vast fields of tsunami debris
Hundreds of fires
Fire, gas, electrocution hazards
Exposure to harsh winter
environment for displaced persons
Collapsed structure risks
Water contamination risks
Mold risks in flooded structures
Infectious disease risks
Limited warning period
Delay in warning
Severe radiation exposure of NPP
employees/responders
Fire and explosions at nuclear plants
Contamination of crops
Contamination of water supply
Contamination of seawater/
marine life
Radiation hazard
Possible short-term and long-term health risks
due to radiation
Fears of invisible radiation hazard
Uncertainty regarding risks is a major stressor
Perception that hazard/risk information was
withheld o minimized
Loss
Mortality due to earthquake
structural collapse
Loss of roads
Loss of bridges
Loss of rail lines
Loss of dikes leading to
loss due to flooding
Mass mortality
> Death of loved ones
> Death of friends
> Death of community leaders
> Loss of ‘‘breadwinners’’
> Orphaning of children
Bodies lost in the sea (no proof of life
or death)
Traumatic bereavement
Complicated grief
Family distress
> Dealing with loss, trauma
> Caring for injured family
members
Community-wide destruction
Loss of homes
> Displacement
> Loss of possessions
Loss of utilities (power, water)
Loss of survival necessities
Loss of community services
Loss of businesses
Impact on coastal industries (fishing,
tourism, agriculture)
Loss of schools
Saltwater-affected lands unable to
sustain forests, agriculture
Massive economic losses
Long-term loss of access to homes
and communities
Contamination of debris
Damage to crops
Contamination of water supplies
Loss of power, utilities, services in
areas served by damaged NPPs
Loss of agricultural use of radiationcontaminated land
Economic losses
Closure of businesses and schools
Loss of sense of community
Loss of access to services (health, mental health)
Loss of freedom of movement
Loss of utilities (power, water)
Loss of necessities
Loss of possessions
Loss of security
Perceived loss of control
Evacuation from home
Displacement
Stranding of survivors out of reach
of help for days/weeks
Living in shelters
Fear of indoor environments
Community-wide destruction
Decrease in exports of goods from
affected regions
Massive property damage
Extensive tsunami debris
Lack of security
Lack of power
Lack of clean water
Unemployment
Financial hardships
Fear of returning to work at sea
(fishermen)
Mandated evacuation from home
within 20-30 km of damaged
power plants
Other communities required to
stay indoors for weeks
Displacement
Living in shelters
Fear of radiation hazard
Community-wide disruption
Fear of contamination of food, water
Lack of power
Exposure to freezing temperatures
Lack of clean water
Stigmatization and discrimination of
communities
Distrust of Government information/updates
Change
Trauma Signature Analysis
Disaster Medicine and Public Health Preparedness
Hazard
7
8
2011 Great East Japan Disaster: Trauma Signaturea
Disaster Medicine and Public Health Preparedness
Risk Factors for Psychological Distress and Mental
Disorders
Exposure Severity
Great East Japan Disaster Characteristics
Exposure to hazards
Earthquake: Exposure to severe ground shaking
41 million persons (32% of Japanese population)
Strong fear reactions and perceived life threat
Estimate: 20 million of 41 million total exposed
Tsunami: direct tsunami impact
1.6 million population in the tsunami-affected areas
Radiation: exposure requiring evacuation
170 000-300 000 persons evacuated in 20 km zone
Actual/perceived CBRNE exposure
Millions in Fukushima and surrounding prefectures
Physical injury requiring medical care
6000 injuries
Witnessing grotesque scenes, dead bodies
Up to 1.6 million in tsunami-affected areas 1 10 000s of responders
Exposure to postimpact severe environment
Multiple high-intensity impacts
10 000s homeless/displaced with direct exposure to harsh
environment
Tsunami- and radiation-exposed were also earthquake-exposed
Exposure to loss
Mortality
Almost 16 000 confirmed deaths
Missing/disappeared and/or presumed dead
More than 2900 missing 1-y postdisaster
Bereavement
Close to 80 000 bereaved first-line family members
(assume 4:1 ratio)
Residents of .380 000 fully or partially-collapsed structures
Loss of primary dwelling
Severe financial losses
National financial losses
Exposure to change
Displacement/relocation to shelters
Loss of electrical power/gas for cooking
Lack of clean water
VOL. 00/NO. 00
Damage to infrastructure
Moderate
.10 000
Moderate
.10 000
Moderate
.1000
Moderate
.1000
Moderate
.1000
Moderate
.100
Moderate
.1000
Moderate
.1000
Moderate
.1000
Severe
.100 000
Severe
.100 000
Severe
.10 000
Severe
.10 000
Severe
.10 000
Severe
.1000
Severe
.10 000
Severe
.10 000
Severe
.10 000
Very severe
.1 million
Very severe
.1 million
Very severe
.100 000
Very severe
.100 000
Very severe
.100 000
Very severe
.10 000
Very severe
.100 000
Very severe
.100 000
Very severe
.100 00
Extreme
.10 million
Extreme
.10 million
Extreme
.1 million
Extreme
.1 million
Extreme
.1 million
Extreme
.100,000
Extreme
.1 million
Extreme
.1 million
Extreme
.1 million
Assessed for individuals, but assumed for most who lost
primary dwelling or businesses
Most expensive disaster in history.
