Disaster Psychiatry

Disaster Psychiatry

Although the symptoms of anxiety and depression have long been described as part of the human response to disaster, the most well-known early attempt of a psychiatrist to track such responses was by Erich Lindemann in his study of the 1942 Cocoanut Grove fire. He attempted to define in psychiatric language responses of normal grief, abnormal grief, responses to stress and loss, and the effects of witnessing a disaster.

The language of traumatic response to war (e.g., nostalgia, shell shock, battle fatigue, war neurosis) began to appear in descriptions of combat trauma and disaster in the 1970s. Posttraumatic stress disorder (PTSD) first appeared as a diagnostic category under anxiety disorders in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) and as its own unique stress syndrome in DSM-IV, as a direct result of the Vietnam War. DSM-5 has just refined and expanded the diagnostic criteria.

The first organized attempts to treat the mental health of people exposed to a disaster involved use of the debriefing model; developed from combat psychiatry, these efforts sought to return soldiers to full functioning for duty. Disaster psychiatry arose as a subspecialty in the late 1990s in the face of increased media coverage of large-scale disasters. The National Institute of Mental Health (NIMH) formed a “Violence and Traumatic Stress” branch in 1991. In 1993, the American Psychiatric Association (APA) recommended that branch chapters form disaster committees. Disaster psychiatry is currently a pertinent focus for psychiatry in the US in the wake of episodes of terrorism and disaster that have hit close to home, e.g., the 1995 Oklahoma bombing; the September 11, 2001, attack on the World Trade Center; Hurricane Katrina's devastation of the Louisiana and Mississippi coast; and more recently shootings in Aurora and Sandy Hook, and Hurricane Sandy, as well as the bombing at the Boston Marathon in April 2013.

A 2001 NIMH-sponsored consensus workshop on best practices established the need for a better understanding of how to facilitate research on disasters in a manner that is ethical, relevant, and capable of providing evidence-based practices (including the initial formalization of Psychological First Aid). This is difficult to do via standard research paradigms, given that disasters often come without warning and the populations to be studied are inherently vulnerable.

Preparation for a Disaster

Successful disaster response should be flexible, creative, and have the capacity to adjust and react to an unstable and changing milieu. Disaster responses are more likely to be effective if they are organized and understand the goals of disaster psychiatry and how those goals shift according to the phase of the disaster. Tables 91-1 and 91-2 (created by the NIMH consensus) outline the organization of disaster responses, with attention to the broad scope of interventions.

Preparing for a disaster before its occurrence requires a plan that facilitates reaching the most basic and urgent goals and then expanding services as they become necessary and available. The priority should be planning for a system of communication and delegation within a team. Predicted disasters can have more comprehensive plans. These plans should be accessible.

It is important to know the functions of inter-related organizations and how to communicate with them so that efforts and resources can be distributed most effectively in the chaos of a disaster. The most effective preparation for a disaster involves familiarizing a team with the other players that will spring into action in the face of disaster. Anniversaries of disasters may be used as a reminder to rehearse or review disaster plans that are in place, at a time when participants can best understand their relevance.

Systems

Disaster behavioral health is an integral part of the overall public health and medical preparedness, response, and recovery system. Disaster recovery is coordinated through the National Disaster Recovery Framework (NDRF), and the majority of states provide and coordinate disaster behavioral health services through a State Disaster Behavioral Health Coordinator. Psychiatrists or mental health organizations interested in disaster psychiatry must prepare for disasters by familiarizing themselves with existing systems of disaster response, by building relationships with other agencies around disaster preparedness, and by forming action plans that include defined relationships within a system of disaster response (in advance of a disaster).

Perhaps the most complicated and prominent elements of disaster psychiatry involve interfacing with existing disaster response systems. The initial phases of a disaster mental health response are based on an outreach model. Mental health practitioners go out into the affected community, where they will work side-by-side with pre-existing systems within the community.

There will be formal disaster response systems already in various stages of mobilization and implementation. The mental health response occurs within a network of disaster responses that include safety, medical treatment, shelter, nutrition, transportation, distribution of clothing (and other necessities), location of individuals and families, and provision of accurate information about ongoing disaster and safety plans.

