Psychological first aid: Emergency care for terrorism and disaster survivors
Knowing the basics of psychic resilience can help you prevent long-term psychopathology and determine who needs medication and monitoring.
The night started like any other for Dr. Z. Kids in bed (too late) by 10:30, dog out by 11, fell asleep reading journal by 11:15. Sirens jolt her out of a solid stage 4. Her eyes widen, pulse quickens, mouth dries as she follows the glow of the TV into the living room. On TV, fire frames shots of tearful faces, body bags, and firefighters in protective suits. She catches the announcer’s voice: “…explosion at City Power and Light nuclear facility at 3:10 AM today. Fifty-five are known dead, and thousands are being told to evacuate. The blast’s cause is unknown, but terrorism is suspected.”
As her numbness slowly ebbs, Dr. Z’s questions rise insistently. How can I help the survivors? My patients? My children? What if the media call me? How could I have been better prepared for this?
Disaster shakes us to our human and biological core. More than any other clinical encounter, it reminds us that psychiatrists share the vulnerabilities of those we seek to help. Yet it also reminds us that even simple concepts and interventions can mobilize the healing process.
Are you ready to provide emergency psychiatric care following a disaster in your community—be it a nuclear accident, tornado, airplane crash, or terrorist act? Here is evidence—some counterintuitive—that can help you prepare.
‘Psychological first aid’ for disaster survivors
Re-create sense of safety
Encourage social support
Re-establish sense of efficacy
Human reactions to disaster are often conceptualized as the mammalian survival response: flight, fight, and fright (freezing). In most cases, these reactions are adaptive and dissipate after safety is restored. Posttraumatic stress disorder (PTSD) develops in about 5% of natural disaster victims and 33% of mass shooting victims. 1
Responses that do go awry appear to be associated with abnormally low cortisol and persistent adrenergic activation, leading to sensitization of the fear response. 2 Reminders of trauma or persistent stressors—such as pain, problems with finances or housing, or bereavement—may exacerbate sensitization. On the other hand, preclinical studies suggest that social support 3,4 and active coping 5 mitigate physiologic stress responses, confirming numerous clinical observations that associate lack of social support and avoidant coping with eventual PTSD development.
Three basics. Just as our emergency medicine colleagues must often revert to life-support basics, we must remind ourselves of biology’s three basics for psychic resilience:
- safety (including—as much as possible—protection from reminders of trauma and ongoing stress)
- meaningful social connection
- re-establishing a sense of efficacy to overcome helplessness (Table 1).
Like the stress response, these protective factors seem hard-wired into our biological make-up. They form the foundation for all phases of disaster psychiatry interventions, from planning to immediate interventions through longterm follow-up.
As a mental health professional, plan to operate within established disaster plans and agencies, not only for the sake of efficiency but also because structure and support are paramount in disaster situations. Check with the American Psychiatric Association’s local branch to determine if a disaster mental health plan exists. If not, explore how to work directly with local American Red Cross chapters and hospitals, which recruit personnel for the Disaster Medical Assistance Teams mobilized by the public health service.
Normal reactions to disaster for adults and children
Shock, fear, grief, anger, guilt, shame, helplessness, hopelessness, numbness, emptiness Decreased ability to feel interest, pleasure, love
Confusion, disorientation, indecisiveness, worry, shortened attention span, poor concentration, memory difficulties, unwanted memories, self-blame
Tension, fatigue, edginess, insomnia, generalized aches and pains, startling easily, rapid heartbeat, nausea, decreased appetite and sex drive
Difficulties being intimate, being over-controlling, feeling rejected or abandoned
Children’s age-specific disaster responses
Separation fears, regression, fussiness, temper tantrums, somatization Sleep disturbances including nightmares, somnambulism, night terrors
May still have the above, as well as excessive guilt and worries about others’ safety, poor concentration and loss of school performance, repetitious re-telling or play related to trauma
Depression, acting out, wish for revenge, sleeping and eating disturbances, altered view of the future
Immediate disaster mental health plans vary in detail according to local needs and resources but should at least address:
- providing on-site interventions
- disseminating information about responses to trauma
- identifying and publicizing local mental health resources.
Immediately following a disaster, psychiatrists are frequently asked to assist with on-site crisis and medical interventions, evaluate survivors with unusual or intense reactions, and provide public education about psychological reactions to disaster.
On-site response. All responders, regardless of discipline, should provide disaster survivors with “psychological first aid,” which is directed at reestablishing safety, connection, and efficacy. Basic crisis intervention principles are useful when support and reassurance are not enough. 6
For example, relaxation exercises can reduce anxiety and improve sleep. Use focused, structured relaxation tools—such as progressive muscle relaxation and breathing training—as unstructured exercises can exacerbate dissociation and re-experiencing. Grounding techniques, by which survivors learn to focus all senses on immediate surroundings, often alleviate dissociation and flashbacks.
Care for children. Because children’s reactions to disaster greatly depend on their caregivers’ responses (social referencing), focus acute interventions for children on:
- re-connecting them with their families
- reducing caregivers’ distress
- educating caregivers about providing age appropriate information and support (see Related resources).
Medical care. As physicians, psychiatrists may be called upon to intervene medically. Although it is generally advisable to stay within our usual practice, medical personnel may be in short supply. Fortunately, Good Samaritan laws exist in every state, and the potential for a successful malpractice suit against a physician responding in a disaster is almost zero, unless the physician’s performance is grossly negligent (such as moving the neck of a patient with obvious head or neck injuries). 7
Principles regarding informed consent and right to refuse treatment—along with the usual exceptions—apply during disasters.
