Evidence-Based Reviews

Psychological first aid: Emergency care for terrorism and disaster survivors

Current Psychiatry. 2004 May;3(5):12-23

References

1. Effects of traumatic stress in a disaster situation. Washington, DC: National Center for Post-Traumatic Stress Disorder. Department of Veterans Affairs, September 12, 2001 (Accessed March 31, 2004 at http://www.ncptsd.org/facts/disasters/fs_effects_disaster.html).

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5. LeDoux JE, Gorman JM. A call to action: overcoming anxiety through active coping. Am J Psychiatry 2001;158:1953-5.

6. Hillman JL. Crisis intervention and trauma: new approaches to evidence-based practice. New York: Kluwer Academic/Plenum Publishers, 2002.

7. Daniels G. Good Samaritan acts. Emerg Med Clin North Am 1999;17:491-504.

8. Mental-health intervention for disasters. Washington, DC: National Center for Post-Traumatic Stress Disorder, Department of Veterans Affairs, Sept. 12, 2001. (Accessed March 31, 2004 at http://www.ncptsd.org/facts/disasters/fs_treatment_disaster.html.)

9. Difede J, Apfeldorf WJ, Cloitre M, et al. Acute psychiatric responses to the explosion at the World Trade Center: a case series. J Nerv Ment Dis 1997;185:519-22.

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20. Black J. Forming the libidinal cocoon: the Dallas airplane crashes, the Guadalupe river drownings, and Hurricane Hugo in the Virgin Islands. In: Austin LS (ed). Responding to disaster: a guide for mental health professionals. Washington DC: American Psychiatric Publishing, 1992;169:84.-

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Keys to effective disaster psychiatry

Be prepared Contact your local American Psychiatric Association district branch or American Red Cross chapter to learn about existing mental health disaster plans Remember the three basics of psychic resiliency: safety, support, and efficacy Know your place, ask for help, and use existing resources
Care for survivors Your presence alone may be healing Assess thoroughly; symptoms may be related to medical issues or pre-existing conditions, not just stress response Do no harm; avoid psychological debriefing interventions and unnecessary medications Follow up with survivors who exhibit risk factors or symptoms persisting >2 months Consider trauma-focused CBT for survivors with acute stress disorder
Care for yourself As a survivor, tend to your own safety and self-care needs Consult frequently with colleagues within and outside the disaster area for support, information, and guidance

Long-term interventions

Longer-term disaster interventions include continued outreach and education and needed follow-up services. Existing structures may provide effective follow-up, but additional resources are often needed.

Federal programs. Following a presidentialdeclared disaster, the Federal Emergency Management Agency (FEMA) provides funding for crisis counseling. Programs are typically funded for 9 to 15 months and administered through the emergency services and disaster relief branch of the Substance Abuse and Mental Health Services Administration (SAMHSA) and community mental health organizations. Examples include Project Heartland following the 1995 Oklahoma City federal building bombing and Project COPE following California’s 1989 Loma Prieta earthquake.

Cognitive-behavioral therapy. For adult survivors with acute stress disorder, specific cognitive-behavioral therapy (CBT) provided by trained therapists may prevent PTSD and other trauma sequelae, such as depression.²¹ CBT interventions may begin as early as 2 weeks after trauma and focus sequentially on anxiety management, cognitive restructuring, imaginal exposure followed by in vivo exposure, and relapse prevention.

Three controlled trials found 6-month PTSD rates of 14% to 20% among acute stress disorder patients treated with CBT, compared with 58% to 67% with supportive counseling.^22-24 Although studies of interventions immediately following trauma are lacking, trauma-focused CBT is also recommended for children.²⁵ Evidence-based treatments for PTSD are discussed in detail elsewhere.²⁶

Not unprepared after all

With some reflection, Dr. Z realized she had the tools to help her community. Her feelings of helplessness receded as she envisioned how she could help survivors understand their experiences, re-create a sense of safety, restore important connections to loved ones, and begin to rebuild their lives (Table 5).

Related resources

For clinicians

Young BH, Ford JD, Ruzek JI, et al. Disaster mental health: a guidebook for clinicians and administrators. Washington, DC: National Center for Post-Traumatic Stress Disorder, 1998. http://ncptsd.org/publications/disaster/index.html
Hillman JL. Crisis intervention and trauma: new approaches to evidence-based practice. New York: Kluwer Academic/Plenum Publishers, 2002.
Office of the Surgeon General Web site on medical aspects of nuclear, biological, and chemical warfare. http://www.nbc-med.org

For survivors and clinicians

National Center for Post-Traumatic Stress Disorder. Disaster mental health: Dealing with the aftereffects of terrorism. http://www.ncptsd.org/terrorism/index.html
Substance Abuse and Mental Health Services Administration. Emergency mental health and traumatic stress. http://www.mentalhealth.org/cmhs/EmergencyServices/default.asp
American Academy of Child and Adolescent Psychiatry. Talking to children about terrorism and war. http://www.aacap.org/publications/factsFam/87.htm

Drug brand names

Clonidine • Catapres
Guanfacine • Tenex

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.