THE ROLE OF PSYCHIATRISTS
IN DISASTER

Summary of a Consensus Conference Held
September 18 & 19, 1995

Uniformed Services University of the Health Sciences
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The Role of Psychiatrists in Disaster6. AUTHOR(S)

Editors: Robert J. Ursano, M.D., Ann E. Norwood, M.D.
Associate Editors: Marcia H. Gillerist; Maribeth Hilliard,
B.A.; Catherine Levinson, LCSW C
7. PERFORMING ORGANIZATION NAME(S) ANO ADDRESS(ES)Department of Psychiatry
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road
Bethesda, MD 20814
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Emergency Services and Disaster Relief BranchCenter for Mental Health Services, Substance Abuse
Mental Health Administration (SAMHSA)
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This is a distillation of key points developed during a Consensus Conference on
therole of psychiatrists in disaster which was held at the Uniformed Services Uni­
versity of the Health Sciences (USUHS) on September 18-19, 1995. The major goalof the conference was to identify unique contributions which psychiatrists could
bring to disaster communities and their victims. This publication represents a
consolidation of perspectives from psychiatrists, other physicians, and non-medical
experts in disasters on ways in which psychiatrists can aid communities to prepare
for and recover from major catastrophes.

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disaster, psychiatry, role, trauma, community
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CONSENSUS CONFERENCE
ON THE ROLE OFPSYCHIATRISTS IN DISASTEREDITORS'
Robert J. Ursano, M.D.

Ann E. Norwood, M.D.

ASSOCIATE EDITORS
Marcia H. Gillerist
Maribeth Hilliard, B.A.
Catherine Levinson, LCSW-C

September, 1997
Department of Psychiatry
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road
Bethesda, Maryland 20814-4 799

TABLE OF CONTENTS

Preface............................................................................................................i
Conference Participants ................................................................................ .iii
Executive Summary .......................................................................................vii
Summary ........................................................................................................ !
References ......................................................................................................23
Appendix A ...................................................................................................31
Appendix B ................................................................................................... 3 5

PREFACE

The consensus conference on the Role of Psychiatrists in Disaster was held at the
Uniformed Services University of the Health Sciences (USUHS) on September 17 & 18,
1995. The conference was primarily an outgrowth of the American Psychiatric
Association's Committee on Psychiatric Dimensions of Disaster's efforts to pool
psychiatric expertise on disaster preparation, response, and research. It was supported bya grant from the Emergency Services and Disaster Relief Branch, Center for Mental
Health Services, Substance Abuse and Mental Health Services Administration(SAMHSA). The major goal of the conference was to identify unique contributions
which psychiatrists could bring to disaster communities and their victims. The
delineation of any gaps in mental health aspects of disaster recovery was also a desired
outcome.
Participants were selected to represent a broad spectrum of experience withtrauma and disasters. Psychiatrists with extensive experience with the American Red
Cross and with international disasters participated in the conference. Similarly,
psychiatrists active in the investigation of human responses to trauma and disaster wereinvited to attend. Psychiatrists with additional education and interest in Child Psychiatry,
Consultation/Liaison Psychiatry, and Academic Psychiatry also participated. Finally,
non-psychiatrists with expertise in disaster response shared their experiences of roles
psychiatrists had played in past events and ways in which psychiatrists could be ofincreased benefit in the future.
This document presents the results from the conference. It represents a
consolidation of perspectives from psychiatrists, other physicians, and non-medical
experts in disasters on ways in which psychiatrists can aid communities prepare for andrecover from major catastrophes. It is hoped that this publication will serve as aspringboard for further development of the role of psychiatrists in disaster.

CONSENSUS CONFERENCE PARTICIPANTS
Uniformed Services University ofthe Health Sciences
September 18 & 19, 1995

Gregory Belenky, M.D.
COL, MC, USA
Associate Professor
Department of Psychiatry
Uniformed Services Universityof the Health Sciences;
Director, Division ofNeuropsychiatry,
Walter Reed Army Institute of Research
Building 40
Washington, D.C. 20307

Raquel E. Cohen, M.D.
Professor
Department of Psychiatry
University of Miami
Medical School;
Chair, American Psychiatric Association's
Committee
on Psychiatric Dimensions of Disaster;
Director
The Children's Center
State Attorney's Office1350 N.W. 12th Avenue
Miami, FL 33136-2111

George T. Brandt, M.D.
Maj, USAF, MC
Assistant Professor
Department of Psychiatry
Uniformed Services Universityof the Health Sciences
430 I Jones Bridge Road
Bethesda, MD. 20814-4799

R. Susan Daily, M.D.
Member, American Psychiatric Association's
Committee
on Psychiatric Dimensions of Disaster;
Clinical Assistant Professor
University of Oklahoma
Health Science CenterCollege of Medicine - Tulsa;
Chief of Staff
Children's Medical Center
5300 East Skelly Drive
Tulsa, OK 74135

Michael Blumenfield, M.D.
Member, American Psychiatric Association's
Committee
on Psychiatric Dimensions of Disaster;
Professor of Psychiatry, Medicine & Surgery
Department of Psychiatry & Behavioral Sciences
New York Medical College
Room N314
Psychiatric InstituteWestchester County Medical Center
Valhalla, N.Y. 10595

Harry C. Holloway, M.D.
COL, MC, USA (Ret)Professor, Department of Psychiatry
Uniformed Services Universityof the Health Sciences;
Associate Administrator
Office of Life and Microgravity Sciences
and Applications
NASA
300 E Street, S. W.
Washington, D.C. 20546

111

Carol S. Fullerton, Ph.D.
Associate Professor (Research);
Science Director, Center for the
Study of Traumatic Stress
Department of Psychiatry
Uniformed Services Universityof the Health Sciences
4301 Jones Bridge Road
Bethesda, MD 20814-4799

Ann E. Norwood, M.D.
LTC,MC, USA
Corresponding Member, American Psychiatric
Association's
Committee on Psychiatric Dimensions ofDisaster;Administrative Director
Center for the Study of Traumatic Stress;
Assistant Professor
Assistant Chair
Department of Psychiatry
Uniformed Services Universityof the Health Sciences
4301 Jones Bridge Road
Bethesda, MD 20814-4 799

Craig H. Llewellyn, M.D.
COL, MC, USA (Ret)Professor and Chair
Department of Military Medicine
Professor of Preventive
Medicine and Biometrics
Uniformed Services Universityof the Health Sciences
4301 Jones Bridge Road
Bethesda, MD 20814

Thomas A. Mellman, M.D.
Chief, Post Traumatic Stress Disorder Section
VA Medical Center
Psychiatric Service
1201 N.W. 16th Street
Miami, FL 33125

Robert S. Pynoos, M.D.
Associate Professor; Director,
Program of Trauma, Violenceand Sudden Bereavement
UCLA
Suite 2408 Adult Psychiatry
300 UCLA Medical Plaza
Los Angeles, CA 90024

Jane Morgan, R.N.
Mental Health AssociateAmerican Red Cross
8111 Gate House Road
Falls Church, VA 22042

Carol North, M.D.
Member, American Psychiatric Association's
Committee
on Psychiatric Dimensions of Disaster;
Assistant Professor of Psychiatry
Washington University School of Medicine
Department of Psychiatry
Campus Box 8134
4940 Children's Place
St. Louis, MO 63110

James R. Rundell, M.D.
Lt Col, USAF, MC
Associate Professor of Psychiatry
Uniformed Services Universityof the Health Sciences;Training Director
Capitol Region Tri-Service
Psychiatry Residency Program
SGOHP/ Department of Psychiatry
Malcolm Grow USAF Medical Center
Andrews Air Force Base
MD 2031-5300

IV

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I

I

I

~

Jon A. Shaw, M.D.
Professor of Psychiatry & Pediatrics;
Director,
Division of Child and Adolescent Psychiatry
University of Miami
P.O.Box 016960
Miami, FL 3310-1

Leonard Zunin, M.D.
Staff Psychiatrist
Napa State Hospital
2100 Napa Vallejo Highway
Napa, CA 94558

Robert J. Ursano, M.D.
Col, USAF, MC, FS (Ret)Professor and Chairman
Department of Psychiatry
Uniformed Services Universityof the Health Sciences
4301 Jones Bridge Road
Bethesda, MD 20814-4799

Frank Young, M.D.
RADM
Director, Office of Emergency Preparedness;Room 4-81
5600 Fishers Lane
Rockville, MD 20857

Sally Taylor, M.D.
Member, American Psychiatric Association's
Committee
on Psychiatric Dimensions of Disaster;
Assistant Professor of Psychiatry
UTHSCSA
Department of Psychiatry
7703 Floyd Curl Drive
San Antonio, TX 78284-7794

Lars Weisaeth, M.D.
Professor of Psychiatry
Division of Disaster Psychiatry
University of Oslo/The Norwegian Armed
ForcesJoint Medical Service
P.O. Box 39 Gaustad
N-0320 Oslo, Norwayv

vi

THE ROLE OF PSYCHIATRISTS IN DISASTERSEXECUTIVE SUMMARY
Psychiatrists bring a wide range of skills and expertise useful for preparing forand responding to disasters. In the aftermath of a disaster, the medical skills of thepsychiatrist are very valuable.
• Basic first aid and CPR can prove lifesaving.
• A calm, professional approach can help prevent panic.
• A psychiatrist's leadership to coordinate an organized response and assistanceat triage stations promotes accurate prioritization of medical/surgicaldispositions and effective allocation and matching of resources to need.
• The ability to distinguish between common reactions of hyperarousal from
pathological ones can ensure appropriate management of individuals.