World Bank estimate: $235 billion
Moderate
.1000
Moderate
.100
Moderate
.400
Moderate
.1000
Moderate
.1000
Moderate
.$10 million
Severe
.10 000
Severe
.1000
Severe
.4000
Severe
.10 000
Severe
.10 000
Severe
.$100 million
Very severe
.100 000
Very severe
.10 000
Very severe
.40 000
Very severe
.100 000
Very severe
.100 000
Very severe
.$1 billion
Extreme
.1 million
Extreme
.100 000
Extreme
.400, 000
Extreme
.1 million
Extreme
.1 million
Extreme
.$10 billion
170 000 long-term displaced
550 000 peak displacement
3-4 million without power initially
500 000 (in 200 000 households) without power for 2 weeks
4-5 million without water initially
.1 million (in 400 000 households) without water for 2 weeks
Damage to 4200 roads, 78 bridges, 29 railways, 45 dikes
Moderate
.1000
Moderate
.10 000
Moderate
.10 000
Moderate
Severe
.10 000
Severe
.100 000
Severe
.100 000
Severe
Very severe
.100 000
Very severe
.100 000
Very severe
.100 000
Very severe
Extreme
.1 million
Extreme
.1 million
Extreme
.1 million
Extreme
Abbreviation: CBRNE, chemical, biological, radiological, nuclear, and explosive.
This disaster was of sufficient magnitude to be rated Extreme (frequency of several times per century) or Very Severe (frequency of 1 or several times within a 10- to 20-year period) on most
of the psychological risk factors. Severe ratings occur 1 or several times within a 3- to 5-year period.
a
Trauma Signature Analysis
TABLE 4
Trauma Signature Analysis
‘‘missing’’ persons. As expected, the earliest sitreps (from day
1 of the disaster) grossly underestimated these numbers due to
incomplete data. However tallies increased rapidly, and the
sum of dead and missing surpassed 20 000 on March 20 and
peaked at 28 000 on the final sitrep (April 4). This last
number was actually an overestimate, primarily due to
multiple counts of missing persons. At the 1-year anniversary,
the number of confirmed deaths was 15 867, and 2909
persons were still reported as missing, a figure that continues
to be updated.18 For the TSIG analysis, the focus was on
estimating numbers of bereaved family members dealing with
known or presumed loss of loved ones; precise mortality
figures were not essential, but a workable estimate emerged
and stabilized within the early weeks.
As anticipated in a tsunami, injuries were far fewer than
fatalities,19 and tabulating injuries was not an urgent priority
initially. Although the highest count of injuries recorded in
the sitreps was less than 3000, these slowly accumulated to an
official estimate of 6109 injuries at the 1-year anniversary.18
Displacement of disaster-affected persons peaked at 550 000
on March 15, including those displaced due to tsunami
destruction and those evacuated from the 20-km ‘‘no-go’’
zone around the Fukushima Dai-ichi power plant. Numbers of
displaced and sheltered persons declined quickly to about
170 000 by the end of March 2011.
Widespread power outages affected large numbers of persons,
creating significant hardships during the March winter season.
Millions remained for weeks without access to water that was
clean and not contaminated with radiation. Along Honshu’s
east coast, from Chiba to Aomori, 129 225 buildings were totally
destroyed, 254 204 were partially destroyed, and 691 786
sustained major damage.18 A total of 4200 roads, 78 bridges,
and 29 railways were damaged or destroyed.18,20-22 The World
Bank estimated the economic cost of the disaster at $235 billion,
making this the costliest disaster in history.23
Event Description and Hazard Profile
As a tectonic event of extraordinary scale, the earthquake was
caused as the Pacific plate slipped violently downward
beneath the tectonic plate on which Japan sits, causing a
sudden upthrust of 400 km of seafloor, which triggered the
tsunami at the ocean surface. Along the fault plane of origin,
in the vicinity of the profound ocean depths of the Japan
Trench, the earthquake and the tsunami were inseparable
geophysical phenomena. In contrast, the impacts were
experienced along the Japanese coastline as 2 discrete and
highly-distinctive disaster events. Damaging earthquake
S waves reached the Japanese coast in less than a minute
(and Tokyo within 90 seconds), while tsunami waves arrived
along Japan’s east coast 20 to 80 minutes later.
The Earthquake
This earthquake was the largest in Japanese history and 1 of
the 5 most powerful seismic events since 1900.20,21 Releasing
1000 times more energy than the temblor that flattened
Port-au-Prince, Haiti, in 2010, the Japanese earthquake
subjected 41 million persons (32% of the 2011 Japanese
population) to very strong, severe, or violent ground shaking.24
The main shock was followed by frequent, high-magnitude
aftershocks (726 powerful aftershocks were recorded throughout
the Japanese archipelago within the first 12 days).25
The Tsunami
The tsunami was the most deadly and destructive of the
3 hazards. The epicenter was sufficiently distant from Japan
(120 km) to generate a procession of powerful tsunami waves,
yet close enough to land that the warning interval to alert the
public was typically less than 40 minutes. Tsunami waves
rushed ashore, propelling massive quantities of debris
(estimated at 25 million tons).26,27 Waves surged inland,
‘‘running up’’ the coastal hillsides. More than 94% of total
deaths were attributed to the tsunami, with drowning
accounting for 92% of the fatalities.21,22 An additional 922
deaths were attributed to acute hardships in the aftermath
(eg, unprotected exposure to winter conditions), especially in
populations cut off from aid by inland flooding and the
destruction of roads and bridges.21,28
Radiation Hazards
An onrush of tsunami waves affected multiple coastal nuclear
power plants. Fukushima Dai-chi, one of the world’s largest
nuclear power facilities, sustained significant damage from
high-velocity tsunami waves that cascaded over the protective seawalls.29-31 Damage from the waves inactivated the
plant’s cooling systems, leading to explosions, fires, and
complete meltdowns in 3 of the 6 reactors. The radiation
crisis worsened during a period of weeks, as various remedies
to cool the reactors were implemented and failed. The
severity of the radiation health threat escalated to a 7 (highest)
on the International Nuclear Events Scale as Fukushima
Dai-ichi became the second worst civilian nuclear/radiation
event in history (after Chernobyl). Significant quantities of
radioactive materials were released into the environment,
prompting authorities to evacuate approximately 200 000
citizens from a 20-km radius zone around the power plant
and to severely restrict activities for citizens living within the
20- to 30-km perimeter.32 Japan began monitoring food and
water, conducting radiation scans of evacuees, and placing
radiation limits on food products.30 Radiation contamination
will remain in the environment for many years, resulting in
long-term, low-level exposures.32
Disaster Stressors
Japanese citizens experienced a wide range of disaster stressors
associated with exposure to hazards during the impact of the
disaster and adversities thereafter. A comprehensive array
of stressors was tabulated by disaster phase (impact and
postimpact) and hazard (earthquake, tsunami, and radiation)
and compiled from news sources and published research.
