Evidence-Based Reviews

Psychological first aid: Emergency care for terrorism and disaster survivors

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

Knowing the basics of psychic resilience can help you prevent long-term psychopathology and determine who needs medication and monitoring.

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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).

2. Yehuda R, McFarlane AC, Shalev AY. Predicting the development of post-traumatic stress disorder from the acute response to a traumatic event. Biol Psychiatry 1998;44:1305-13.

3. Levine S, Lyons DM, Schatzberg AF. Psychobiological consequences of social relationships. Ann NY Acad Sci 1997;807:210-18.

4. Uchino BN, Garvey TS. The availability of social support reduces cardiovascular reactivity to acute psychological stress. J Behav Med 1997;20:15-27.

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.

10. DiGiovanni C. Domestic terrorism with chemical or biological agents: psychiatric aspects. Am J Psychiatry 1999;156:1500-5.

11. Rundle JR. Psychiatric issues in medical-surgical disaster casualties: consultation-liaison approach. Psychiatr Q 2000;71:245-58.

12. Brewin CR, Andrews B, Valentine JD. Meta-analysis of risk factors for post-traumatic stress disorder in trauma-exposed adults. J Consult Clin Psychol 2000;68:748-66.

13. Mental health and mass violence: evidence-based early psychological intervention for victims/survivors of mass violence. Washington, DC: National Institute of Mental Health, Nov. 1, 2002 (Accessed Oct. 29, 2003 at http://www.nimh.nih.gov/research/massviolence.pdf.)

14. Austin LS. Organizing a disaster response program in one’s home community. In: Austin LS (ed). Responding to disaster: a guide for mental health professionals. Washington, DC: American Psychiatric Publishing, 1992;53-68.

15. Rousseau AW. Notes from Oklahoma City’s recovery. In: Hall RCW, Norwood AE (eds). Disaster psychiatry handbook. Washington, DC: American Psychiatric Association Committee on Psychiatric Dimensions of Disaster, undated:3-11. (Accessed Oct. 29, 2003 at http://www.psych.org/disasterpsych/pdfs/apadisasterhandbk.pdf.)

16. Yildiz A, Sachs GS, Turgay A. Pharmacological management of agitation in emergency settings. Emerg Med J 2003;20:339-46.

17. Gelpin E, Bonne O, Peri T, et al. Treatment of recent trauma survivors with benzodiazepines: a prospective study. J Clin Psychiatry 1996;57:390-4.

18. Mitchell JT. When disaster strikes. J Em Med Serv 1983;8:36-9.

19. Rose S, Bisson J, Wessely S. Psychological debriefing for preventing posttraumatic stress disorder (PTSD). Cochrane Database Syst Rev 2002;(2):CD000560.-

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.-

21. Ehlers A, Clark DM. Early psychological interventions for adult survivors of trauma: a review. Biol Psychiatry 2003;53:817-26.

22. Bryant RA, Moulds M, Guthrie R, Nixon RD. Treating acute stress disorder following mild traumatic brain injury. Am J Psychiatry 2003;160:585-7.

23. Bryant RA, Sackville T, Dang ST, et al. Treating acute stress disorder: an evaluation of cognitive behavior therapy and supportive counseling techniques. Am J Psychiatry 1999;156:1780-6.

24. Bryant RA, Harvey AG, Dang ST, et al. Treatment of acute stress disorder: a comparison of cognitive-behavioral therapy and supportive counseling. J Consult Clin Psychol 1998;66:862-6.

25. Cohen JA. Treating acute posttraumatic reactions in children and adolescents. Biol Psychiatry 2003;53:827-33.

26. Foa EB, Keane TM, Friedman MJ. Effective treatments for PTSD. New York: Guilford Press, 2000.

The night started like any other for Dr. Z. Kids in bed (too late) by 10:30, dog out by 11, fell asleep reading journal by 11:15. Sirens jolt her out of a solid stage 4. Her eyes widen, pulse quickens, mouth dries as she follows the glow of the TV into the living room. On TV, fire frames shots of tearful faces, body bags, and firefighters in protective suits. She catches the announcer’s voice: “…explosion at City Power and Light nuclear facility at 3:10 AM today. Fifty-five are known dead, and thousands are being told to evacuate. The blast’s cause is unknown, but terrorism is suspected.”