Medical training prepares psychiatrists for recognizing disease and developing
differential diagnoses. This fund of knowledge is helpful in:• Identifying the etiology(ies) of altered mental status, especially in theaftermath of trauma where medical illness or injury can be inappropriately
diagnosed as psychiatric and vice versa.
• Responding to toxic chemical exposures, whether delivered from terrorists'
weapons or through industrial accidents, knowledge of pharmacology andexperience with anticholinergic agents.
• Facilitating communication across a wide range of professional boundaries:
interacting with community officials, disaster response agencies, police, fireand rescue, school systems, hospital staff, and medical personnel to name but
a few.

The psychiatrist's familiarity with an epidemiological approach to understanding
disease in a group context is invaluable in the context of disasters. This model is a useful
tool in identifying:• High risk groups f~r psychological distress based on exposure to trauma (e.g.,body retrieval workers).
• Vulnerable groups such as the elderly and children.
• "Vectors" of disease such as communication of fear via rumor or media.

The psychiatrist's knowledge of developmental models for human behavior
matches interventions to individuals incorporating knowledge of their vulnerabilities andresilience throughout the life cycle. Similarly, knowledge of the natural history andepidemiology of disease is'helpful in correctly identifying all factors contributing to anindividual's physical and/or emotional distress.

Vll

In addition to general medical assessment and interventions, the psychiatrist
brings a number of specialized medical skills. The psychiatrist is knowledgeable of theassessment and differential diagnosis of disorders of cognition, affect, and behavior. .
He/she is especially helpful in situations in which psychiatric disorders are co-morbidwith medical conditions. Facility with medical, psychological and socio/culturalinterventions allows the psychiatrist to choose from a broad armamentarium oftreatments. Psychiatrists can:• Prescribe medications for psychiatric disorders.
• Provide symptomatic relief as appropriate for sleep problems andhyperarousal.
• Recognize and treat substance intoxication and withdrawal syndromes.
• Screen carefully for the presence of organic brain disorders andsuicidal/homicidal ideation.

Psychiatrists have a number of educational experiences which provide them withexpertise in disaster consultation.
• Child training in the general residency or in fellowship provides a backgroundin consulting to non-medical organizations and leaders such as school
principals, teachers and guidance counselors.
• Consultation/liaison training provides a firm foundation in working with the
medically ill and their primary treatment team, chaplains, families and others
in a hospital setting. It also exposes psychiatrists to experience with acuteemergencies and a broad range of organic brain disorders.

Psychiatrists are well-suited to provide consultation to disaster organizations suchas the Red Cross, FEMA and emergency systems as well as community leaders. The
physician's medically based connections with these institutions are very helpful ingaining entree. The medical identity also facilitates participation across internationalboundaries.

Psychiatrists enjoy special psychotherapeutic skills useful in disasters.
• Experience in working with injured patients and the management of associatedhyperarousal.
• Ability to deal with issues of death and dying are prominent in disaster work.
• Facility in sleep management and the judicious use of medications is an
important contribution.
Increasingly, disasters are an all-too-common feature of modem life. Educationin the unique features of Disaster Psychiatry, as well as adaptation of traditional
interventions, ensures that psychiatrists are prepared to make significant contributions to
the prevention and mitigation of psychiatric morbidity resulting from disasters.

VlllTHE ROLE OF PSYCHIATRISTS IN DISASTERS
SUMMARYHISTORY OF THE ROLE OF PSYCHIATRISTS IN DISASTER
The scientific examination of psychic trauma and its sequelae is just over ahundred years old. The study of traumatic stress contributed to the differentiation of
psychiatry as a distinct specialty from neurology, the discovery of the concept of theunconscious, and stimulated the development of psychotherapy.
Beginning with the massive railway accidents in England in the middle of the
19th Century, collective stress situations have been the focus of increasing attention.
Psychiatrists have been intimately involved both as researchers and as clinicians since thesystematic studies in the field were first initiated during the first decade of the 20th
century. Research was stimulated, in part, by efforts to understand the biomedical andpsychosocial effects of explosions. This interest in explosions was part of thecontemporary climate of ideas during the first decade of this century, and paved the way
for a fuller understanding of the mass occurrence of "shellshock" which followed in
World War I. The development of an understanding of the true nature of shellshock(psychological rather than biological) was a significant breakthrough in the developmentof psychiatric science.
The Swiss psychiatrist Edouard Stierlin was the pioneer in the study of disasters
from a psychiatric perspective. Stierlin studied two man-made disasters (a railway
accident and a mining disaster in 1906) and compared them with victims of a natural
disaster (the 1907 earthquake in Meson, Italy which killed 70,000). He published twoworks on victims of disaster based on these studies which contained interesting findings,
many of which have been replicated in modem research.
The first description of post-traumatic stress reaction in rescuers was provided by
Hesnard, who studied the many-sided effects of two well known French catastrophes,
ship explosions in 1907 and 1911. Unfortunately, with the exception of Eric Lindeman's
study of the Coconut Grove Night Club fire in Boston during World War II and a few
other studies, civilian disasters were not studied again systematically with adequate
research methods until the 1970' s.
Military psychiatrists, serving organizations which focus highly on groups andlarger social systems, have made important contributions to civilian psychiatry throughtheir findings in stress studies. Studies of collectively stressful situations yielded some of
the most widespread treatment practices in psychiatry today, such as group therapy andthe concept of the therape~tic community as well as approaches to social and community
psychiatry. (In contrast, academic psychology did not incorporate the important findings
from war-related studies until the 1980' s.)

EPIDEMIOLOGY
Disasters are not necessarily equal opportunity events. Consider floods, forexample, people who build on flood plains because the land is inexpensive represent agroup with special characteristics such as a lower socioeconomic status as well as the
special personal characteristics of individuals willing to live under the threat of floods.
Groups of individuals exposed to cataclysmic events may share certain characteristics
associated with their own sets of vulnerabilities and protective factors from effects ofdisaster. Examples of such special populations include combat veterans, children, andrescue workers. Therefore, it is important to consider the characteristics of the affected
population when considering disaster-related activities.
The number and scope of disaster-affected persons may be larger than realized
and may include not only the individuals trapped in the immediate disaster situation but,also, their family and close friends, peers and other acquaintances, rescue workers,
disaster relief (e.g., Red Cross, mental health volunteers) and agency personnel (e.g.,
insurance adjusters), if not to some degree the entire community. In highly publicizeddisasters such as the Oklahoma City bombing, the affected population may also include
regional, national, and international news audiences who may be greatly impacted by theintensity of live video accounts. Other populations which are touched by disasters
include individuals inconvenienced by a disaster's physical effects, (e.g., blocked roads
and loss of electrical power), as well as its secondary effects such as economic loss (e.g.,
tourist trade curtailed on tropical islands due to recent hurricanes).
Different types of disasters are thought to elicit different responses from affected
populations. Technological accidents may evoke higher rates of psychiatric disorders
than natural disasters; willful acts of terrorism are thought to evoke the most severereactions. Disaster-specific contributors to severity of impact may include the associateddegree of terror (i.e., threat to life or limb) and horror (i.e., grotesque scenes); suddennessof onset, duration and intensity of impact, degree of damage (e.g., number of casualties;
personal injury and property damages); and grief over loss of loved ones. Disasters withseveral of these properties are thought to promote the highest risk for severe psychiatricimpact.
Besides predisposing characteristics of populations exposed to disasters, pre­existing individual considerations affect personal response to traumatie events. In
disaster studies, pre-existing psychiatric illness is predictive of psychiatric problems after
the event. However, with the increasing magnitude of the disaster agent and the greater
the exposure to it, personal vulnerability appears to be less predictive as more individuals
without previous psycholagical problems are affected. Other personal predictors of riskfor post-disaster psychiatric problems include loss of a loved one, litigation, female
gender, advanced age, and lower socioeconomic status.