Disaster Medicine and Public Health Preparedness
9
Trauma Signature Analysis
Many of the listed stressors were recognized risk factors for
psychological distress and potential psychopathology.
Trauma Signature
A triple-threat trauma defines this event.6 Historically,
undersea or coastal earthquakes have generated massive
tsunamis, and this combination of seismic hazards has proved
to be deadly and destructive.19 The March 2011 disaster in
Japan introduced the additional element of a major radiation
hazard, creating a hybrid disaster event.3,4 Among the
41 million Japanese citizens who directly experienced forceful
ground shaking from the earthquake, 1.6 million lived in
coastal areas that were also inundated by the tsunami. All
200 000 persons living within the 20-km evacuation zone
around the Fukushima Dai-ichi nuclear power plant had
initially experienced ground shaking from the earthquake,
and many were also affected by the tsunami.
DISCUSSION
Synopsis of Psychological Risk Factors
The Great East Japan Disaster will be remembered for the
superimposition of earthquake, tsunami, and radiation
hazards that amplified the degree of harm and complicated
the response. With almost 19 000 dead, or missing and not
found, widespread damage to infrastructure, and an economic
price tag unequaled in disaster history, this was a landmark
event. Less quantifiable, but much more prolonged and
pervasive, were the psychological effects of this disaster that
will need to be monitored. The entire nation has been
mourning the loss of life, and some Japanese citizens will need
mental health intervention, including bereaved family
members of those who died or whose bodies have never
been found. One-third of the nation was subjected to very
strong ground shaking from the earthquake, and some have
been traumatized. Hundreds of thousands were in the path of
life-threatening tsunami waves, fleeing for survival and
witnessing harm and death. Hundreds of thousands were in
mandatory evacuation zones due to potentially high radiation
exposure, and they will be fearful of ongoing contamination
and lifelong health risks. Predictably, the need for psychological support and mental health intervention related to the
various exposures to hazards, loss, and change will be
sustained. One essential component of the TSIG analysis
was the review of the evidence-based literature; a synopsis of
key findings follows.
Mental Health Correlates
The Earthquake
The exposure of one-third of the Japanese population to the
fear-provoking ground shaking during the mainshock,
followed by a barrage of potent aftershocks, was a major
psychological stressor, as documented in previous studies of
earthquakes in Japan and elsewhere.5,33-35 Intense fear during
an earthquake and perceived threat to life are risk factors for
psychological distress and posttraumatic stress disorder
10
Disaster Medicine and Public Health Preparedness
(PTSD), independent from the extent of damage, death, or
harm.35,36 For millions of Japanese citizens who felt the
sensations of the earthquake without injury, and were beyond
the geographic range of the tsunami or radiation hazards, the
experience of the mainshock/aftershock kinesthetics was the
most salient psychological stressor.
The Tsunami
Studies of the psychological impact of the 2011 Japanese
tsunami were built on a robust literature, in which the
severity of traumatic exposure to a tsunami37-40 and perceived
threat to life39,40,41 were identified as the strongest psychological risk factors. The experience of loss in the tsunami,
including loss of loved ones, livelihood, and resources, has
consistently predicted psychopathology, complicated grief,
depression, and distress.37,38,42-45 Wide-ranging psychological
consequences were observed among tsunami survivors who
were displaced and experienced loss of place.38,41,43 In a
tsunami, loss of loved ones is intermingled with myriad other
stressors: separation of family members during frenzied flight,
companions submerged in the on-rushing waves, bodies swept
into the sea, prolonged searching for the missing, lack of proof
of either life or death, discovery of decomposed bodies in the
debris fields or washing ashore, prolonged delays required for
body identification, and inability to conduct funerals or to
perform rituals of remembrance.
Rates of psychological consequences in tsunami survivors
have been found to be higher in women,38,40,44,46,47 the
elderly,48 and individuals with preexisting mental illness.48,49
For children who survived tsunami disasters, the strongest
psychological risks factors were loss of parents, impairment of
caregivers, disruption of daily routines, and interruption of
schooling.41,50 Disaster health care workers have been
severely affected psychologically.38,47,51
Radiation Hazards
Undetectable by the human senses, radiation is one of the
most dreaded hazards, with the capacity to provoke
disproportionate fear and horror.52-55 Radiation may cause
DNA damage that may progress to cancer or genetic
abnormalities, a fact that further magnifies the fear level for
persons who perceive that they have been exposed.56
Communicating radiation risks accurately to a fearful public is
essential for favorably influencing prosocial behaviors in
situations of mass congregation (eg, sheltering) or exodus (eg,
evacuation) to defuse conditions that could incite mass
panic.57,58 Members of an international team of radiation
experts invited by the Japanese government to survey radiation
hazards at Fukushima Dai-ichi concluded that ‘‘the provision of
timely, accurate, clear, and credible information may be the
single most important way to save lives.’’31,59
The incineration of the Chernobyl nuclear power plant was
the worst peacetime radiation incident. Decades after the
VOL. 00/NO. 00
Trauma Signature Analysis
event, radiation-exposed residents reported symptoms of
anxiety, depression, PTSD, and unrelenting stress; appraised
their physical health negatively; and described pervasive
feelings of powerlessness.60-63 Radiation can lead to lifelong
displacement from home communities, stigmatization, and
discrimination against people and products from the contaminated areas.52,62 Psychological consequences may persist
for multiple generations.63-65
Multiple Impacts
The nation of Japan experienced 3 high-severity exposures
combined into a megadisaster. Each of the 3 major events had
the potential for producing significant psychological consequences, but their co-occurrence magnified the effects.
