Disaster psychiatry

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Disaster psychiatry is a field of psychiatry which focuses on responding to natural disasters, climate change, school shootings, large accidents, public health emergencies, and their associated community-wide disruptions and mental health implications. [1] All disasters, regardless of exact type, are characterized by disruption: disruption of family and community support structures, threats to personal safety, and an overwhelming of available support resources. [2] Disaster psychiatry is a crucial component of disaster preparedness, aiming to mitigate both immediate and prolonged psychiatric challenges. Its primary objective is to diminish acute symptoms and long-term psychiatric morbidity by minimizing exposure to stressors, offering education to normalize responses to trauma, and identifying individuals vulnerable to future psychiatric illness. [3]

Contents

Psychiatric Outcomes of Disasters

Normal and Pathological Trauma Response

Psychiatric responses to trauma and disaster encompass a spectrum of emotional and behavioral reactions in individuals. These reactions may include anxiety, fear, sadness, numbness, as well as disturbances in sleep, cognition, and mood. Additionally, an uptick in substance use is commonly observed. [2] Formal psychiatric diagnoses commonly associated with exposure to acute traumatic events include Post-Trumatic Stress Disorder (PTSD) (intense feelings of terror, intrusive thoughts, and avoidance of emotional triggers, present for more than 1 month), and Acute Stress Disorder (ASD) (similar symptoms to PTSD but lasting less than 1 month), as well as Major Depressive Disorder MDD, separation anxiety disorder, substance abuse disorder, insomnia, and suicide. [4] Psychiatric disturbances post-disaster can be attributed to various factors, including exposure to toxins, illness, dehydration, or acute injuries (such as traumatic brain injury) directly resulting from involvement in the disaster. [1] Psychiatric illness may affect individuals with no known previous psychiatric history before the disaster. For example, after the Oklahoma City bombing, 40% of those with diagnosed MDD or PTSD had no previous psychiatric history prior to the attack. [2] While research has explored whether certain types of disasters are more prone to causing psychiatric morbidity, the evidence suggests that the severity of a disaster is more influential than its exact typology. [2]

Risk Factors and Assessment of Patients

One of the critical roles of the disaster psychiatrist is identifying individuals more prone to developing genuine psychiatric illnesses in response to a disaster, beyond the typical stress-response. The likelihood of future psychiatric morbidity increases with the intensity of traumatic stressors encountered. [2] [1]

Associated Risk Factors: [2] [1]

Assessment can involve the use of standardized screening scales, such as the PCL-5 PTSD scale, which can be completed in 5–10 minutes, although this scale has not been validated in the disaster setting. [2]

Role of the Psychiatrist in Disaster Preparedness and Response

Unique Features of Disaster Psychiatry

In contrast to conventional psychiatric care, disaster psychiatry prioritizes mental health over disease states. The initial primary focus after a disaster is on individuals undergoing a transient and normal psychological response to a traumatic event. In this paradigm of care, less emphasis may be placed on assigning diagnostic labels prematurely. Second, disaster psychiatry follows a preventative medicine model that is more akin to the investigation and outbreak of an infectious disease. In this paradigm, the pathogen (psychiatric symptoms), the source (traumatic event/disaster), and the exposed individuals (patients) are identified. [1]

Disaster Preparedness

Incorporating psychiatric professionals into community-level disaster planning facilitates their introduction to various stakeholders, including local police, fire departments, schools, and government officials. The principal aim of psychiatry in disaster preparedness is to proactively prevent exposure to stressors, ultimately avoiding disasters or minimizing their impact on individuals. Hospitals are mandated to have a disaster response plan to meet accreditation requirements, such as those outlined by JCAHO, which can include considerations for the psychiatric elements of disaster response, making stakeholders aware of available resources and potential adverse effects on community mental health resulting from disasters. [1]

Additionally, the preparedness of local psychiatric resources can be tested with through disaster exercises, identifying areas of weakness and ways to increase the capacity of mental health systems to respond to increase demands during disasters. [5]

Acute Intervention  

Natural resilience in the face of disaster is common, and most victims (70-90%) do not need formal psychiatric treatment. First-year PTSD prevalence is 10-20% in the general population after a disaster (higher in disaster workers), with about 25% of those with PTSD symptoms going on to experience chronic dysfunction. [2] Early interventions are crucial for addressing PTSD symptoms after a disaster, as symptoms meeting full diagnostic criteria may not immediately manifest In the initial disaster stages. [2] Psychiatrists may be on-site at the disaster area to emphasize limiting exposure to distressing scenes (scenes of violence, deceased bodies, etc.) and ensuring victim privacy, informing future response planning. [6] [1]