Psychiatrists can also aid in a system of disaster responses as medically-trained professionals, assisting with triage to ensure that emergency medical treatment is provided first and that identification of those individuals who have been physically injured occurs. Psychiatrists are often called on by the public to provide information about the typical and atypical psychological responses to disasters.

In addition, psychiatrists can identify first responders who appear to be suffering, because of the emotional events around them. Mental health providers can create treatment teams that include periodic checking-in to evaluate how the team/system is functioning.

In the immediate aftermath it is likely that many local systems of mental health care will be disrupted. Experience suggests that funneling resources and routines toward use of local agencies will be most productive in shifting the disaster system of care toward a long-term system of care. Disaster responders provide an emergency system while local systems find ways to resume their operation.

Staged Disaster Intervention

The phases of disaster response shift as the imminence of the disaster and the needs of the community shift. A response that is not capable of adaptation is only temporarily useful, given that the problems evolve over time.

In defining acute and traumatic stress, as well as grief reactions, the mental health field has recognized the variety of psychological responses that occur over time. A variety of short-term goals for disaster psychiatrists have been described. Common themes include the following:

• Orienting mental health workers to the environment and to the function of the mental health team. Practical application includes finding the existing hierarchy, making introductions, asking for their observations about needs, and defining your team's availability and capacity.

• Observing elements of the environment . This facilitates learning which factors interfere with stress reduction and with group and individual mental health, and effectively communicating these observations.

• Engaging survivors in the context in which they can be found and encouraging the supportiveness of a given context. Disaster psychiatry takes place in shelters, on the streets, in schools and hotels, in waiting rooms of housing, in health care systems, and in disaster relief centers. The outreach model appears to be the best way to engage a vulnerable population that may be resistant to mental health treatment. Providing general information and a willingness to assist in a range of activities (e.g., providing food service or clothing distribution) is often an effective way to start a conversation that touches on how a person is coping and what mental health needs he or she might have.

• Screening survivors for risk factors and for traumatic stress reactions that suggest they need further services. Aside from attending to blatant stress reactions, attention to risk factors can guide clinicians to individuals who may be in need of further assessment and services. Table 91-3 lists known risk factors for longer-term sequelae in response to a disaster.

  TABLE 91-3

  Risk Factors Associated with Adverse Mental Health Outcomes after a Disaster

  From Young B. Emergency outreach: navigational and brief screening guidelines for working in large group settings following catastrophic events, NC-PTSD Clin Q 11(1):1–7, 2004.

  Pre-disaster Factors	Within-disaster Factors	Post-disaster Factors
  Female gender	Bereavement	Resource deterioration
  Age: 40–60 years old	Injury	Social support deterioration
  Minority groups	Severity of exposure	Social support increase
  Poverty or low socioeconomic status (SES)	Panic	Marital distress
  Presence of exposed children in the home	Horror	Loss of home/property finances
  Psychiatric history	Life threat	Alienation and mistrust
  	Relocation or displacement	Peri-traumatic reactions
  		Avoidance coping

• Providing information to survivors, disaster workers, and the general public about normal and expected responses, concerning signs and symptoms, health and resilience-enhancing activities, and where to go for further help if symptoms emerge. This is best achieved by becoming familiar with the system to ensure that information is consistent and easily accessible. This goal also highlights the fact that mental health services are not limited to the survivors of the disaster.

Table 91-1 conveys the wide array of activities that are performed by a disaster psychiatrist. It is important to notice that only a small portion of the activities are listed as “treatment” in the classical sense. A large portion of the activities are devoted to restoring the ongoing function of the community of rescuers and victims. This is important because the broader the scale of the disaster, the more limited the access is to classical treatment settings. Experience during Hurricane Katrina revealed that emergency rooms and psychiatric hospitals filled up quickly and remained accessible only to the most severely disturbed.

Some tasks, such as monitoring rumors and media coverage and their impact, re-establishing community structure, fostering social interactions, and outreach, are high impact. The problem-solving abilities (meeting the challenges of individuals, groups, or families with attention, flexibility, and creativity) of mental health professionals provide preparation for provision of care in a disaster situation.