Medically Unexplained Physical Symptoms in the Aftermath of Disasters

Abstract

Many studies have examined the health problems amongsurvivors of disasters, showing that the most frequentlyreported symptoms after disasters are mental health prob-lems, such as posttraumatic stress symptoms, depression,and anxiety (1, 2).In the last decade, the Netherlands was struck by a fewnational disasters. On October 4, 1992, an El Al Boeing747 airplane crashed into two apartment buildings in anAmsterdam suburb. Six years after the airplane crash,a study of the health effects of the crash was conducted.This study showed that, in addition to mental healthproblems, physical symptoms were very prevalent amongthe survivors of the plane crash (3, 4). On May 13, 2000,a fireworks depot exploded in a residential area of the cityof Enschede. The explosions and subsequent fire killed 22people and injured over 900 people, and about 500 homeswere severely damaged or destroyed. The Dutch govern-ment declared this a national disaster, and the Ministry ofHealth, Welfare, and Sports decided to launch a study intothe health effects of this disaster. This study showed thata substantial proportion of those who were affected by thefireworks disaster suffered from physical symptoms, suchas headache, fatigue, and pain in the stomach, chest,joints, and muscles (5, 6). These symptoms are oftenlabeled as medically unexplained physical symptoms(MUPS), but other labels, such as psychosomatic symp-toms or functional somatic syndromes, have been given aswell (7).Survivors of disasters may attribute these physical symp-toms to (suspected) exposure to toxic substances, and thismay lead to social unrest and amplification of the healthproblems (8, 9). For example, after the Bijlmermeer airplanecrash in Amsterdam, many survivors reported healthsymptoms that they attributed to possible toxic exposures,such as depleted uranium (3). General practitioners,however, associated only a small proportion (about 20percent) of the most frequently reported symptoms witha diagnosis, and thus the majority of symptoms wereunexplained (4).In the nontraumatized general population, MUPS are alsovery common, with reported prevalence rates ranging from5 to 35 percent (10, 11). The majority of these symptomscannot be explained by a medical diagnosis; generalpopulation studies have shown that the etiology of 30–75percent of such symptoms as headache, fatigue, andstomachache is unknown (10, 12, 13).After disasters, the prevalence rates of MUPS seem toincrease. However, since many but not all survivors developthese symptoms, the question arises as to which factorspredict who will or will not develop MUPS. Mayou andFarmer (14) divided risk factors into three categories:predisposing, precipitating, and perpetuating factors (whichwe call the ‘‘3-P model’’). Predisposing factors are factorsthat already exist before the disaster took place, such ascertain demographic characteristics and personality factors.Precipitating factors are directly related to the disaster, forexample, injury, relocation, fear, and loss of property. Thesefactors might increase the proportion of survivors thatdevelops MUPS. After the disaster, perpetuating factors,for example, the coping style of the survivor and lack ofsocial support, are factors that might maintain or exacerbatethe symptoms (figure 1).Since MUPS are associated with impaired emotional andphysical functioning (15, 16), it is useful to identify riskfactors that clinicians can use for early screening of MUPS