Debriefing, held shortly after an event, normalizes stress responses, aids psychological recovery, corrects cognitive distortions, and helps individuals return to social and work groups without formal evaluation, which some victims may be hesitant to participate in. [1] This debriefing may involve Psychological First Aid (PFA) – a broadly-applicable therapeutic framework which reduces stigma without formal diagnosis or treatment. PFA takes a flexible, educational, and supportive approach, focusing on psychological safety, community self-reliance, connectedness, and instilling hope by building personal strength. [2]

High-risk or severe cases may necessitate early intervention with psychotherapy, particularly Cognitive Behavioral Therapy (CBT), which is a well-studied early treatment focusing on social and emotional regulation. [2] Psychiatric medications, such as antidepressants, sleep aids, and anti-anxiety medications, may be considered for acute stabilization of severely impacted patients. SSRIs and SNRIs are typically first-line medications. [4] [2] Goals include managing symptoms, treating grief and loss, early recognition and treatment of psychiatric disorders, managing relapses of previously diagnosed psychiatric illness in response to disaster, and differentiating between normal and pathological responses to trauma. [4]

Community Intervention

The aftermath of a disaster often brings additional stress and disruption, largely influenced by the response to the event. Communities may feel overwhelmed by outsiders, including intrusive media and curiosity seekers, straining local resources like hotels and restaurants at a time when a community may be more interested in seeking solace and resources from within. [2] The disruption of psychiatric well-being is directly tied to the degree of community and workplace disruption, including disruption of economic resources. This impact can persist long after the disaster, evident in debates over memorial design and recurrent grief on anniversaries of the disaster. [1] Normalizing feelings of anxiety and fear using popular media is one approach to addressing these challenges. [1]

Related Research Articles

Neurosis is a term mainly used today by followers of Freudian thinking to describe mental disorders caused by past anxiety, often that has been repressed. In recent history, the term has been used to refer to anxiety-related conditions more generally.

Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being. Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the fight-or-flight response. These symptoms last for more than a month after the event. Young children are less likely to show distress, but instead may express their memories through play. A person with PTSD is at a higher risk of suicide and intentional self-harm.

Psychological trauma is an emotional response caused by severe distressing events that are outside the normal range of human experiences, with extreme examples being violence, rape, or a terrorist attack. The event must be understood by the affected person as directly threatening the affected person or their loved ones with death, severe bodily injury, or sexual violence; indirect exposure, such as from watching television news, may be extremely distressing and can produce an involuntary and possibly overwhelming physiological stress response, but does not produce trauma per se.

Adjustment disorder is a maladaptive response to a psychosocial stressor. It is classified as a mental disorder. The maladaptive response usually involves otherwise normal emotional and behavioral reactions that manifest more intensely than usual, causing marked distress, preoccupation with the stressor and its consequences, and functional impairment.

Acute stress disorder is a psychological response to a terrifying, traumatic or surprising experience. It may bring about delayed stress reactions if not correctly addressed. Acute stress may present in reactions which include but are not limited to: intrusive or dissociative symptoms, and reactivity symptoms such as avoidance or arousal. Reactions may be exhibited for days or weeks after the traumatic event.

Complex post-traumatic stress disorder (CPTSD) is a stress-related mental disorder generally occurring in response to complex traumas, i.e., commonly prolonged or repetitive exposures to a series of traumatic events, within which individuals perceive little or no chance to escape.

Gender is correlated with the prevalence of certain mental disorders, including depression, anxiety and somatic complaints. For example, women are more likely to be diagnosed with major depression, while men are more likely to be diagnosed with substance abuse and antisocial personality disorder. There are no marked gender differences in the diagnosis rates of disorders like schizophrenia and bipolar disorder. Men are at risk to suffer from post-traumatic stress disorder (PTSD) due to past violent experiences such as accidents, wars and witnessing death, and women are diagnosed with PTSD at higher rates due to experiences with sexual assault, rape and child sexual abuse. Nonbinary or genderqueer identification describes people who do not identify as either male or female. People who identify as nonbinary or gender queer show increased risk for depression, anxiety and post-traumatic stress disorder. People who identify as transgender demonstrate increased risk for depression, anxiety, and post-traumatic stress disorder.

Childhood trauma is often described as serious adverse childhood experiences (ACEs). Children may go through a range of experiences that classify as psychological trauma; these might include neglect, abandonment, sexual abuse, emotional abuse, and physical abuse, witnessing abuse of a sibling or parent, or having a mentally ill parent. These events have profound psychological, physiological, and sociological impacts and can have negative, lasting effects on health and well-being such as unsocial behaviors, attention deficit hyperactivity disorder (ADHD), and sleep disturbances. Similarly, children whose mothers have experienced traumatic or stressful events during pregnancy have an increased risk of mental health disorders and other neurodevelopmental disorders.