Many Japanese citizens were exposed to 2 or all 3 of the major
events, and were affected by a composite of adversities and a
nationally-shared sense of grief and loss in the aftermath.
Disaster mental health research has consistently demonstrated that multiple-exposure events are more stressful and
more traumatizing than single exposures.12,13,66,67
Evidence-Based Mental Health and
Psychosocial Responses
Immediately postimpact, TSIG investigators outlined key
elements that would constitute an effective and comprehensive mental health response to the Japan disaster:
(1) prioritizing disaster mental health response, (2) guiding
mental health response based on identification of the eventspecific risk factors, (3) providing timely evidence-based
mental health and psychosocial support in the early aftermath
(coupled with a gatekeeper function to minimize the use
of nonempirically-based interventions), (4) conducting
on-scene validated mental health assessment, (5) tailoring
mental health interventions to the cultures represented
within the affected population, and (6) maintaining postdisaster mental health surveillance.6
The Japanese disaster mental health response was exemplary
from several vantage points. In the first two days, operating
on national guidelines for mental health and psychosocial
response (enacted after the Kobe earthquake),17,68 the
Japanese Society for Psychiatry and Neurology established a
disaster-response committee and activated a disaster-response
operations center to coordinate the efforts of all major
national disaster mental health research and professional
entities. By the third day, the National Center for Neurology
and Psychiatry had launched a disaster mental health
information website containing national guidelines, policy
directives, and manuals.17,69,70 This consolidation of national
mental health leadership was instrumental in staffing and
coordinating the rapid dispatch of mental health teams and
professional advisors to the field.17,70
The mental health response was multipronged: (1) maintaining and reestablishing access to psychiatric care and
medications for the population of patients with preexisting
psychiatric diagnoses; (2) providing outreach and support for
disaster-affected citizens dealing with event-related distress,
traumatic memories, loss of loved ones, complicated grief and
bereavement, postimpact adversities, stressful shelter conditions,
displacement from tsunami-devastated areas, and evacuation
from areas threatened by radiation; and (3) providing
psychological support for disaster responders.17,69,70
Particularly impressive was the degree of command and
control exerted by mental health leadership regarding the use
of acceptable interventions based on standardized guidelines.
The coherence among mental health professionals, including
nationally recognized opinion leaders, facilitated adherence
to science-based policy for acute and long-term mental
health care. The centralization of psychiatric leadership and
ongoing communications among the leading entities presented a unified front.
In terms of the actual response, emphasis was placed on
psychoeducation, early dispatch of mental health teams,
outreach to vulnerable and hard-to-reach populations, early
and ongoing mental health surveillance, and the provision of
practical support and evidence-based interventions. Specifically proscribed were nonscience-based approaches and
interventions that have been demonstrated to be ineffective,
such as single-session psychological debriefing.17,70 Emphasis
was placed on individual and community resilience, spontaneous (natural) recovery, watchful waiting, and provision of
psychological first aid.17,70 Based in part on lessons learned
from the Kobe earthquake and intimate knowledge of the
affected populations, strong emphasis was placed on cultural
competence. Matched to the suggested template for optimal
response,6 the Japanese response was laudable.
Current and Future Directions for Trauma
Signature Analysis
TSIG analysis appears to provide a useful framework for
translating early and available data from sitreps, scientific
disaster monitoring systems, and subject matter experts into
guidance regarding the constellation of major psychological
risk factors at play. Collaborating researchers are in the
process of calibrating and refining the 6 components that
constitute the complete TSIG analysis process: (1) initial
predeployment/postimpact TSIG analysis, (2) TSIG-targeted
deployment of disaster mental health assets, (3) evidencebased early intervention with evaluation, (4) on-scene
validated mental health assessment, (5) identification and
intervention for high-risk individuals, and (6) monitoring
and evaluation throughout recovery. This TSIG analysis case
study addresses the first of these components.
The first TSIG analysis case study examined the 2010
earthquake in Haiti as ‘‘a potent example of the rare
catastrophic event where all major risk factors for psychological
distress and impairment are prominent and compounding.’’5
Disaster Medicine and Public Health Preparedness
11
Trauma Signature Analysis
In contrast to the Japanese disaster, the disaster mental health
response in Haiti was neither prioritized nor evidence based.
Prevailing challenges in disaster mental health response
(all evident in Haiti) included: (1) mass convergence of
responders to the disaster scene, (2) provision of nonevidencebased ‘‘psychosocial’’ programs, (3) failure to evaluate and target
programs to event-specific psychological risks, (4) failure to
conduct on-scene needs assessments, (5) failure to identify
persons at high risk for psychopathology, (6) lack of disaster
mental health services maintained throughout the recovery
period, (7) absence of ongoing monitoring of survivor mental
health status, and (8) failure to evaluate intervention efficacy.