As her numbness slowly ebbs, Dr. Z’s questions rise insistently. How can I help the survivors? My patients? My children? What if the media call me? How could I have been better prepared for this?

Disaster shakes us to our human and biological core. More than any other clinical encounter, it reminds us that psychiatrists share the vulnerabilities of those we seek to help. Yet it also reminds us that even simple concepts and interventions can mobilize the healing process.

Are you ready to provide emergency psychiatric care following a disaster in your community—be it a nuclear accident, tornado, airplane crash, or terrorist act? Here is evidence—some counterintuitive—that can help you prepare.

Table 1

‘Psychological first aid’ for disaster survivors

Re-create sense of safety Provide for basic needs (food, clothing, medical care) Ensure that survivors are safe and protected from reminders of the event Protect them from onlookers and the media Help them establish a “personal space” and preserve privacy and modesty
Encourage social support Help survivors connect with family and friends (most urgently, children with parents) Educate family and friends about survivors’ normal reactions and how they can help
Re-establish sense of efficacy Give survivors accurate, simple information about plans and events Allow survivors to discuss events and feelings, but do not probe Encourage them to re-establish normal routines and roles when possible Help resolve practical problems, such as getting transportation or relief vouchers Discuss self-care and strategies to reduce anxiety, such as grounding and relaxation techniques Encourage survivors to support and assist others

Disaster’s psychobiology

Human reactions to disaster are often conceptualized as the mammalian survival response: flight, fight, and fright (freezing). In most cases, these reactions are adaptive and dissipate after safety is restored. Posttraumatic stress disorder (PTSD) develops in about 5% of natural disaster victims and 33% of mass shooting victims.¹

Responses that do go awry appear to be associated with abnormally low cortisol and persistent adrenergic activation, leading to sensitization of the fear response.² Reminders of trauma or persistent stressors—such as pain, problems with finances or housing, or bereavement—may exacerbate sensitization. On the other hand, preclinical studies suggest that social support^3,4 and active coping⁵ mitigate physiologic stress responses, confirming numerous clinical observations that associate lack of social support and avoidant coping with eventual PTSD development.

Three basics. Just as our emergency medicine colleagues must often revert to life-support basics, we must remind ourselves of biology’s three basics for psychic resilience:

safety (including—as much as possible—protection from reminders of trauma and ongoing stress)
meaningful social connection
re-establishing a sense of efficacy to overcome helplessness (Table 1).

Like the stress response, these protective factors seem hard-wired into our biological make-up. They form the foundation for all phases of disaster psychiatry interventions, from planning to immediate interventions through longterm follow-up.

Disaster planning

As a mental health professional, plan to operate within established disaster plans and agencies, not only for the sake of efficiency but also because structure and support are paramount in disaster situations. Check with the American Psychiatric Association’s local branch to determine if a disaster mental health plan exists. If not, explore how to work directly with local American Red Cross chapters and hospitals, which recruit personnel for the Disaster Medical Assistance Teams mobilized by the public health service.

Table 2

Normal reactions to disaster for adults and children

All ages
Emotional	Shock, fear, grief, anger, guilt, shame, helplessness, hopelessness, numbness, emptiness Decreased ability to feel interest, pleasure, love
Cognitive	Confusion, disorientation, indecisiveness, worry, shortened attention span, poor concentration, memory difficulties, unwanted memories, self-blame
Physical	Tension, fatigue, edginess, insomnia, generalized aches and pains, startling easily, rapid heartbeat, nausea, decreased appetite and sex drive
Interpersonal	Difficulties being intimate, being over-controlling, feeling rejected or abandoned
Children’s age-specific disaster responses
Preschool	Separation fears, regression, fussiness, temper tantrums, somatization Sleep disturbances including nightmares, somnambulism, night terrors
School-age	May still have the above, as well as excessive guilt and worries about others’ safety, poor concentration and loss of school performance, repetitious re-telling or play related to trauma
Adolescent	Depression, acting out, wish for revenge, sleeping and eating disturbances, altered view of the future