Stress-related disorders constitute a category of mental disorders. They are maladaptive, biological and psychological responses to short- or long-term exposures to physical or emotional stressors. The National Institute of Environmental Health Sciences categorizes Obsessive-Compulsive Disorder (OCD) and Post-Traumatic Stress Disorder (PTSD) as stress-related disorders. However, the World Health Organization's ICD-11 excludes OCD but categorizes PTSD, Complex Post-Traumatic Stress Disorder (CPTSD), adjustment disorder as stress-related disorders.

Prolonged exposure therapy (PE) is a form of behavior therapy and cognitive behavioral therapy designed to treat post-traumatic stress disorder. It is characterized by two main treatment procedures – imaginal and in vivo exposures. Imaginal exposure is repeated 'on-purpose' retelling of the trauma memory. In vivo exposure is gradually confronting situations, places, and things that are reminders of the trauma or feel dangerous. Additional procedures include processing of the trauma memory and breathing retraining.

Derealization is an alteration in the perception of the external world, causing those with the condition to perceive it as unreal, distant, distorted or falsified. Other symptoms include feeling as if one's environment is lacking in spontaneity, emotional coloring, and depth. It is a dissociative symptom that may appear in moments of severe stress.

PTSD or post-traumatic stress disorder, is a psychiatric disorder characterised by intrusive thoughts and memories, dreams or flashbacks of the event; avoidance of people, places and activities that remind the individual of the event; ongoing negative beliefs about oneself or the world, mood changes and persistent feelings of anger, guilt or fear; alterations in arousal such as increased irritability, angry outbursts, being hypervigilant, or having difficulty with concentration and sleep.

<span class="mw-page-title-main">Post-traumatic stress disorder among athletes</span> Prevalence of PTSD among athletes

Posttraumatic stress disorder (PTSD) is a cognitive disorder, which may occur after a traumatic event. It is a psychiatric disorder, which may occur across athletes at all levels of sport participation.

<span class="mw-page-title-main">Richard Bryant (psychologist)</span> Australian psychologist

Richard Allan Bryant is an Australian medical scientist. He is Scientia Professor of Psychology at the University of New South Wales (UNSW) and director of the UNSW Traumatic Stress Clinic, based at UNSW and Westmead Institute for Medical Research. His main areas of research are posttraumatic stress disorder (PTSD) and prolonged grief disorder. On 13 June 2016 he was appointed a Companion of the Order of Australia (AC), for eminent service to medical research in the field of psychotraumatology, as a psychologist and author, to the study of Indigenous mental health, as an advisor to a range of government and international organisations, and to professional societies.

Operational stress injury or OSI is a non-clinical, non-medical term referring to a persistent psychological difficulty caused by traumatic experiences or prolonged high stress or fatigue during service as a military member or first responder. The term does not replace any individual diagnoses or disorders, but rather describes a category of mental health concerns linked to the particular challenges that these military members or first responders encounter in their service. There is not yet a single fixed definition. The term was first conceptualized within the Canadian Armed Forces to help foster understanding of the broader mental health challenges faced by military members who have been impacted by traumatic experiences and who face difficulty as a result. OSI encompasses a number of the diagnoses found in the Diagnostic and Statistical Manual of Mental Disorders (DSM) classification system, with the common thread being a linkage to the operational experiences of the afflicted. The term has gained traction outside of the military community as an appropriate way to describe similar challenges suffered by those whose work regularly exposes them to trauma, particularly front line emergency first responders such as but not limited to police, firefighters, paramedics, correctional officers, and emergency dispatchers. The term, at present mostly used within Canada, is increasingly significant in the development of legislation, policy, treatments and benefits in the military and first responder communities.

Early childhood trauma refers to various types of adversity and traumatic events experienced during the early years of a person's life. This is deemed the most critical developmental period in human life by psychologists. A critical period refers to a sensitive time during the early years of childhood in which children may be more vulnerable to be affected by environmental stimulation. These traumatic events can include serious sickness, natural disasters, family violence, sudden separation from a family member, being the victim of abuse, or suffering the loss of a loved one. Traumatic experiences in early childhood can result in severe consequences throughout adulthood, for instance developing post-traumatic stress disorder, depression, or anxiety. Negative childhood experiences can have a tremendous impact on future violence victimization and perpetration, and lifelong health and opportunity. However, not all children who are exposed to negative stimuli in early childhood will be affected severely in later life; some children come out unscathed after being faced with traumatic events, which is known as resilience. Many factors can account for the invulnerability displayed by certain children in response to adverse social conditions: gender, vulnerability, social support systems, and innate character traits. Much of the research in this area has referred to the Adverse Childhood Experiences Study (ACE) study. The ACE study found several protective factors against developing mental health disorders, including mother-child relations, parental health, and community support. However, having adverse childhood experiences creates long-lasting impacts on psychosocial functioning, such as a heightened awareness of environmental threats, feelings of loneliness, and cognitive deficits. Individuals with ACEs are more prone to developing severe symptoms than individuals in the same diagnostic category.

