OVERVIEW

Disasters, especially unpredicted ones, provide fertile ground for psychiatric problems. The etymology of disaster is rooted in the Latin, dis astros (“against the stars”), words that describe both the unpredictability and the devastation of such events. The World Health Organization (WHO) defines disaster as “a severe disruption, ecological and psychosocial, which greatly exceeds the coping capacity of the affected community.” Much as trauma can overwhelm the coping capacities of an individual, disasters overwhelm neighborhoods, systems, laws, organizations, and the smooth operation of society.¹ Mental health assessment and treatment in the face of a disaster must always consider the public health perspective and the impact that disruption of a community has on resiliency.

Disasters and their effects on the environment, populations, and individuals are often classified according to whether they are natural (e.g., hurricanes, earthquakes, floods, or fires) or manmade; manmade disasters are often further classified as intentional (e.g., acts of terrorism) or accidental (e.g., an industrial accident). These classifications help shape the psychological impact of the disaster and the appropriate mental health response. Disaster psychiatry is a field that has emerged and continues to consolidate around the experience gained during specific disasters (i.e., with a growing body of anecdotal evidence and a lagging body of research). The field focuses on the tasks of the mental health specialists both in preparation for, and the subsequent phases of, disasters.

HISTORY OF 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, and war neurosis) began to appear in descriptions of combat trauma and disaster in the 1970s. Kai Erikson described the “disaster syndrome” in his sociological study of the Buffalo Creek flood, and “aftermath neurosis” was coined in 1979 to describe the symptoms of hostage victims. Posttraumatic stress disorder (PTSD) first appeared as a diagnostic category under anxiety disorders in DSM-III and as its own unique stress syndrome in DSM-IV, as a direct result of the Vietnam War. 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. Hence, much of our information about disaster psychiatry comes from military psychiatry.

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 Outreach was founded in 1998 as an organization focused on the delivery and development of disaster psychiatry, and it held the first International Congress on Disaster Psychiatry in 2000. The Psychiatry Committee on Disasters is now a very active committee of the APA.

Disaster psychiatry is currently a pertinent focus for psychiatry in the United States in the wake of episodes of terrorism and disaster that have hit close to home (e.g., the 1995 Oklahoma bombing; the September 11th, 2001, attack on the World Trade Center; and most recently, Hurricane Katrina’s devastation of the Louisiana and Mississippi coast).

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. It was readily apparent that this is nearly impossible via standard research paradigms, given that disasters come without warning and the populations to be studied are inherently vulnerable.

Current literature on disasters is often retrospective, reflective, or specific to the military.

PREPARATION FOR A DISASTER

There is an inherent problem in preparing for disasters that are by definition unpredictable (both in their timing and their form). Experience with disasters teaches that despite our level of preparedness, an approach that is flexible, creative, and has the capacity to adjust and to react to an unstable and changing milieu is crucial to a successful disaster response. Disaster responses are more likely to be efficacious if they are organized and understand the goals of disaster psychiatry and how those goals shift according to the phase of the disaster. Tables 90-1² and 90-2³ (created by the NIMH consensus) outline the organization of disaster responses, with attention to the broad scope of interventions.

Table 90-1 Key Components of Early Intervention after a Disaster

Table 90-2 Guidance for Timing of Early Interventions after a Disaster

Preparing for a disaster before its occurrence requires the formation of a plan that facilitates reaching the most basic and urgent goals and then expanding services as they become necessary and available. Planning for a system of communication and delegation within a team is prioritized. More formally delineated strategies can be made for increasingly predictable disasters and they should be easy to access. 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.

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. Relationships may be formalized by making collaborative disaster plans. It is important to know the functions of interrelated organizations and how to communicate with them so that efforts and resources can be distributed most effectively in the chaos of a disaster.

SYSTEMS

Perhaps the most complicated and prominent elements of disaster psychiatry involve interfacing with existing disaster response systems. This is due to the fact that in the initial phases of a disaster the mental health response is based on an outreach model that requires mental health practitioners to go out into the affected community, where they will find themselves working side-by-side with preexisting systems within the community, as well as with formal disaster response systems that will be in various stages of mobilization and implementation.

The complexity is due to the seldom practiced relationships between community-based systems (including police, hospitals, churches, nonprofit organizations, and governmental organizations) and state and national agencies (including the American Red Cross and the Federal Emergency Management Agency [with their specific charters of disaster response]), as well as the National Guard, the Coast Guard, and the often-witnessed surge of well-intentioned trained and untrained volunteers.

The obvious remedy is to have these relationships defined in advance so that there can be true collaboration between practitioners, agencies, existing infrastructures, and imported emergency responses. Psychiatrists or mental health organizations interested in disaster psychiatry must therefore 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).

This is not a simple task. Rousseau⁴ and others have described how the formation of disaster plans is often abandoned because of the overwhelming complexity of the task. But it is essential that a plan to address mental health needs define itself within a network of disaster responses and goals 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.

Related posts:

31: Psychiatric Illness during Pregnancy and the Postpartum Period 39: Personality and Personality Disorders 85: The Role of Psychiatrists in the Criminal Justice System 65: Aggression and Violence 91: Coping with the Rigors of Psychiatric Practice 63: Genetics and Psychiatry

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