The complete TSIG analysis process is currently under
development to address these gaps and to infuse science-based
assessment, intervention, and evaluation for disaster-affected
populations and disaster response personnel.
experience ongoing health surveillance and stigmatization
of both the contaminated land and its people. From these
events, we created a TSIG analysis that translates the physical
forces of harm into the most probable and prominent
psychological correlates for the disaster-affected populations.
This analysis was achieved rapidly with the help of sitrep data
that were collected as the disaster unfolded.
The Japanese disaster mental health response was timely,
vigorous, science based, and exemplary. Few nations have the
capacity to prioritize, mount, and coordinate an evidencegrounded response of such excellence. TSIG analysis was
designed to provide critical information to guide and expedite
a disaster mental health response in the manner so ably
modeled by Japan.
About the Authors
This TSIG analysis is one in a series of case studies that apply
the TSIG methodology to a range of natural and humangenerated disasters and complex emergencies.5-7,71-76 We
have conducted TSIG case studies for the Haitian 2010
earthquake;5,71,72 Deepwater Horizon oil spill in the Gulf of
Mexico;72 the Great East Japan Disaster;6,73 river floods in
North Dakota;7,74 internal displacement in Colombia, South
America;75 the 2011outbreak of ‘‘super tornadoes’’ in the
United States;76 and the Russia-Georgia conflict in South
Ossetia.77 With each case study, the database of evidencebased research studies has been expanded. In addition, TSIG
developers have presented a series of workshops and institutes
to introduce the methodology and to actively seek feedback
and collaboration.78-80 For further refinement and validation
of the TSIG approach, developers will conduct an Internetbased Delphi process with a group of nominated experts in
disaster public health, and disaster mental and behavioral
health, to examine all elements of the process in depth. Once
the process is validated, developers will seek real-world, realtime applications, with the ultimate goal of providing timely,
actionable guidance for international disaster mental health
response.
CONCLUSIONS
The defining signature of the Great East Japan Disaster was
the triple impact of earthquake, tsunami, and radiation
hazards, compounded by extreme environmental conditions
in the immediate aftermath that created challenges for
survival and response. The psychological impact of these
3 events was extreme, and feelings of fear, panic, and threat
to life during the disaster were powerful stressors experienced
by up to one-third of the Japanese population. Economic
losses were unequaled in disaster history and translated into
personal stressors for those who lost homes and livelihoods.
Displacement will be long term for former inhabitants of
coastal communities that were obliterated by the tsunami and
the evacuation zone around the Fukushima Dai-ichi nuclear
power plant. Residents from areas near the plant will
12
Disaster Medicine and Public Health Preparedness
Center for Disaster and Extreme Event Preparedness (DEEP Center), University
of Miami Miller School of Medicine, Miami (Drs Shultz and Espinel and
Ms Rosen); Australian Centre for Posttraumatic Mental Health, Department of
Psychiatry, The University of Melbourne, East Melbourne, Australia (Dr Forbes);
US Geological Survey and Colorado School of Mines, Golden, Colorado
(Dr Wald); Clinical and Health Psychology, University of Edinburgh, Scotland
(Dr Kelly); Department of Civil, Architectural, and Environmental Engineering,
University of Miami, College of Engineering, Coral Gables, Florida (Dr SoloGabriele); Department of Neuroscience, University of North Dakota School of
Medicine and Health Sciences, Fargo, North Dakota (Dr McLean); Public Health
Programs, University of the Andes, Bogota, Colombia (Dr Bernal); Trauma
and PTSD Program, Columbia University, and Department of Psychiatry,
The New York State Psychiatric Institute, New York, New York (Dr Neria).
Address correspondence and reprint requests to James M. Shultz, MS, PhD,
Center for Disaster and Extreme Event Preparedness (DEEP Center), University
of Miami Miller School of Medicine, 251 174 St, #2319, Sunny Isles Beach FL
33160 (e-mail: [email protected]).
REFERENCES
1. Office for the Coordination of Humanitarian Assistance. Japan Earthquake and Tsunami, Situation Report 1; March 11, 2011. http://
reliefweb.int/node/391666. Accessed February 20, 2012.
2. Center for Excellence in Disaster Management and Humanitarian
Assistance. Japan earthquake and tsunami update, Monday, March 12,
2011. http://reliefweb.int/node/391694. Accessed February 20, 2012.
3. Keim M. The public health impact of industrial disasters. Am J Disaster
Med. 2011;6(5):265-274.
4. Boyarsky I, Shneiderman A. Natural and hybrid disasters—Causes,
effects and management. Top Emerg Med. 2002;24(3):1-25.
5. Shultz JM, Marcelin LH, Madanes SB, Espinel Z, Neria Y. The ‘‘trauma
signature:’’ understanding the psychological consequences of the 2010
Haiti earthquake. Prehosp Disaster Med. 2011;26(5):353-366.
6. Shultz JM, Kelly F, Forbes D, et al. Triple threat trauma: evidence-based
mental health response for the 2011 Japan disaster. Prehosp Disaster Med.
2011;26(3):141-145.
7. Shultz JM, McLean A, Herberman Mash HB, et al. Mitigating flood
exposure: reducing disaster risk and trauma signature. Disaster Health.
2012;1(1):1-15.
8. Norris FH, Friedman MJ, Watson PJ, Byrne CM, Diaz E, Kaniasty K:
60,000 disaster victims speak: part I. an empirical review of the empirical
literature, 1981-2001. Psychiatry. 2002;65(3):207-239.