<span class="mw-page-title-main">Trauma and first responders</span> Trauma experienced by first responders

Trauma in first responders refers to the psychological trauma experienced by first responders, such as police officers, firefighters, and paramedics, often as a result of events experienced in their line of work. The nature of a first responder's occupation continuously puts them in harm's way and regularly exposes them to traumatic situations, such as people who have been harmed, injured, or killed.

<span class="mw-page-title-main">Dual representation theory</span>

Dual representation theory (DRT) is a psychological theory of post-traumatic stress disorder (PTSD) developed by Chris Brewin, Tim Dalgleish, and Stephen Joseph in 1996. This theory proposes that certain symptoms of PTSD - such as nightmares, flashbacks, and emotional disturbance - may be attributed to memory processes that occur after exposure to a traumatic event. DRT proposes the existence of two separate memory systems that run in parallel during memory formation: the verbally accessible memory system (VAM) and situationally accessible memory system (SAM). The VAM system contains information that was consciously processed and thus can be voluntarily recalled or described. In contrast, the SAM system contains unconsciously processed sensory information that cannot be voluntarily recalled. This theory suggests that the VAM system is impaired during a traumatic event because conscious attention is narrowly drawn to threat-related information. Therefore, memory of the trauma is heavily focused on fear, which affects information processing. This gives rise to PTSD symptoms such as trauma-related cognitions, appraisals, and emotions. The SAM system captures vivid sensory information during the traumatic event, which is automatically recalled through exposure to trauma-related triggers. This system is thought to be responsible for the presence of flashbacks and nightmares in PTSD symptomatology.

Being exposed to traumatic events such as war, violence, disasters, loss, injury or illness can cause trauma. Additionally, the most common diagnostic instruments such as the ICD-11 and the DSM-5 expand on this definition of trauma to include perceived threat to death, injury, or sexual violence to self or a loved one. Even after the situation has passed, the experience can bring up a sense of vulnerability, hopelessness, anger and fear.

Extreme weather events can have a significant impact on mental health, particularly in the form of post-traumatic stress disorder (PTSD). With the increasing frequency and severity of these events due to climate change, it is important to understand how they can lead to long-lasting psychological trauma and learn to provide support for those affected.

References

  1. 1 2 3 4 5 6 7 8 9 10 Norwood, Ann E.; Ursano, Robert J.; Fullerton, Carol S. (2000). "Disaster Psychiatry: Principles and Practice". Psychiatric Quarterly. 71 (3): 207–226. doi:10.1023/A:1004678010161. ISSN   0033-2720. PMID   10934746. S2CID   21207487.
  2. 1 2 3 4 5 6 7 8 9 10 11 12 13 Textbook of disaster psychiatry (2nd ed.). Cambridge: Cambridge university press. 2017. ISBN   978-1-107-13849-0.
  3. ↑ Norwood, Ann E.; Ursano, Robert J.; Fullerton, Carol S. (2000-09-01). "Disaster Psychiatry: Principles and Practice". Psychiatric Quarterly. 71 (3): 208. doi:10.1023/A:1004678010161. ISSN   1573-6709.
  4. 1 2 3 Saeed, Sy Atezaz; Gargano, Steven P. (2022-01-02). "Natural disasters and mental health". International Review of Psychiatry. 34 (1): 16–25. doi:10.1080/09540261.2022.2037524. ISSN   0954-0261.
  5. ↑ Raphael, B.; Ma, H. (March 2011). "Mass catastrophe and disaster psychiatry". Molecular Psychiatry. 16 (3): 247–251. doi: 10.1038/mp.2010.68 . hdl: 1885/53381 . ISSN   1476-5578.
  6. ↑ Raphael, B; Ma, H (2011). "Mass catastrophe and disaster psychiatry". Molecular Psychiatry. 16 (3): 247–251. doi: 10.1038/mp.2010.68 . hdl: 1885/53381 . ISSN   1359-4184. PMID   21331093.
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