2

DSM-IV has added a new disaster-related diagnosis, Acute Stress Disorder(ASD). This diagnosis closely resembles Post-Traumatic Stress Disorder (PTSD) but has
an earlier onset (within 4 weeks of the trauma) and a shorter duration (lasting between 2days and 4 weeks). Because ASD is a new diagnosis, there are few investigations
available on its prevalence or natural history. Future research will examine to what
extent this diagnosis predicts the later onset of Post-Traumatic Stress Disorder and otherpsychiatric conditions.
The psychiatric disorder classically associated with disasters is Post-TraumaticStress Disorder (PTSD). Studies of disasters have reported widely varying rates of
PTSD, as low as 2% following a volcano, 4% after torrential rain and mudslides, and 4%­
8% following flooding and exposure to dioxin contamination. Other researchers havereported much higher rates of PTSD: 44% after a dam break and flood, 53% following
bushfires, and 54% following an airplane crash landing. Although only a minority ofsurvivors of most disasters develop diagnosable cases of PTSD, some symptoms may beabundant or even universal.
The natural history of PTSD is that symptoms often begin within hours, andusually within a few days, of the traumatic event. Delayed onset (by definition, beyond
six months) is uncommon, although cases beginning later, as many as years after the
event, have been described. A study of the Buffalo Creek dam break and mudslides
found that 20% of all PTSD cases identified were delayed cases. Studies of Vietnam
veterans found that 16% of post-Vietnam PTSD cases had delayed onset.
PTSD symptoms typically begin to fade within weeks of the event, although thiscan vary considerably. Many studies report that roughly half of the cases in the general
population resolve by six months. Chronic PTSD with symptoms which can persist for
many years, however, has also been described, including one-third of the cases persisting
for at least three years. Chronicity has been predicted by the presence of pre-existing
psychiatric disorders, neuroticism, a history of early separation from parents in childhood,and family history of anxiety or antisocial behavior, as well as litigation. (The mostmarked chronicity in PTSD sufferers has been observed in prisoners of war, amongwhom 50% to 90% have been found to have active PTSD after forty years.)
Research indicates that other psychiatric disorders often accompany PTSD in
disaster survivors. The most prevalent co-existing disorders appear to be major
depression and anxiety disorders. Given the well documented potential for improvementwith treatment, these disorders should not be overlooked in evaluation of disastersurvivors for post-traumatic symptoms. A complete psychiatric past history of these
disorders as well as substance abuse should be taken and considered carefully inassessment and planning of treatment for disaster survivors.

3

Post-traumatic Stress Disorder is not the only psychiatric disorder seen following
disasters. Major depression, substance abuse, generalized anxiety disorder, andadjustment disorder have also been diagnosed in individuals exposed to a disaster.
Psychological reactions to physical injury and illness are also important postdisaster
responses to include in a differential diagnosis.
Not to be overlooked is the resilience of people after disasters. In spite of theoverwhelming prevalence of PTSD symptoms after extreme traumas, the majority ofsurvivors do not become psychiatrically ill. Reassuring these individuals that their
symptoms represent normal responses to extreme events, and helping them re-establish
their balance, can go a long way toward helping them cope with such extreme situations.
There are few data pertaining specifically to women following major disasters.
The field of psychiatric response to disaster is relatively new, as is the comparison of
women separately to men; hence, the marriage of the two phenomena has rarely occurredin the research literature to date. In the general population, however, it is well
documented that women are more prone to depressive and anxiety disorders than aremen, although men greatly outpace women in substance use disorders. Therefore, it is
not unexpected that in extreme situations such as disaster, women, compared to men,might be especially prone to depressive and anxiety disorders, including PTSD (asopposed to substance abuse for men). In numerous disaster studies, women have beenshown to have significantly higher rates of post-disaster psychiatric disorders than men.
Women are found to be more likely than men to visit physicians and to take medication
after disasters. Therefore, health professionals may represent a potentially more usefulsource of post-disaster intervention for women than for men.

BARRIERS THAT IMPEDE THE PSYCHIATRIST'S FUNCTION
IN THE TIME OF A DISASTER
Psychiatrists increasingly are assisting citizens after catastrophic events andforging a new role in the process. A number of barriers impede the active involvement of
psychiatrists in disaster response. They can be categorized as:• Internal characteristics - an internalization of a professional identity which focuses on
office-based medical care
• Interprofessional characteristics - conflict between psychiatry and other mental healthcare providers• Community characteristics - the general public's perception and expectations of what
psychiatrists do
In order to further psychiatric participation in disasters, these obstacles must be removed
or circumvented.

4Internal Characteristics
Psychiatrists interested and willing to participate in helping post-disaster victims
often need to modify expectations and attitudes which are helpful in their usual clinicalpractices. Disaster psychiatrists must be comfortable in a professional collaboration withdisaster emergency workers to join and assist in their objectives - assisting a victim in asetting of chaos, obtaining full historical data, and coping with shifting scenarios, blurringof roles and a large ratio of helpers to victims.
Interprofessional Characteristics
Disaster events are characterized by the rapid appearance, seemingly out of
nowhere, of multiple agencies, volunteers and professional groups who are eager to find aniche and participate in the emergency activities. Each group follows different
guidelines, objectives, regulations and schedules. Generally, these activities are difficult
to coordinate. Psychiatrists are one group of the many mental health professionals thatare interested in participating as part of a cadre dealing with behavioral/emotional issues.
Areas of "turf' control, ideological guidelines, and power-yielding are barriers
that appear in many settings. These issues can be mitigated when clear leadership androle definition are agreed upon before a disaster occurs.
Community Characteristics
The historical reputation of psychiatrists' activities as associated only withmentally disturbed individuals impedes the role of psychiatrists assisting citizens reacting
emotionally to traumatic circumstances. At times, there is a circular reinforcement when
psychiatrists cannot change their methodology and thus interact with a "victim" as if heor she were a "patient."
The small number of psychiatrists available to participate in these efforts reduces
the "critical mass" of professionals who can impact on the awareness of lay andgovernmental leaders, who, in turn, could begin to change community expectations of theprofession. Through the past years, these barriers have been a challenge to psychiatrists.
Now recognizing the existence of these barriers, psychiatrists are beginning to address
them formally and informally.

THE PSYCHIATRIST IN PRACTICE IN THE DISASTER COMMUNITY
Problems
The local psychiatrist is usually in private practice or works for the local mental healthcenter. This means a heavily booked schedule with minimum backup available andminimum free time (vacation, etc.). Their family usually lives in the disaster area andtheir own physical and fiscal resources may have been damaged or lost. Family membersof the psychiatrist may have been injured or lost.

5Advantages
The private practice psychiatrist has a unique advantage in knowing the local
resources, terrain, politics, and culture. This psychiatrist is known to the medical
community, the general populace, and local officials which provides for immediate
access to the disaster site, trust-building, and access to resources. Their recommendations
regarding mental health needs may be the only ones for up to 36 hours post-disaster.
With proper training (which involves a minor time commitment) the local psychiatrist
can be invaluable in decreasing the overall morbidity among community members, healthprofessionals, and local rescue workers. Of equal importance, the local physician willremain in the community and will be caring for the longer term sequelae - long after
external resources have disappeared.

Clinical Vignette
A single white female in her early 30 5 presented with a history of incapacitating
chronic depression (greater than 1 year) but new onset nightmares and sleep disruption
for the past 3 months. Investigation revealed extensive media exposure to the Murrah
Building bombing with particular interest in the child victims 3 months prior to thisexam.
Further investigation revealed an untreated disaster exposure one year prior to thebombing. The woman participated in a failed rescue attempt of three children in a carcarried away by flood waters. She was also present three days later when the car andbodies were retrieved.
Neither she nor any of the other flood rescue workers received any debriefing.
She had not revealed any of these experiences to past therapists (psychologist, social
workers) as she felt they could not relate to the medical exposure of the bomb experience
just as she, herself, did not relate to the failed rescue of the drowned children.
Knowledge that the psychiatrist was a medical professional allowed her to reveal her
source of emotional pain and begin to deal with her PTSD.
SPECIAL POPULATIONS
To effectively use the skills and knowledge of a psychiatrist participating inemergency post-disaster programs, psychiatrists need to pay special attention to different
and vulnerable populations. These populations have certain specific characteristics which
demand modifications in post-disaster approach counseling. Among many of thesegroups we have selected the following:

6

•
•
•
•
•
•
•
•
•

Medically ill/chronic illness/injuries
Psychiatric illness (alcohol and drug use)
Handicapped (blind deaf)
Cultural minorities
Elderly
Isolated populations
ChildrenBereaved
Disaster workers
Individuals with Disabilities

Psychiatrists are in a unique position to use their medical skills to ascertain
rapidly the physical/mental conditions and needs of the victims following a disaster.
Generally, a short, concise history has been gathered by the emergency personnel who
desire consultation or direct examination of the victim. Individuals with physicalhandicaps and with marginal daily coping skills will have stress reactions to the alteredenvironment. Family members who accompany the disabled victim will need help todeal both with their own problems plus the ones presented by their disabled or
chronically ill relatives.
Psychiatric Illness
Victims who have a diagnosis of mental illness or addiction syndromes present acomplex diagnostic challenge to psychiatry - sorting out the manifestation of stress
reactions, exacerbation of their mental illness and effects of abrupt withdrawal of
alcohol/drugs, all of which produce complicated behavior profiles. The expectation isthat the victim may become cognitively and emotionally impaired for an interval of time,
but return to a baseline of usual behavior. Intervention focuses on increasing the victim's
awareness of the emotional effects of disaster, and assisting in improving the ability tocope. When feasible, the appropriate medication should be obtained and instituted.
Ideally, in regions that are disaster prone, psychiatrists should counsel their patients tohave a 2-3 week supply of medication in "disaster kits."
Handicapped Populations
Individuals suffering from handicapping conditions such as blindness, deafness or
impaired muscle function are vulnerable when their familiar surroundings suffer theeffects of disaster. Disorientation and increased dependency needs influence the level of
emotional reactions which, in tum, may affect behavior and coping capacity. The
psychiatrist can assist the emergency staff to address the needs of the handicapped
individual in the new surrounding of an evacuation shelter. The victim may also manifest
a clinical syndrome necessitating diagnosis and treatment.