9. Norris FH, Friedman MJ. Watson PJ: 60,000 disaster victims speak:
part II. summary and implications of the disaster mental health research.
Psychiatry. 2002;65(3):240-260.
VOL. 00/NO. 00
Trauma Signature Analysis
10. Norris FH. Range, Magnitude, and Duration of the Effects of
Disasters on Mental Health: Review Update 2005. Hanover, NH:
Dartmouth Medical School and National Center for Posttraumatic
Stress Disorder.
11. Andrulis DP, Siddiqui NJ, Gantner JL. Preparing racially and ethnically
diverse communities for public health emergencies. Health Aff (Millwood).
2007;26(5):1269-1279.
12. Shultz JM, Espinel Z, Galea S, Reissman DB. Disaster ecology:
implications for disaster psychiatry. In: Ursano RJ, Fullerton CS,
Weisaeth L, Raphael B (eds). Textbook of Disaster Psychiatry. Cambridge,
UK: Cambridge University Press; 2007:69-96.
13. Shultz JM, Espinel Z, Flynn BW, Cohen RE, Hoffmann Y. DEEP PREP:
All-Hazards Disaster Behavioral Health Training. Tampa, FL: Disaster Life
Support Publishing; 2007.
14. Kessler RC, McLaughlin KA, Koenen KC, Petukhova M, Hill ED. The
importance of secondary trauma exposure for post-disaster mental
disorder. Epidemiol Psychiatric Sci. 2012;21:35-45.
15. Centre for Research on the Epidemiology of Disasters. EM-DAT: The
International Disaster Database. http://www.emdat.be. Accessed August 24,
2012.
16. World Association of Disaster and Emergency Medicine (WADEM).
Health Disaster Management: Guidelines for Evaluation and Research. http://
www.wadem.org/guidelines.html. Accessed August 24, 2012.
17. Kim Y. Great East Japan Earthquake and early mental-health response.
Psychiatry Clin Neurosci. 2011;65:539-548.
18. Emergency Disaster Measures Headquarters, National Police Agency
of Japan. Damage situation and police countermeasures associated
with 2011 Tohoku district – off the Pacific Ocean Earthquake,
July 11, 2012. http://www.npa.go.jp/archive/keibi/biki/higaijokyo_e.pdf. Accessed
July 16, 2012.
19. Keim M. The public health impact of tsunami disasters. Am J Disaster
Med. 2011;6(6):341-350.
20. United States Geological Survey. Magnitude 9.0 - Near The East Coast
Of Honshu, Japan: Summary. http://earthquake.usgs.gov/earthquakes/
eqinthenews/2011/. Accessed February 20, 2012.
21. Wikipedia. 2011 Tōhoku earthquake and tsunami. http://en.wikipedia.org/
wiki/2011_T%C5%8Dhoku_earthquake_and_tsunami. Accessed February
20, 2012.
22. CATDAT. Japan Tohoku earthquake and tsunami: CATDAT 41 report
(October 2, 2011). http://earthquake-report.com/2011/10/02/japan-tohokuearthquake-and-tsunami-catdat-41-report-october-2-2011/. Accessed February
25, 2012.
23. World Bank. The recent earthquake and tsunami in Japan: implications
for East Asia. http://siteresources.worldbank.org/INTEAPHALFYEAR
LYUPDATE/Resources/550192-1300567391916/EAP_Update_March2011_
japan.pdf?cid5EXTEAPMonth1. Accessed February 20, 2012.
24. United States Geological Survey. Earthquake shaking map: M 9.0, Near
the East Coast of Honshu, Japan. http://earthquake.usgs.gov/earthquakes/
pager/events/us/c0001xgp/onepager.pdf. Accessed February 20, 2012.
25. United States Geological Survey. M 8.9, Near the East Coast of Honshu,
Japan: Aftershock Map—Mainshock and 726 Aftershocks. Last Updated:
23 March 2011, 17:39:53 UTC. http://earthquake.usgs.gov/earthquakes/
aftershocks/?event5c0001xgp&source5us&title5M8.9%20NEAR%20THE%
20EAST%20COAST%20OF%20HONSHU,%20JAPAN.
Accessed
February 20, 2012.
26. Japanese Geotechnical Society. Geo-hazards During Earthquakes and
Mitigation Measures: Lessons and Recommendations from the 2011 Great
East Japan Earthquake; July 2011. http://www.geosyntheticssociety.org/
Uploads/Japan_Earthquake.pdf. Accessed February 27, 2012.
27. Oh J-H. A Consideration for the better Preparedness against Mega-Disaster:
Lessons from the 2011 Great Eastern Japan Earthquake and Tsunami. Buson,
South Korea: Pukyong National University. http://www.kf.or.kr/file/
kor_1/Panel_1_Jai-Ho_Oh_%EB%B0%9C%ED%91%9C%EC%9A%94%
EC%95%BD%EB%AC%B8.pdf. Accessed February 27, 2012.
28. Norio O, Ye T, Kajitani Y, Shi P, Tatano H. The 2011 Eastern Japan
Great Earthquake Disaster: overview and comments. Int J Disaster Risk
Sci. 2011;2(1):34-42.
29. Kyoto University International Environment and Disaster Management
Graduate School of Global Environmental Studies. Mega Disaster in a
Resilient Society: The Great East Japan (Tohoku Kanto) Earthquake and
Tsunami of 11th March 2011. March 25, 2011.
30. Dauer LT, Zanzonico P, Tuttle RM, Quinn DM, Strauss HW. The
Japanese tsunami and resulting nuclear emergency at the Fukushima
Daiichi power facility: technical, radiologic, and response perspectives.
J Nucl Med. 2011;52:1423-1432.
