Immediate disaster mental health plans vary in detail according to local needs and resources but should at least address:
- providing on-site interventions
- disseminating information about responses to trauma
- identifying and publicizing local mental health resources.
Immediate interventions
Immediately following a disaster, psychiatrists are frequently asked to assist with on-site crisis and medical interventions, evaluate survivors with unusual or intense reactions, and provide public education about psychological reactions to disaster.
On-site response. All responders, regardless of discipline, should provide disaster survivors with “psychological first aid,” which is directed at reestablishing safety, connection, and efficacy. Basic crisis intervention principles are useful when support and reassurance are not enough.6
For example, relaxation exercises can reduce anxiety and improve sleep. Use focused, structured relaxation tools—such as progressive muscle relaxation and breathing training—as unstructured exercises can exacerbate dissociation and re-experiencing. Grounding techniques, by which survivors learn to focus all senses on immediate surroundings, often alleviate dissociation and flashbacks.
Care for children. Because children’s reactions to disaster greatly depend on their caregivers’ responses (social referencing), focus acute interventions for children on:
- re-connecting them with their families
- reducing caregivers’ distress
- educating caregivers about providing age appropriate information and support (see Related resources).
Medical care. As physicians, psychiatrists may be called upon to intervene medically. Although it is generally advisable to stay within our usual practice, medical personnel may be in short supply. Fortunately, Good Samaritan laws exist in every state, and the potential for a successful malpractice suit against a physician responding in a disaster is almost zero, unless the physician’s performance is grossly negligent (such as moving the neck of a patient with obvious head or neck injuries).7
Principles regarding informed consent and right to refuse treatment—along with the usual exceptions—apply during disasters.
Evaluating survivors in shelters and hospitals requires knowing the normal and abnormal responses to disaster, being able to differentially diagnose changes in mental status, and understanding risk factors for trauma’s psychiatric sequelae. Aside from PTSD, trauma’s long-term effects include other anxiety disorders, depression, substance abuse, and eating disorders. In addition to the usual components of a psychiatric evaluation, assessments must address event-related factors such as proximity to the disaster, loss of significant others or property, physical injuries, immediate needs, and social support.8
Normal stress reactions. Frequently described as “a normal response to an abnormal situation,” the normal stress reaction is multidimensional and depends on the person’s developmental level (Table 2). About 10% to 25% of survivors experience intense affect and dissociation, whereas a similar number may appear unusually calm.
Interventions beyond the“first aid” described above are not usually needed unless individuals:
- are a danger to themselves or others
- are psychotic
- have no social supports
- cannot perform tasks necessary for self-care and to begin the recovery process.
Always re-assess when there is any question about a survivor’s immediate reaction to trauma.
In DSM-IV-TR’s trauma-related diagnoses, the symptom clusters often do not capture many disaster survivors’ subjective experience: the shattering of fundamental beliefs regarding themselves (invulnerability), the world (predictability, safety), and others (trust, benevolence).9 By empathizing with these responses, you can help survivors feel less isolated and estranged.
Differential diagnosis. Survivors’ mental status changes may be manifestations of the stress response, but they also may represent:
- exacerbations of pre-existing psychiatric or general medical conditions
- hypoxemia, hypovolemia, or CNS trauma from physical injury
- responses to medications used for resuscitation or pain control, such as atropine, epinephrine, lidocaine, or morphine.
Effects of bioterrorism agents must also be considered. For example, organophosphorus compounds such as the nerve agents sarin and soman can cause impaired concentration, depression, and anxiety. Anthrax can cause rapidly progressing meningitis.10 Delirium must be differentiated from dissociation; patients with dissociation can be re-oriented, and changes will resolve with time rather than fluctuate.11
Psychopathology risk factors. Multiple studies have addressed risk factors for post-disaster psychiatric sequelae (usually PTSD). In general, risk increases with repeated trauma exposure (including TV viewing), prior trauma, lack of social support, injury, pre-existing psychiatric problems, traumatic bereavement (having witnessed the violent death of a loved one), avoidant coping, and having strong negative beliefs about the meanings of normal stress reactions such as tearfulness, anxiety, and insomnia.
Because a recent meta-analysis supports these observations,12 follow-up evaluation for signs of PTSD is recommended for:
- survivors with one or more of the risk factors discussed above
- vulnerable groups such as rescue workers, children, and dependent individuals
- survivors whose symptoms persist after 2 months.13
Decompensation immediately after a disaster seems to be the exception for psychiatric patients, despite their longer-term vulnerability. One psychiatrist who in 1989 survived Hurricane Hugo—the most intense storm to strike the Mid-Atlantic region in 100 years—noted that demand for inpatient psychiatric services did not increase in the storm’s aftermath. The only patient calls she received were inquiries about her own physical safety.14