7

Cultural Diversity
Socio-cultural origins of victims have important influences on how victims
manifest post-disaster behavior and how they accept help from "strangers." Therefore,
experiences with and knowledge of specific cultures from the regional area of the disasterare helpful to the psychiatrist participating in the emergency program. Differences incultures and language can add to miscommunication and mistaken diagnosis. There is atendency among physicians to over-diagnose pathological post-disaster reactions inminority/culturally diverse victims. Culturally competent psychiatrists may prevent
labeling these victims with idiosyncratic behaviors as more disturbed.
Geriatric Populations
This group is an especially vulnerable post-disaster population. They may lacksupport systems and may have a declining physical capacity including diminishedfunctional capacities. The psychiatrists will be able to use their medical andpsychological skills to assist the elderly with the multiple physiological and emotional
reactions produced by trauma. Attention should focus on :
•
•
•
•
•

Acute physical trauma secondary to the disaster such as fractures or subdural
hematomas
Loss of familiar personal space
Use of multiple medications
Chronic health conditions
Cognitive changes due to losses of "cues" and manifesting as disorganization,
confusion, and memory changes
Isolated Populations

Among the groups that may be affected by disaster are individuals who are
categorized as "homeless." This group is a difficult group to assist and counsel. Due totheir lack of previous shelter and social connections, they may fall between the cracks ofthe emergency assistance programs. The homeless may also fear or resent authority
figures who could provide assistance. They tend to stay only briefly in the official
shelters and are soon lost to the emergency teams.

8

Occasionally, the psychiatrist might help link a homeless family to social
resources by assessing their psychosocial needs and using his/her influence to obtain theinterest of a church or social group. Unless a community develops a categorical special
program for this population, they will suffer the consequences of the community
disruption and scarcity of resources after a disaster.
Children
The psychological effects of natural disaster on children and adolescents has
become an emerging focus of study. In recent years, reports have been published on thepsychological responses of children and adolescents to hurricane, fire, earthquake andflood. The spectrum of post-traumatic stress symptomatology in children and adolescents
generally parallels the psychological responses of adults to overwhelming disaster. Acutepsychological responses to natural disaster include trauma-specific fears, fears ofrecurrence, regressive behavior, externalizing symptoms, behavioral reenactments, post­traumatic play, avoidance of "traumatic reminders," emotional detachment, anxiety anddepressive disorders, school problems, symptoms of physiological hyperarousal andchanged attitudes about the self, world, and future. Psychological trauma associated with
exposure to an overwhelming stressor may be etiological for a number of psychiatricdisorders, i.e., Mood Disorders, Attention Deficit Hyperactivity Disorder, Phobic
Disorder, Anxiety Disorders, Dissociative Disorders, Substance Abuse, Conduct
Disorder, Somatoform Disorders, and Personality Disorders such as Borderline
Personality Disorder, etc.
Only recently have investigators attempted to delineate between the short-termand long-term psychological effects associated with exposure to disaster. Increasing
attention has been focused on the acute psychological and psychiatric comorbidity foundwith the core post-traumatic symptomatology. There is evidence that the prevalence of
post-traumatic stress symptomatology in children is high in the immediate aftermath ofdisaster and remains particularly high for females for sustained periods of time. While
initially other indices of behavioral and emotional distress may be dampened, there is a
rapid rebound with increasing severity and diversity of emotional and behavioral
problems over time.
The increasing severity and diversity of psychological and psychiatric symptom
configurations appear to be related to the unfolding of the "secondary stressors." These
stressors include losses related to the destruction of the community, loss of home,
unemployment, marital and family discord, disruption of peer groups, economic hardship,
slow rates of recovery and restoration, exposure to "traumatic reminders" and increased
indices of social maladjustment, i.e., school absenteeism, divorce, child maltreatment etc.
Subsequent to the Armenia earthquake of 1988, for example, children manifested
significant psychiatric comorbidity to include PTSD, PTSD-depression, depression andseparation anxiety. Long-term post-traumatic stress related pathologies include chronic
PTSD, and comorbid mental and physical disorders, personality and developmental
disturbances, and age appropriate expressions of a lack of well-being and general9dissatisfaction. In follow-up studies of children after the Buffalo Creek disaster, twoyears after the disaster, 37% of the children and adolescents were given a "probable"
diagnosis of PTSD and 17 years after the disaster 7% of those re-evaluated had PTSD; allof these individuals were women. The risk factors that best predicted continuing post­traumatic symptomatology for these children and adolescents were degree of life threat,parental psychopathology, female gender and an irritable and/or depressed family
atmosphere. Additionally, there is a spectrum of "adaptational possibilities" found inchildren 20 years after the Buffalo Creek Disaster which was related to the family's initial
response to the disaster; psychopathology in the children resonated with parental
psychopathology.
The increasing awareness of psychological and psychiatric comorbidity associatedwith the stress response syndromes has resulted in increasing recognition that mental
health personnel sensitive to the complexity ofbiopsychosocial issues have to beavailable in the immediate aftermath of disaster. There are at least five categories ofchild psychiatric victims after disaster:
•

•

•
•

•

Children who were previously defined as psychiatrically disturbed and who werereceiving psychotropic medication for conditions such as Psychotic Disorders, Mood
Disorders, Attention Deficit Hyperactive Disorder, Tourette's, Obsessive Compulsive
Disorder and whose conditioned worsened due to the lack of access to medications
Children who had previously existing psychosocial and psychiatric problems whichwere exacerbated by the additional stress of the disaster with increased psychiatriccomorbidity
Children who under the impact of the stressors associated with disaster develop
classical post-traumatic stress symptomatology,
Children who respond to the disaster with psychiatric comorbidity; depression,anxiety and somatoform disorders, i.e., vague pains, gastrointestinal complaints,
headaches, dermatitis, conversion reactions etc.
Children who upon exposure to the continuing psychosocial and familial adversity
after the disaster begin to manifest emotional and behavioral problems such as
psychophysiological manifestations of stress, i.e., asthma, gastrointestinal disorders,vague aches and pains, symptoms of depression, suicidal behavior, aggressive
dyscontrol problems, Attention Deficit Hyperactivity Disorder, antisocial behavior,and Substance Abuse etc.

The role of the child psychiatrist is many faceted. Initially, the child psychiatrist
trained in the biopsychosocial dimensions of emotional and behavioral problems will act
both in the role of primary care physician and discerner of the potential biological facets
underlying psychological problems. His expertise in the assessment and differential
diagnosis of medical as well as psychiatric conditions enables him to recognize
psychiatric and psychophysiological reactions requiring immediate medical-psychiatrictreatment. It is a maxim of military medicine that the most qualified physician is the one
most skilled to perform triage, sorting out patients to appropriate avenues of intervention.

10

The positioning of the most skilled person at the entry point into the health care system
ensures that medical/surgical emergencies are not missed and that resources are usedefficiently and effectively.
The child psychiatrist's training in multiple systems makes him particularly
skilled to interface with the medical-community-school milieu both as a consultant and a
resource. It is apparent that in the post-disaster period there is an increasing widening of
emotional and behavioral problems requiring the attention of child psychiatrists sensitive
to the biological, psychological and social dimensions of the stress response syndromes(biopsychosocial model).
The Bereaved
Psychiatrists are in a special position to assist in understanding normal andpathological responses to loss and to facilitate healthy recovery. While it may be obvious
to most people that someone would grieve the loss of a friend or family member, theimpact of the loss of pets and possessions may not be as readily recognized orappreciated. The psychiatrist can assist in distinguishing between uncomplicatedbereavement and the development of a major depressive disorder (in which there may be
no difference in criteria other than the length of time). The use of antidepressant andsleep medications may be of benefit for some patients.
While there is substantial literature on the loss of a spouse and its effect on thesurvivor's immune function, less is known about the impact of the devastation of acommunity on residents' immune function. The widespread destruction of homes andneighborhoods, sudden unemployment, displacement, and the effect of other losses on
immune and endocrine function may amplify the individual's physiological, behavioral
and psychological responses.
Disaster Workers
A great deal of attention in disaster work lately has focused on the role ofdebriefing disaster workers in the aftermath of a traumatic event. There are many training
courses available on debriefing. It must be remembered, however, that one should thinkof debriefing as only one intervention in a vast armamentarium. Early primaryintervention through consultation should be a priority. One of the universal stressors
associated with disasters is exposure to the dead and the grotesque. Proper training forindividuals involved in areas such as search and rescue, body handling, and mortuary
operations can help diminish overwhelming exposure. For example, the psychiatrist can
provide consultation to inexperienced leaders that those involved in handling the deadand mutilated should avoid looking at faces, hands, personal effects and other things
which intensify identification with the dead and therefore increase the risk ofpsychological sequelae.