31. Becker SM. Learning from the 2011 Great East Japan Disaster: insights
from a special radiological emergency assistance mission. Biosecur
Bioterror. 2011;9(4):394-404.
32. Wikipedia. Fukushima Daiichi nuclear disaster. http://en.wikipedia.org/
wiki/Fukushima_Daiichi_nuclear_disaster. Accessed February 27, 2012.
33. Kuwabara H, Shioiri T, Toyabe SI, et al. Factors impacting on
psychological distress and recovery after the 2004 Niigata–Chuetsu
earthquake, Japan: community-based study. Psychiatry Clin Neurosci.
2008;62:503-507.
34. Lau JTF, Yu X, Zhang J, et al. Psychological distress among adolescents in
Chengdu, Sichuan at 1 month after the 2008 Sichuan earthquake.
J Urban Health. 2010;87(3):504-523.
35. Basoglu M, Kilic C, Salcioglu E. Livanou M: Prevalence of posttraumatic
stress disorder and comorbid depression in earthquake survivors in
Turkey: an epidemiological study. J Trauma Stress. 2004;17(2):133-144.
36. Kato H. Posttraumatic symptoms among victims of the Great HanshinAwaji earthquake in Japan. Psychiatry Clin Neurosci. 1998;52(suppl):
S59-S65.
37. National Center for PTSD. Tsunami and Mental Health: What Can
We Expect? Washington, DC: US Department of Veterans Affairs.
http://www.ptsd.va.gov/public/pages/tsunami-mental-health.asp.
Accessed
February 27, 2012.
38. Carballo M, Heal B, Horbaty G. Impact of the tsunami on psychosocial
health and well-being. Int Rev Psychiatry. 2006;18(3):217-223.
39. Hollifield M, Hewage C, Gunawardena CN, et al.: Symptoms and coping
in Sri Lanka 20-21 months after the 2004 tsunami. Brit J Psychiatry.
2008;192:39-44.
40. Wahlström L, Michélsen H, Schulman A, Backheden M. Different types
of exposure to the 2004 tsunami are associated with different levels of
psychological distress and posttraumatic stress. J Trauma Stress.
2008;21(5):463-470.
41. Thienkrua W, Cardozo BL, Chakkraband ML, et al. Symptoms of
posttraumatic stress disorder and depression among children in tsunamiaffected areas in southern Thailand. JAMA. 2006;296(5):549-559.
42. Souza R, Bernatsky S, Reyes R, de Jong K. Mental health status of
vulnerable tsunami-affected communities: a survey in Aceh province,
Indonesia. J Trauma Stress. 2007;20(3):263-269.
43. van Griensven F, Chakkraband ML, Thienkrua W, et al. Mental health
problems among adults in tsunami-affected areas in southern Thailand.
JAMA. 2006;296(5):537-548.
44. Lommen MJ, Sanders AJ, Buck N, Arntz A. Psychosocial predictors of
chronic post-traumatic stress disorder in Sri Lankan tsunami survivors.
Behav Res Ther. 2009;47(1):60-65.
45. Bryant RA. Recovery after the tsunami: timeline for rehabilitation. J Clin
Psychiatry. 2006;67(suppl 2):50-55.
46. MacDonald R. How women were affected by the tsunami: a perspective
from Oxfam. PLoS Med. 2005;2(6):e178.
47. Carballo M, Heal B, Hernandez M. Psychosocial aspects of the tsunami.
J R Soc Med. 2005;98(9):396-399.
48. Bhugra D, van Ommeren M. Mental health, psychosocial support and
the tsunami. Int Rev Psychiatry. 2006;18(3):213-216.
49. Kristensen P, Weisaeth L, Heir T. Psychiatric disorders among disaster
bereaved: an interview study of individuals directly or not directly
exposed to the 2004 tsunami. Depress Anxiety. 2009;26(12):1127-1133.
50. Neuner F, Schauer E, Catani C, Ruf M, Elbert T. Post-tsunami stress: a
study of posttraumatic stress disorder in children living in three severely
affected regions in Sri Lanka. J Trauma Stress. 2006;19(3):339-347.
51. Armagan E, Engindeniz Z, Devay AO, Erdur B, Ozcakir A. Frequency of
post-traumatic stress disorder among relief force workers after the tsunami
Disaster Medicine and Public Health Preparedness
13
Trauma Signature Analysis
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
14
in Asia: do rescuers become victims? Prehosp Disaster Med. 2006;
21(3):168-172.
Dodgen D, Norwood AE, Becker SM, Perez JT, Hansen CK. Social,
psychological, and behavioral responses to a nuclear detonation in a US
city: implications for health care planning and delivery. Disaster Med
Public Health Prep. 2011;5(suppl 1):S54-S64.
Slovic P. Perception of risk from radiation. Radiat Prot Dosimetry.
1996;68(3/4):165-180.
Becker SM. Emergency communication and information issues in terrorist
events involving radioactive materials. Biosecur Bioterror. 2004;2(3):195-207.
Becker SM. Communicating risk to the public after radiological
incidents. BMJ. 2007;335(7630):1106-1107.
Christodouleas JP, Forrest RD, Ainsley CG, Tochner Z, Hahn SM,
Glatstein E. Short-term and long-term health risks of nuclear-powerplant accidents. N Engl J Med. 2011;364:2334-2341.
Auf der Heide E. Common misconceptions about disasters: panic, the
‘‘disaster syndrome,’’ and looting. In: O’Leary MR, ed. The First 72
Hours: A Community Approach to Disaster Preparedness. Bloomington, IN:
iUniverse; 2004:340-380.