Evaluating survivors in shelters and hospitals requires knowing the normal and abnormal responses to disaster, being able to differentially diagnose changes in mental status, and understanding risk factors for trauma’s psychiatric sequelae. Aside from PTSD, trauma’s long-term effects include other anxiety disorders, depression, substance abuse, and eating disorders. In addition to the usual components of a psychiatric evaluation, assessments must address event-related factors such as proximity to the disaster, loss of significant others or property, physical injuries, immediate needs, and social support. 8
Normal stress reactions. Frequently described as “a normal response to an abnormal situation,” the normal stress reaction is multidimensional and depends on the person’s developmental level (Table 2). About 10% to 25% of survivors experience intense affect and dissociation, whereas a similar number may appear unusually calm.
Interventions beyond the“first aid” described above are not usually needed unless individuals:
- are a danger to themselves or others
- are psychotic
- have no social supports
- cannot perform tasks necessary for self-care and to begin the recovery process.
Always re-assess when there is any question about a survivor’s immediate reaction to trauma.
In DSM-IV-TR’s trauma-related diagnoses, the symptom clusters often do not capture many disaster survivors’ subjective experience: the shattering of fundamental beliefs regarding themselves (invulnerability), the world (predictability, safety), and others (trust, benevolence). 9 By empathizing with these responses, you can help survivors feel less isolated and estranged.
Differential diagnosis. Survivors’ mental status changes may be manifestations of the stress response, but they also may represent:
- exacerbations of pre-existing psychiatric or general medical conditions
- hypoxemia, hypovolemia, or CNS trauma from physical injury
- responses to medications used for resuscitation or pain control, such as atropine, epinephrine, lidocaine, or morphine.
Effects of bioterrorism agents must also be considered. For example, organophosphorus compounds such as the nerve agents sarin and soman can cause impaired concentration, depression, and anxiety. Anthrax can cause rapidly progressing meningitis. 10 Delirium must be differentiated from dissociation; patients with dissociation can be re-oriented, and changes will resolve with time rather than fluctuate. 11
Psychopathology risk factors. Multiple studies have addressed risk factors for post-disaster psychiatric sequelae (usually PTSD). In general, risk increases with repeated trauma exposure (including TV viewing), prior trauma, lack of social support, injury, pre-existing psychiatric problems, traumatic bereavement (having witnessed the violent death of a loved one), avoidant coping, and having strong negative beliefs about the meanings of normal stress reactions such as tearfulness, anxiety, and insomnia.
Because a recent meta-analysis supports these observations, 12 follow-up evaluation for signs of PTSD is recommended for:
- survivors with one or more of the risk factors discussed above
- vulnerable groups such as rescue workers, children, and dependent individuals
- survivors whose symptoms persist after 2 months. 13
Decompensation immediately after a disaster seems to be the exception for psychiatric patients, despite their longer-term vulnerability. One psychiatrist who in 1989 survived Hurricane Hugo—the most intense storm to strike the Mid-Atlantic region in 100 years—noted that demand for inpatient psychiatric services did not increase in the storm’s aftermath. The only patient calls she received were inquiries about her own physical safety. 14
Caregivers and rescue workers—including psychi-atrists—are also disaster survivors, and you need to tend to your needs for safety and support. Consult frequently with colleagues within and outside the disaster area, as much for support as for information and guidance. 15 Remember also that rescue workers are occasionally targets for victims’ rage at their circumstances. Anticipating and explaining this displacement reduces its toxicity.
Uses psychotropics judiciously in the first 48 hours of trauma. Medication effects may interfere with neurologic assessment of the injured, and monitoring and follow-up may not be possible.
However, drug therapy should start quickly when survivors are acutely psychotic or their behavior endangers themselves, others, or the milieu. Medications usually include a fast-acting benzodiazepine and/or an antipsychotic, as described in guidelines for managing agitation. 16 Always provide structure and supervision for medicated patients.
No guidelines exist for using medications to manage distressing—but less-severe—acute stress-related symptoms. Some experts advocate using adrenergic antagonists such as clonidine, guanfacine, and beta blockers to reduce excessive arousal. These drugs have not been adequately studied in this setting, however, and may harm those with cardiovascular instability from preexisting conditions or injuries.
Psychoeducation: Simple messages for workers and trauma survivors
Get adequate rest, food, sleep
Avoid exposure to trauma cues, including TV images
Seek support from loved ones and peers
Talk about events and feelings only if this feels comfortable and helpful
Return to normal routine as much as possible
Take action to rebuild, but at a reasonable pace
Reach out to others who may need assistance
Short-term (<1 week) benzodiazepine use for panic symptoms and severe insomnia is acceptable, but longer-term use may increase PTSD risk. 17 A selective serotonin reuptake inhibitor may help individuals with pre-existing PTSD or depression, if you can arrange follow-up.
In the aftermath
‘Debriefing.’ Critical incident stress debriefing (CISD) is a structured, one-session group intervention in which survivors’ experiences and emotional reactions are discussed and education and follow-up recommendations are provided. Developed by Mitchell in 1983, 18 CISD was widely used until systematic evaluations revealed that it did not alleviate psychological distress or prevent PTSD. 19