11

A strikingly common problem in disaster workers (including medical personnel)
is overdedication. Consultation must emphasize the necessity of ensuring that all
personnel (including leaders) receive adequate recovery time for sleep, nutrition, andrespite. Fatigue and exhaustion ultimately take a toll on effectiveness, increasing theprobability of accidents and mistakes, and may diminish healthy coping mechanisms.
The psychiatrist should also stay alert to the tendency for some individuals to respond to
the physical and psychological stressors by increasing their use of alcohol and tobacco
products. Similarly, the psychiatrist must watch for symptoms of withdrawal in
substance dependent individuals who do not have access to their particular substance.
Other organic brain syndromes can result from dehydration, exposure to toxins, etc. The
psychiatrist is uniquely trained to assist in the differential diagnosis and treatment ofthese conditions.
As physicians, psychiatrists are in a special position to understand the stressors ofattending to the physically injured and grotesque. Psychiatrists' personal experiences intheir medical training allow them the capacity to listen to stories about the complex
thoughts, feelings, and behaviors associated with working with the sick and injured and tosensitively inquire about areas which non-medical personnel may not consider.
BIOMEDICAL PERSPECTIVES
Sleep
Mental Operations
Psychiatrists have a role in the management of sleep before, during, and after
disasters. Before disasters, effective management of sleep to sustain alertness andperformance may serve, ifthe disaster looming is a function of human error, to preventthe disaster. During disasters, effective sleep management increases resiliency andcoping in the face of a rapidly changing situation. After disasters, effective sleep
management will sustain emergency personnel, speed structural recovery, and facilitate
the treatment of the sick and injured. Finally, there is the special case of managing sleepin acute traumatic stress casualties. (This special case is treated later in this section under"medication").
Adequate sleep sustains mental performance. With less than adequate sleep,
performance degrades over time. Total sleep deprivation degrades human mental
performance by 25% for each succeeding 24 hours awake. The recuperative value ofsleep depends primarily upon the sleep's duration and continuity. The effects of sleep
deprivation on performance are based in robust changes in brain physiology. Using
Positron Emission Tomography (PET), it has been demonstrated that sleep deprivation
decreases brain activation: The greatest decreases occur in those areas of the brain
involved in complex mental operations, exactly those mental operations necessary for
effective coping and adaptation.

12Medications and Sleep
In laboratory studies comparing the effects of several stimulant drugs on
performance during sleep deprivation, caffeine, given in doses of 300-600 mg, improves
performance for 8-10 hours after 48 hours without sleep and does so without undesirable
side effects. Both triazolam (Halcion®) and zolpidem (Ambien®) can induce sleep in
non-sleep conducive (operational) conditions. However, both have drug-hangover effects
that impair performance during subsequent waking. Flumazenil (Mazicon®) given uponawakening, reverses these drug-hangover effects and restores full alertness andperformance. Flumazenil is not in itself a stimulant. The potential is there to develop adual drug system (e.g., triazolam to induce sleep, followed by flumazenil on awakening
to restore performance) for use in inducing recuperative sleep during continuous
operations. Such a system, implemented by psychiatrists during a disaster, would ensure
good duration and continuity of sleep in emergency personnel.
A variety of non-invasive, unobtrusive techniques to monitor alertness real-time,
including embedded reaction time tests, on-line, real-time EEG analysis, eye tracking,and pupillometry are under development. By testing and cross-comparing thesetechnologies it will be possible to develop a system to warn personnel before, during, andafter disasters of imminent performance failures.
Perhaps the first area in which psychiatrists should be cognizant is that patientswith medical and psychiatric illness may not have an adequate supply of their
medications. This is a primary consideration in the evaluation of altered mental states.
Proactively, psychiatrists in high risk areas for natural disasters should encourage andassist patients in the development of a special disaster bag which contains at least a
week's supply of medications and salient medical information for use in emergencies.
Psychiatrists have a role in research on pharmacological agents in the
management of stress casualties among disaster victims, and in the actual clinicalpharmacological management of such casualties. At present, there is no conclusive
evidence that any pharmacotherapeutic agent is of benefit in the treatment of acutetraumatic stress reactions or in the prevention of Post-Traumatic Stress Disorder (PTSD).
Antipsychotic medications and long-acting benzodiazepines have no role in the treatmentof traumatic stress casualties or the prevention of PTSD. Anecdotal observations by the
Israeli Defense Force during the 1973 Arab-Israeli War and the 1982 War in Lebanon
suggest that the use of these medications in the treatment of combat stress reactions,while effective in symptom reduction over the first few hours, interferes with coping andreadjustment, further debilitating the soldier, reducing the likelihood of full recovery overthe 2-3 days post-trauma, and creating longer term disability. It was observed that mental
health professionals in the Gulf War were poised to use benzodiazepines liberally had
there been large numbers of combat stress casualties. Benzodiazepines are effective in
reducing anxiety and promoting sleep. However, it is questionable whether

13pharmacologic relief from anxiety is needed for acute stress casualties, especially if itcomes at the cost of impairing coping and adaptation. That mental health personnel in
the Gulf War were eager to administer long-acting benzodiazepines reflects their beliefs
that these agents were therapeutically indicated and that combat stress casualties would
be unmanageable if not sedated even while awake. Both beliefs are unfounded. If sleep
induction is needed, then a short-acting, sleep-induction/rapid reawakening drug
combination might be useful. Most contemporary short-acting, sleep-inducing drugs
interact with the benzodiazepine receptor, and while effectively inducing sleep, being
short-acting, leave residual sedation which impairs cognitive performance (particularly
new learning) and may thus impair resiliency, adaptation, and coping, and worsen apatient with acute traumatic stress reaction. Short-acting, sleep inducing drugs, triazolam(Halcion® ) and zolpidem (Ambien®) are effective in inducing sleep in non-sleep
conducive (operational) conditions. However, even these short-acting drugs have drug­
hangover effects that impair performance during subsequent waking. As describedabove, a dual drug system (e.g., triazolam or zolpidem to induce sleep, followed byflumazenil on awakening to restore performance) could be used to induce recuperative
sleep without subsequent impairment of resiliency, coping, learning, and adaptation.
Medications
The SSRis may have a beneficial effect in treating acute stress casualties,
especially if combined with event reconstruction and debriefing. These agents are,relative to older antidepressants, free from side-effects, including performance
impairment. To our knowledge, they have not been tried in the management of acutestress reaction or the prevention of Post-Traumatic Stress Disorder. In clinical settings,
these agents appear to improve day-to-day performance and increase resiliency indepressed, demoralized individuals. Needed are prospective, randomized, double-blindstudies of their efficacy when used immediately post-trauma in exposed individuals
whether they are at that point symptomatic or not. Other agents may prove effective in
reducing the risk of an acute stress reaction progressing to chronic PTSD. Controlled,
prospective studies will provide information upon which to base recommendations forclinical practice.
Nutrition
Because major disasters disrupt community infrastructure, there are significant
challenges posed in the area of nutrition. Attention should be paid to ensuring thatsurvivors have access to safe drinking water to maintain hydration. The loss of
refrigeration and limited ability to replenish food stocks restrict the types of foods thatcan be provided with resulting changes in diet. These dietary shifts may contribute to thedevelopment of diarrhea or constipation which may pose health hazards for vulnerable
populations. Special attention must be paid to the ability of those on special diets, i.e.,
persons with diabetes, hypertension, etc. to obtain appropriate sustenance. In the
consultative mode, the psychiatrist must continually remind leaders to ensure that disasterworkers maintain adequate hydration and eat regularly.

14

THE PSYCHIATRIST AS PHYSICIAN:
CARE FOR THE MEDICALLY INJURED/ILL
Acute Disaster Phase
The psychiatrist has a broad view of medical and psychiatric etiologies ofalterations in human behavior. Many medical etiologies effect changes in behavior.
Head injuries need to be recognized and triaged for timely surgical or neurologicalassessment and intervention. Due to the chaotic and disorganizing effects of disasters,
initial triage is often inefficient and groups that look similar will be mixed. Intoxication
and withdrawal phenomena, such as delirium tremens, commonly alter mental status.
Differentiating between the etiologic chemical agents involved is essential to direct thepatients to appropriate treatment. Infections such as CNS malaria, hepatitis, andtuberculosis, though much more prevalent in the third world, remain a consideration ofwhich the clinician needs to be vigilant. It must also be remembered that disasters suchas earthquakes may cause increased spread of pathogens such as cryptococcus.
Common things happen commonly. Dehydration and fatigue, in both victims andrescue workers, can significantly degrade adaptation and performance. The mental healthinterventions of water and rest are simple and curative. The military literature is repletewith vignettes of how adequate water intake, rest, and respite are necessary for continued
effective functioning in high stress environments.
Additionally psychiatry contributes to understanding the co-morbidities which
increase with physical injury, such as the twofold increase in the risk for Post-TraumaticStress Disorder in those who are physically injured.
In the initial stages after a disaster, efficient triage of casualties is the major
priority. As noted earlier, the disaster-trained psychiatrist is the mental health expert
ideally suited to triage because of his ability to distinguish medical and surgicalconditions presenting as alterations in behavior or cognition. After triage assessments,
acute definitive care can be delivered. The first interventions to improve the recovery
environment are encouraging rest, respite, providing information, and locating family
members as well as the standard psychiatric intervention of letting those exposed tell theirstories to organize the extraordinary events that have occurred.
While individuals from other mental health disciplines can seek out clinicalexperiences in working with the medically ill and dying, all psychiatrists are exposed tothese difficult circumstances as part of their medical training. Intensive and critical caresettings as well as bum and rehabilitation units pose special challenges for clinicians andrequire special training and experience. Psychiatrists can play a central role in supporting
patients and their families as well as nursing and other care providers.