Drury J, Cocking C, Reicher S. Everyone for themselves? a comparative
study of crowd solidarity among emergency survivors. Br J Soc Psychol.
2009;48(pt 3):487-506.
Becker SM. Protecting public health after major radiation emergencies:
nuclear crisis in Japan is a powerful reminder of past lessons. BMJ.
2011;342:717.
Chernobyl Forum: 2003-2005. Chernobyl ‘s Legacy: Health, Environmental and
Socioeconomic Impacts. Vienna: International Atomic Energy Agency; 2006.
Saenko V, Ivanov V, Tsyb A, et al. The Chernobyl accident and its
consequences. Clin Oncol (R Coll Radiol). 2011;23(4):234-243.
Bromet EJ, Havenaar JM, Guey LT. A 25-year retrospective review
of the psychological consequences of the Chernobyl accident. Clin Oncol
(R Coll Radiol). 2011;23(4):297-305.
Beehler GP, Baker JA, Falkner K, et al. A multilevel analysis of longterm psychological distress among Belarusians affected by the Chernobyl
disaster. Public Health. 2008;122(11):1239-1249.
Havenaar JM, de Wilde EJ, van den Bout J, Drottz-Sjoberg BM, van den
Brink W. Perception of risk and subjective health among victims of the
Chernobyl disaster. Soc Sci Med. 2003;56(3):569-572.
Havenaar JM, Rumyantzeva GM, van den Brink W, et al. Long-term
mental health effects on the Chernobyl disaster: an epidemiologic survey
in two former soviet regions. Am J Psychiatry. 1997;154:1605-1607.
Butler AS, Panzer AM, Goldfrank LR. Institute of Medicine Committee
on Responding to the Psychological Consequences of Terrorism Board
on Neuroscience and Behavioral Health. Preparing for the Psychological
Consequences of Terrorism: A Public Health Approach. Washington, DC:
National Academies Press; 2003.
Raphael B, Taylor M, McAndrew V. Women, catastrophe and mental
health. Aust NZ J Psychiatry. 2008;42:13-23.
Kim Y, Abe Y, Araki H, et al. Guidelines for Local Mental Health Care
Activities after a Disaster. Tokyo, Japan: National Institute of Mental
Disaster Medicine and Public Health Preparedness
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
Health, National Center of Psychiatry and Neurology; 2004. http://
www.ncnp.go.jp/nimh/seijin/EnglishDisasterMentalHealth.pdf. Accessed February
25, 2012.
Takeda M. Mental health care and East Japan Great Earthquake.
Psychiatry Clin. Neurosci. 2011;65:207-212.
Suzuki Y, Kim Y. The Great East Japan earthquake in 2011: toward a
sustainable mental health care system. Epidemiol Psychiatric Sci.
2012;21:7-11.
Shultz JM, Marcelin LH, Espinel Z, Madanes SB, Allen A, Neria YA.
Haiti earthquake 2010: psychosocial impacts. In: Bobrowsky P (ed).
Encyclopedia of Natural Hazards. New York, NY: Springer Publishing,
2013 (in press).
Shultz JM, Neria Y, Espinel Z, Marcelin LH, Madanes S. Trauma
signature analysis: rapid post-impact/pre-deployment guidance for mental
health response. Presented at: International Society for Traumatic Stress
Studies (ISTSS) 26th Annual Meeting; November 5, 2010; Montreal,
Quebec, Canada.
Shultz JM, Espinel Z, Kelly F, Neria Y. Examining the trauma signature
of the Japan tsunami/nuclear crisis. Presented at: Social Bonds and
Trauma Through the Life Span: International Society for Traumatic
Stress Studies (ISTSS) 27th Annual Meeting; November 4, 2011;
Baltimore, MD.
Shultz JM, McLean AJ, Rosen A, Youngs GA, Jensen J, Neria Y. A tale
of two cities: flooding and effects on community resilience [poster].
Presented at: 2nd International Preparedness and Response to Emergencies and Disasters (IPRED II) Conference; January 16-17, 2012; Tel
Aviv, Israel.
Shultz JM, Bueno Ramirez AM, Espinel Z, et al. Displaced within
borders: Colombia’s humanitarian crisis. Presented at: 2nd International
Preparedness and Response to Emergencies and Disasters (IPRED II)
Conference; January 16-17, 2012; Tel Aviv, Israel.
Shultz JM, Herberman Mash HB, Rosen A, Espinel Z, Kelly F, Neria Y.
The trauma signature of the 2011 U.S. super tornado outbreak. Presented
at: 2nd International Preparedness and Response to Emergencies and
Disasters (IPRED II) Conference; January 16-17, 2012; Tel Aviv, Israel.
Migline V, Shultz JM. Psychosocial impact of the Russian invasion of
Georgia in 2008. Presented at: 17th World Congress on Disaster and
Emergency Medicine; June 1, 2011; Beijing, China.
Shultz JM, Neria Y, Espinel Z, Kelly F. Trauma signature analysis:
evidence-based guidance for disaster mental health response. Presented
at: 17th World Congress on Disaster and Emergency Medicine; May 31,
2011; Beijing, China.
Shultz JM, Kelly F, Espinel Z, Neria Y. Rapid evidence-based guidance
for post-impact disaster mental health response: Trauma signature
(TSIG) analysis. Presented at: Social Bonds and Trauma Through the
Life Span: International Society for Traumatic Stress Studies (ISTSS)
27th Annual Meeting; November 2, 2011; Baltimore, MD.
Shultz JM. Trauma signature analysis. Presented at: Innovation and
Results: Surviving the Times. The Joint Commission 2012 Accreditation
Standards Update; November 16, 2011; Lombard, IL.
VOL. 00/NO. 00