15

In the aftermath of a disaster, patients with somatoform disorders or somatizing
mental defenses may present in increasing numbers for reassurance to already over­burdened emergency services. Providing information during triage may effectively treat
this population while simultaneously utilizing resources more efficiently. Anothercommon behavior of which to be alert is patients' self-medication with alcohol and othersubstances for anxiety and depression symptoms.
Subacute or Hospital Phase
Identifying and treating high risk groups in the days and weeks immediately
following a disaster targets interventions to maximize benefits with limited resources.
Victims in the hospital with physical injury have a clear marker of significant life threat,an essential component of the stressor criteria of PTSD and ASD, and are at higher risk
for Post-Traumatic Stress Disorder. After surviving, rehabilitation becomes the next taskof the patient, assimilating the changes of body and self-image after the trauma.
Consultation psychiatrists have great experience in helping patients understand theirillness. Translating medical terminology into lay terms and preparing the patient tocooperate fully in their rehabilitation are important tasks. For example, amputees havemultiple obstacles they must overcome to effectively engage in rehabilitation. Pain
control and mourning the loss of a limb are primary issues faced. Then, cooperation withrehabilitation to build compensatory function in remaining limbs and to begin to workwith a prosthesis becomes important. The maintenance of hope and the capacity tocooperate fully during recovery is essential. The professional element of support during
this time period is equally critical for those at risk. The emotional numbing of a Post­
Traumatic Stress Disorder or the social withdrawal accompanying a Major Depressive
Disorder can have a significant impact on the patient's ability to use rehabilitative
resources as well as family supports during this time of increased stress.
Recovery Phase
Wounds, people, and communities heal. Managing the way in which the trauma
is assimilated into the individual or community can affect both the rate and quality of thehealing. Psychiatry is a rehabilitative specialty that is constantly helping in the process of
assimilation.
Trauma alters the recipient's sense of himself. The victim's basic assumptions oflife (i.e., invulnerability, justice, physical intactness) are challenged by the extraordinary
events of a disaster. The trauma does not go away. The ways in which trauma shapes thevictim's life and the processing of these negative experiences can be managed to change
feelings of helplessness and defeat into a sense of mastery and competence. Psychiatriccare should help share what is learned from those who gain a mastery over events and aid
those who are defeated and·reexperiencing helplessness to have a more competent
response.

16

INTERNATIONAL
Medicine has an international valence and, therefore, in cultures which are notreceptive to mental health professionals per se, a psychiatrist can gain entree by virtue ofhis medical/osteopathic degree. In such countries, the psychiatrist's consultation to otherphysicians can facilitate the provision of sound psychiatric treatment. A particular focus
of concern should be cultural tendencies to over- or undermedicate individuals withpsychological and behavioral responses to trauma. For example, the psychiatrist can beof particular help in the differential diagnosis of PTSD versus psychosis in settings inwhich early dissociative symptoms might be mistaken for a psychotic disorder and overly
medicated. Psychiatrists attuned to the cultural norms of the society are well-positioned
to assist in recognizing somatic presentation of psychiatric conditions as well as
medical/surgical illness presenting as disturbances of mood, thought or behavior.

NUCLEAR /BIOLOGICAL/CHEMICAL (NBC) ACCIDENTS AND TERRORISM
The management of fear created by nuclear/ biological/chemical (NBC) accidents
and terrorism is a key principle in responding to such disasters. To many, the thought ofbeing exposed to an invisible agent is more frightening than the prospect of physicalinjury or death by conventional weapons. In the course of their medical education,
psychiatrists are exposed to terror in a wide variety of settings: the acutely injured or
those in refractory pain, the terminally ill, those lost in another reality and so forth.
Cognizant of the pathophysiology created by various agents and of the differential
diagnosis of acute and chronic toxic exposure, psychiatrists have the ability tocomprehend the medical issues and to communicate them in a manner which reduces
rather than heightens anxiety and fear. Assistance in managing fear is useful not only forlay people, but also for medical personnel. Recent experiences with the flight of medical
caregivers from Ebola-infected patients and earlier problems in caring for HIV-infectedpatients underscore the importance of assisting medical personnel to maintain a task focus
through managing fear effectively.
Psychiatrists are uniquely positioned to evaluate changes in physical and mental
function. By virtue of their medical training, they have the ability to observe andconsider the possibility of NBC as an etiology for illness. This is of particularimportance in terrorism in which the deployment of both chemical and biological agentsto cause immediate and delayed actions through contamination and disease transmission
is a cause for concern. The psychiatrist's ability to think about illness from anepidemiological perspective can play a critical role in the rapid detection and intervention
for such complicated exposures.

t
I

~

17

The use of explosives is perhaps the most common weapon of terror used byterrorists. The psychiatrist's ability to work with the injured and their families in a
medical setting is a valuable skill. Similarly, the psychiatrist's provision of support to therescue and hospital personnel in the wake of such severe trauma facilitates the recovery
of both the injured and their friends and family.
As in the case of natural disasters, the psychiatrist's participation in education ofother medical personnel in the recognition and treatment of psychiatric disorders in thoseseeking attention for medical problems is an important contribution.
MANAGEMENT OF INFORMATIONThe coordinator of disaster efforts should establish a channel of communication
with the media to be certain that there is proper and efficient communication with the
public concerning the disaster, all rescue efforts, and the aftermath. The psychiatricconsultant can provide advice to the coordinator on certain issues which may be helpfulin shaping the nature of the communications which are given to the media. The
psychiatrist can also make it known that he or she will be available to be a resource to themedia and/or be interviewed concerning mental health issues related to the disaster andits aftermath. The psychiatric consultant to the media should consider the following
issues:Rumors and Panic
A major event such as a disaster inevitably brings forth rumors about the cause,
consequences, number of deaths, casualties and expected reoccurrence of the disaster.
Responsible experienced members of the media are usually quite careful to be especiallyaccurate in these situations. However, less experienced reporters or sources to the media
might not readily distinguish between speculative rumors as compared to verified facts.
Attempts to conceal facts and situations, no matter how horrifying or tragic, standa good chance of being magnified by unofficial rumors which leak around the official
spokesperson. The public will be much less likely to develop or continue panic behavior
if they believe they are receiving truthful information from reliable sources. Most helpful
is to have such information analyzed by a credible expert who can put any frightening
information into a proper perspective.
Death Notification
The role of the media is to announce the names of persons injured and killed in adisaster. The media representatives will usually respect a request to delay for a short time
publishing or announcing ·actual names of persons until death notification to the family ismade, especially if they believe they are being given accurate details of the number ofcasualties and the circumstances. The psychiatrist can provide important input to themedia on the psychological impact of both of the above topics.

18

Public Education
In the aftermath of a disaster, the mental health experts will want to prepare
primary victims and secondary victims of the disaster as to what to expect in regard to thedevelopment of symptoms of acute stress and post-traumatic stress. This includes
providing information to victims' family members, parents of children involved, relativesof emergency rescue personnel, employers, etc. Even people who have only heard about
the disaster may be troubled by nightmares and other bothersome symptoms. Therefore,
this information will be useful to the general public as well as to specific groups which
are directly involved. The media, both print and electronic, will want to do stories about
these issues. They will also want to do stories at the anniversary of an event. The
psychiatrist should be a resource for these stories and also be available for interviews.
The media should also be provided, in a timely manner, the time and location of
any open counseling sessions or debriefing sessions that are being set up for specificgroups or for the general public.
Post-Traumatic Stress Symptoms of Media Personnel
Members of the media will expose themselves as much as possible to the "event".
They will witness, examine, film, and tape all the horrifying events and interview victims.
Constant frequent exposure to such events without much sleep is quite common. This
includes people behind the scene who edit the tape, rewrite stories, view pictures, etc.
Members of the media are candidates for the development of Acute Stress and Post­
Traumatic Stress Disorders.
This is a neglected population that will benefit from group discussion, debriefing
and being made aware of the effects of their work on themselves and their families. Since
psychiatrists may be involved as resources to the media about mental health issues
concerning disaster, they may be in a position to have contacts to arrange such meetings
for the media members, themselves.
CONCLUSION
The Psychiatrist As Physician
Psychiatrists bring a wide range of skills and expertise useful for preparing forand responding to disasters. In the aftermath of a disaster, the medical skills of thepsychiatrist are most valuable. Basic first aid and CPR can prove very helpful. A calm,
professional approach helps prevent panic. Assistance at triage stations and leadership tocoordinate an organized response may prove lifesaving. The ability to distinguishbetween common reactions of hyperarousal from pathological ones ensures appropriate
management of individuals.

19Medical training prepares psychiatrists for recognizing illness and developing
differential diagnoses. This fund of knowledge is helpful in identifying the etiology(ies)of altered mental status, especially in the aftermath of trauma where medical illness or
injury can be inappropriately diagnosed as psychiatric and vice versa. Knowledge ofpharmacology and experience with anticholinergic agents is valuable in responding tochemical agents, whether delivered by terrorists or through industrial accidents.
Microbiology and virology education helps the psychiatrist recognize and appropriately
treat or refer biological casualties. The psychiatrist's role as a medical authority
facilitates communication across a wide range of professional boundaries: interactingwith community officials, disaster response agencies, police, fire and rescue, school
systems, hospital staff, and medical personnel, to name but a few. The psychiatrist's
familiarity with an epidemiological approach to understanding disease in a group context
is invaluable in the context of disasters. This model is a useful tool in identifying highrisk groups for psychological distress based on exposure to trauma (e.g., body retrieval
workers), vulnerable groups such as the elderly and children, and "vectors" of diseasesuch as communicators of fear via rumor or media. The psychiatrist's use of adevelopmental model for human behavior assists in helping individuals and inrecognizing their vulnerabilities and resilience throughout the life cycle. Similarly,
knowledge of the natural history and epidemiology of disease is helpful in correctly
identifying all factors contributing to an individual's physical and/or emotional distress.
Expertise in Human Behavior
In addition to general medical assessment and interventions, the psychiatrist
brings a number of specialized medical skills. The psychiatrist is knowledgeable of theassessment and differential diagnosis of disorders of cognition, affect, and behavior.
He/she is especially helpful in situations in which psychiatric disorders occur co­morbidly with medical conditions. Facility with medical, psychological andsocio/cultural interventions allows the psychiatrist to choose from a broadarmamentarium of treatments. In addition to prescribing medications for psychiatricdisorders, psychiatrists also provide symptomatic relief as appropriate for sleep problems
and hyperarousal. Usual attention must be paid to the potential of organic brain disorders
and suicidal/homicidal ideation.
Consultation
Psychiatrists have a number of educational experiences which provide them withexpertise in disaster consultation. Child training in the general residency or in fellowshipprovides a background in consulting to non-medical organizations and leaders such as
school principals, teachers, and guidance counselors. Consultation/liaison andEmergency Psychiatry training provide a firm foundation in working with the medicallyill and their primary treatment team, chaplains, families and others in a hospital setting.
It also exposes psychiatrists to experience with acute emergencies and a broad range oforganic brain disorders.

20Psychiatrists are well-suited to provide consultation to disaster organizations suchas the Red Cross, FEMA and emergency systems as well as community leaders. The
physician's medically based connections with these institutions are very helpful ingaining entree. The medical identity also facilitates participation across internationalboundaries.
Psychiatrists enjoy special psychotherapeutic skills useful in disasters.
Experience in working with injured patients and the management of associatedhyperarousal are very helpful following catastrophes. Similarly, psychiatrists' ability todeal with issues of death and dying are prominent also in disaster work. The importanceof sleep management and the judicious use of medications is an important contribution.

21

22

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APPENDIX A

Disasters are not always nonpartisan events. Consider floods, for example:
people who build on flood plains because the land is inexpensive represent a group withspecial characteristics such as a tendency toward a lower socioeconomic level and all the
special personal characteristics of individuals willing to live on a flood plain. Groups ofindividuals exposed to cataclysmic events may sr.are certain characteristics associatedwith their own sets of vulnerabilities and protective factors from effects of disaster.
Examples of such special populations include combat veterans (Helzer, Robins, &McEvoy, 1987), children, and rescue workers. Therefore it is important to consider thecharacteristics of the affected population when considering disaster-related activities.
The number and scope of disaster-affected persons may be larger than realized,
and may include not only the individuals trapped in the immediate disaster situation, butalso their family and close friends, peers and other acquaintances, rescue workers,
disaster relief (e.g., Red Cross, mental health volunteers) and agency personnel (e.g.,
insurance adjusters), if not to some degree the entire community. In some disasters suchas national catastrophies (e.g., the Oklahoma City bombing) the affected population may
also include regional, national, and international news audiences who may be deeply
affected by the intensity of live video accounts. The affected population may also include
individuals inconvenienced by a disaster's physical effects, (e.g., blocked roads and lossof electrical power), but also those affected by other types of disaster effects such as
economic losses (e.g., tourist trade curtailed on tropical islands due to recent hurricanes).
Different types of disasters are thought to elicit different responses from affected
populations (Gieser, Green, & Winget, 1981; Beigel & Berren, 1985; Baum, Fleming, &Davidson, 1983 ). Technological accidents may evoke higher rates of psychiatricdisorders than natural disasters (Baum, Fleming, & Davidson, 1983), although willfulacts of terrorism are thought to evoke the most severe reactions (Weisaeth & Eitinger,
1993 ). Disaster-specific contributors to severity of impact may include the associateddegree of terror (i.e., threat to life or limb) and horror (i.e., grotesque scenes), suddennessof onset, duration of impact, intensity of impact, degree of damages (e.g., number ofcasualties; personal injury and property damages), and grief over loss of loved ones
(Green, 1990; Green, 1993). Disasters with several of these properties are thought topromote the highest risk for severe psychiatric impact.

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Besides predisposing characteristics of populations exposed to disasters, pre­existing individual considerations affect personal response to traumatic events. In
disaster studies, the personal factor most predictive of psychiatric problems after the
event is pre-existing psychiatric illness, which is highly predictive of post-disaster
psychiatric illness (North, 1995). With increasing magnitude of the disaster agent andincreasing exposure to it, however, personal vulnerability appears to be less predictive, as
more individuals without previous psychological problems are affected (Hocking, 1970;
Shore, Tatum, & Vollmer, 1986; Feinstein & Dolan, 1991; Breslau & Davis, 1992;
Smith, North, & Spitznagel, 1993). Other personal predictors ofrisk for post-disaster
psychiatric problems include loss of a loved one, litigation, female gender, advanced age,and lower socioeconomic status (Gieser, Green, & Winget, 1981; Moore & Friedsam,
1959; Lopez-Ibor, Jr., Canas, & Rodriguez-Gamazo, 1985; Steinglass & Gerrity, 1990;
Weisaeth, 1985; Kasi, Chisholm, & Eskenazi, 1981; Leopold & Dillon, 1963).
The psychiatric disorder classically associated with disasters is post-traumaticstress disorder (PTSD). Studies of disasters have reported widely varying rates of PTSD,
as low as 2% following a volcano (Shore, Tatum, & Vollmer, 1986), 4% after torrential
rain and mudslides (Canino, Bravo, Rubio-Stipec, & Woodbury, 1990), and 4%-8%
following flooding and exposure to dioxin contamination (Smith, Robins, Przybeck,
Goldring, & Solomon, 1986). Other researchers have reported much higher rates of
PTSD: 44% after a dam break and flood (Green, Grace, Lindy, Gieser, Leonard, &Kramer, 1989), 53% following bushfires (Mcfarlane, 1986), and 54% following anairplane crash landing (Sloan, 1988). Although only a minority of survivors of mostdisasters develop diagnosable cases of PTSD, some symptoms may be abundant or evenuniversal (Edwards, 1976; Boyd, 1981; Smith, Robins, Przybeck, Goldring, & Solomon,
1986; Breslau & Davis, 1987; North & Smith, 1990; Norris, 1992; North, Smith, &Spitznagel, 1994).
Research indicates that other psychiatric disorders often accompany PTSD in
disaster survivors. The most prevalent co-existing disorders appear to be major
depression and anxiety disorders (Smith, North, McCool, & Shea, 1990; North & Smith,1990). Given the well documented potential for improvement with treatment, these
disorders should not be overlooked in evaluation of disaster survivors for post-traumatic
symptoms. Because of the significant association of post-disaster psychopathology withpredisaster psychiatric illness, a complete psychiatric past history of these disorders aswell as substance abuse should be taken and considered carefully in assessment andplanning of treatment for disaster survivors.
The natural history of PTSD is that it often begins within hours, and usually
within a few days, of the traumatic event. Delayed onset (by definition, beyond six
months) is uncommon, although cases beginning later, as many as years after the event,
have been described. A study of the Buffalo Creek dam break and mudslides found that
20% of all PTSD cases identified were delayed cases (Grace, Green, Lindy, & Leonard,1993). Helzer's group (Helzer, Robins, & McEvoy, 1987) found that 16% ofpost­
Vietnam PTSD cases had delayed onset.

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PTSD symptoms typically begin to fade within weeks of the event, although thiscan vary considerably. Helzer's group (Helzer, Robins, & McEvoy, 1987) found thatabout half of cases in the general population resolved by six months. Chronic PTSD withsymptoms persisting for many years, however, has also been described, including one­
third of the cases persisting for at least three years in the Helzer et al. (Helzer, Robins, &McEvoy, 1987) study. Chronicity has been predicted by the presence of pre-existing
psychiatric disorders, neuroticism, a history of early separation from parents in childhood,and family history of anxiety or antisocial behavior, as well as litigation (North, 1996).
The most marked chronicity in PTSD sufferers has been observed in prisoners of war,among whom 50% to 90% have been found to have active PTSD after forty years(Sutker, Allain, & Winstead, 1993; Engdahl, Speed, Eberly, & Schwartz, 1991).
Not to be overlooked is the resilience of people after disasters. In spite of theoverwhelming prevalence of PTSD symptoms after extreme traumas, the majority ofsurvivors do not become psychiatrically ill. Reassuring these individuals that their
symptoms represent normal responses to extreme events, and helping them re-establish
their equilibrium, goes a long way toward helping them cope with such extreme
situations.
Gender Effects
There are few data pertaining specifically to women following major disasters.
The field of psychiatric response to disaster is relatively new, as is the concept ofcomparing women to men; hence, the marriage of the two phenomena has rarely occurredin the research literature to date. In the general population, however, it is well
documented that women are more prone to depressive and anxiety disorders than aremen, although men greatly outpace women in substance use disorders (Weissman, Bruce,
Leaf, Florio, & Holzer, III, 1991; Blazer, Hughes, George, Swartz, & Boyer, 1991;
Helzer, Burnam, & McEvoy, 1991; Anthony & Helzer, 1991; Helzer, Robins, &McEvoy, 1987; Breslau, Davis, Andreski, & Peterson, 1991). Therefore, it is not
unexpected that in extreme situations such as disaster, women, compared to men, might
be especially prone to depressive and anxiety disorders, including PTSD (as opposed to
substance abuse for men). In numerous disaster studies, women have been shown to havesignificantly higher rates of post-disaster psychiatric disorders than men (Shore, Vollmer,& Tatum, 1989; Kaltreider, Gracie, & LeBreck, 1992; Palinkas, Petterson, Russell, &Downs, 1993; Grace, Green, Lindy, & Leonard, 1993; Smith, North, & Spitznagel, 1993;
Steinglass & Gerrity, 1990; North, Smith, & Spitznagel, 1994). Women are found to be
more likely than men to visit physicians and to take medication after disasters (North,
Smith, & Spitznagel, 1994). Therefore, health professionals may represent a potentiallymore useful source of post-disaster intervention for women than for men.

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34

APPENDIXBChildren
The psychological effects of natural disaster on children and adolescents has
become an emerging focus of study (Lipovsky, 1991). In recent years reports have been
published on the psychological responses of children and adolescents to hurricane, fire,
earthquake and flood (Bloch et al., 1956; Newman, 1976; Green et al., 1991, 1994;
Bradburn, 1991; Burke et al., 1986; Yacoubian et al., 1989; Garrison et al., 1993; Honig
et al., 1993; Mcfarlane, Policansky & Irwin, 1987; Pynoos et al. 1993; Shannon et al.,
1994; Shaw et al., 1995). The spectrum of post-traumatic stress symptomatology inchildren and adolescents generally parallels the psychological responses of adults tooverwhelming disaster. Acute psychological responses to natural disaster include trauma
specific fears, fears of recurrence, regressive behavior, externalizing symptoms,
behavioral reenactments, post-traumatic play, avoidance of "traumatic reminders",
detachment, anxiety and depressive disorders, school problems, symptoms ofphysiological hyperarousal and changed attitudes about the self, world and future (Blochet al., 1956; Burke et al., Green et al., 1991, 1994; 1986; Newman, 1976; Pynoos et al,
1987; Terr, 1981, 1983). Psychological trauma associated with exposure to an
overwhelming stressor may be etiological for a number of psychiatric disorders i.e.
Major Affective Disorders, Attention Deficit Hyperactivity Disorder, Phobic Disorder,
Anxiety Disorders, Dissociative Disorders, Substance Abuse, Conduct Disorder,
Somatoform Disorders, Personality Disorders such as Borderline Personality Disordersetc. (Terr, 1991, Breslau, 1991, Hubbard et al., 1995)
It is only recently that investigators have begun to attempt to delineate between
the short term and long term psychological effects associated with exposure to disaster.
(Mcfarlane, 1987; Lipovsky, 1991, Pynoos, 1993, Shaw, et al., 1995) Increasing
attention has been focused on the acute psychological and psychiatric comorbidity foundwith the core post-traumatic symptomatology. (Breslau, 1991; Saigh, 1991; Sullivan, etal., 1993; Goenjian et al., 1995) There is evidence that the prevalence of post-traumaticstress symptomatology in children is high in the immediate aftermath of disaster andremains particularly high for females for sustained periods oftime (Green et al.,1991,1994, Shaw et al., 1995). Shaw et al., (1995) suggested that while initially otherindices of behavioral and emotional distress may be dampened there is a rapid reboundwith increasing severity and diversity of emotional and behavioral problems over time
(Mcfarlane, 1987, Shaw et al., 1995).

The increasing severity and diversity of psychological and psychiatric symptom
configurations appear to be related to the unfolding of the "secondary stressors"
associated with the inventory of losses related to the destruction of the community, lossof home, unemployment, marital and family discord, disruption of peer groups, economic
hardship, slow rates of recovery and restoration, exposure to "traumatic reminders" andincreased indices of social maladjustment i.e. school absenteeism, divorce, childmaltreatment etc. Goenjian et al. (1995) found that subsequent to the Armenia
earthquake of 1988, children manifested significant psychiatric comorbidity to include

35

PTSD, PTSD-depression, depression and separation anxiety. Pynoos (1993) has notedthat the long term post-traumatic stress related pathologies include "chronic PTSD,
comorbid mental and physical conditions, develop-mental and personality disturbances,
and age appropriate indications of dissatisfactions and lack of well being". In follow-up
studies of children after the Buffalo Creek disaster, Green et al. (1991, 1994) noted that
two years after the disaster, 37% of the children and adolescents were given a "probable"
diagnosis of PTSD and that 17 years after the disaster 7% of those re-evaluated had
PTSD and all of these individuals were women. Green, et al. ( 1991) found that the risk
factors that best predicted continuing post-traumatic symptomatology was degree of life
threat, parental psychopathology, being female and an irritable and or depressed family
atmosphere. Honig et al., (1993) observed that there is a spectrum of "adaptational
possibilities" found in children 20 years after the Buffalo Creek Disaster which wererelated to the family's initial response to the disaster and that psychopathology in thechildren resonated with parental psychopathology.
The increasing awareness of psychological and psychiatric comorbidity associatedwith the stress response syndromes has resulted in increasing recognition that mental
health personnel sensitive to the complexity of biopsychosocial issues have to beavailable in the immediate aftermath of disaster. There are at least five categories ofchild psychiatric victims after disaster: 1) Children who were previously defined as
psychiatrically disturbed and who were receiving psychotropic medication i.e. Psychotic
children, Mood Disorders, Attention Deficit Hyperactive Disorder, Tourette's, Obsessive
Compulsive Disorder and whose conditioned worsened due to the lack of access to
medications; 2) Children who had previously existing psychosocial and psychiatricproblems which exacerbated under the additional stress of the disaster with increasing
psychiatric comorbidity; 3) Children who under the impact of the stressors associatedwith disaster develop classical post-traumatic stress symptomatology, 4) Children who
respond to the disaster with psychiatric comorbidity to include depression, anxiety andsomatoform disorders i.e. vague pains, gastrointestinal complaints, headaches, dermatitis,
conversion reactions etc.; and 5) Children who upon exposure to the continuing
psychosocial and familial adversity after the disaster begin to manifest emotional andbehavioral problems such as psychophysiological manifestations of stress i.e. asthma,
gastrointestinal disorders, vague aches and pains, symptoms of depression, suicidal
behavior, aggressive dyscontrol problems, Attention Deficit Hyperactivity Disorder,
antisocial behavior, and Substance Abuse etc.
The role of the child psychiatrist is many faceted. Initially the child psychiatrist
trained in the biopsychosocial dimensions of emotional and behavioral problems will act
both in the role of primary care physician and discerner of the biological substrate facetsof psychological problems. His expertise in assessment, differential diagnosis andbiological substrate variables enables him to recognize psychiatric andpsychophysiological reactions requiring immediate medical-psychiatric treatment. It is a
maxim of military medicine that the most qualified and credential physician is the one
most skilled to do triage and sort out patients to appropriate avenues of intervention. The
child psychiatrist's training in multiple systems makes him particularly skilled to36,Iinterface with the medical-community-school milieu both as a consultant and a resource.
It is apparent that in the post-disaster period that there is an increasing widening of
emotional and behavioral problems requiring the attention of child psychiatrists sensitive
not only to the psychosocial matrix but also to the biological substrate and thebiopsychosocial dimensions of the stress response syndromes.

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