Can you guess the one health problem experienced by just about everyone involved in a disaster? It’s not cuts and bruises, not colds or flu, and not exposure or unsafe water. Whether victim, bystander, or responder, we are all guaranteed some degree of mental health disturbance. This isn’t considered abnormal – after all, disasters are traumatic! At best, they are stressful and disruptive. At worse, they are dangerous and life-altering.

At least two out of three people eventually come out fine, with no long-term psychological issues. Even fairly intense disaster symptoms often go away within a few weeks.  But there is a caveat – it all depends on community attention to post-disaster mental health! Given current problems with our mental health system, don’t hold your breath for a good post-disaster response. Unfortunately, without mental health plans in place, you should expect increased long-term psychiatric illness after a disaster.  Even if you personally come out unscathed, increased mental illness causes increased homelessness, substance abuse, criminal behavior, and inability to work.   I definitely call that a major  community psychiatric problem.

Mental Health Month Poster by Army Medicine

Mental Health Month Poster by Army Medicine

Normal Distress Responses:

Stress, helplessness, and anxiety – it makes sense to feel these if your world just turned upside down. People may lose their appetite (not totally bad when trying to conserve stores?), have trouble sleeping, and suffer nightmares or flashbacks. They experience intense fear about personal safety, safety of loved ones, and even safety of belongings (people often stay in unsafe homes to guard their stuff). Trouble concentrating and even confusion is normal. Some grieve loss of loved ones, but also loss of pets, homes, jobs, and possessions – all are legitimate reasons for grief.  Many want to discuss the disaster repeatedly, while others become almost mute. All  are normal responses. There is no right or wrong way to feel.

Even if emotional reactions are normal, they shouldn’t be downplayed or ignored. Some things can make them worse or prevent recovery. Access to basic resources such as food, shelter, communication, transportation, and medical services plays an important role in mental health. Despite preaching personal preparedness, most people won’t be ready. Community leaders must plan to quickly obtain and distribute resources. People need timely, accurate information about the disaster, the response, and ongoing risks. Fear of the unknown is worse than anxiety about the known, no matter how bad.  Reuniting families as quickly as possible should be a priority. Finally, people actively helping others seem to cope better with emotional distress. Advance development of neighborhood and community response groups, plus just-in-time volunteer opportunities not only help speed community recovery, but also help from the mental health standpoint.

By Eva Roman

By Eva Roman

Psychological First Aid (PFA):

After 9/11, we learned that untrained psychological help can do more harm than good, yet the number of people needing support after disaster exceeds what professional mental health providers can provide. As a result, official training in psychological first aid was developed. PFA reduces initial distress from trauma through listening, concern, and compassion, while providing information and helping victims discover practical ways to cope and adapt. PFA training includes triage for those needing professional mental health treatment. Responders practice coping skills and learn to watch each other for signs of stress-related symptoms.

Both professional emergency responders and volunteer disaster response groups, including Community Emergency Response Teams (CERT), Medical Reserve Corps (MRC), and Red Cross generally take PFA training. The National Child Traumatic Stress Network offers a 6 hour Psychological First Aid Online class  (with CME and CE credits for any health care professionals out there!). Better yet, find a live training class in your area – this course really benefits from interaction.

Abnormal Mental Health Responses to Disaster: Call In The Experts

In any disaster, some reactions go beyond normal. When compared to natural disasters, the psychological risk increases for human error and technology failure events, and is higher still for intentional violence. As mentioned above, the effectiveness of the disaster response and relief efforts also influences psychiatric outcomes. When does normal turn to abnormal? Here are some examples:

1) Acute Stress Disorder – not the same as being acutely stressed. The key-mark of this abnormal traumatic response is dissociative symptoms:

  • Sufferers appear strangely numb or detached from those around them, or even from themselves (depersonalization).
  • The world seems unreal or unnatural to them (derealization).
  • Sometimes, they can’t even remember the trauma or disaster (dissociate amnesia).

(d,d,d, – do psychiatrists only know one letter of the alphabet?)  Flashbacks are common in acute stress disorder, as is avoidance of anything that triggers memories of the event. Despite detachment, patients may be hyperarousable, with impairment of normal function (no surprise there). Acute Stress Disorder acts similar to its famous cousin, post-traumatic stress disorder (PTSD), except with onset earlier after the trauma. With good mental health care, it may resolve in 2-4 weeks. Otherwise, it often evolves to true PTSD.

2) Brief Psychotic Disorder – big time reality issues. They experience hallucinations (see or hear things), delusions (believe in clearly unreal things), confusion or disorientation, and may have memory or speech problems. This psychosis happens without history of mental illness, and often resolves spontaneously, but may need temporary medication or even hospitalization.

3) Complicated Grief – normal grief can be very intense for a few weeks or months, particularly if resulting from trauma, but when severe grief persists more than a few months, trained counselling and support are usually necessary.

4) Panic Attacks – spells of intense fear and anxiety, accompanied by physical symptoms such as palpitations, shortness of breath, trembling, sweats, hot flashes, pain and faintness. Panic attacks occur randomly, usually without triggers. They often disappear with time, but symptom severity may warrant medication. Recurrent attacks severe enough to cause altered behavior and thinking are called panic disorder – another one for the professionals.

5) Substance Abuse Disorder – some cope with disaster emotions by increasing alcohol and substance use, particularly with a pre-existing tendency or a family history of substance abuse. Substances temporarily help sleep or anxiety, but require escalating  amounts, leading to dangerous behavior, physical health problems, and inability to fulfill daily responsibilities.

Face of PTSD. Photo by

Face of PTSD. Photo by

Emergency Responders Need Mental Health Support:

Emergency responders, both professional and volunteer, experience “normal” emotional reactions like others in the disaster area, but also have a high risk for acute and post-traumatic stress disorders. Despite training, many lack previous exposure to mass trauma. Even when experienced, disaster severity and  victim type varies. If other responders become casualties, fear and grief further complicate psychological reactions. Group “story telling” sessions help coping, but supervisors also watch staff for dissociative symptoms or other abnormal reactions. Affected responders need professional mental health treatment.

Are you convinced about the need for mental health planning in disaster response? I didn’t even get to effects of disaster on chronic mental illness! Psychological first aid training is an important step, but only goes so far – it’s an intervention, not a treatment. Where are our psychiatrists, psychologists, clinical social workers, and counselors? Like other health care professionals, they need to train now for the unique mental health needs in disasters. It’s time to get them at the table with the healthcare planners, and in the field with medical reserve corps. Invite them now!

Stay safe,

Sheila Sund, M.D.

  1. Sheila I’m so glad that you included the needs of responders in your post as well. I’ve seen some friends drop out of ‘the business’ after working major disasters. Some have all out quit and went into other lines of work, others remained but were never the same. I’ve certainly had my own bouts of anxiety and good healthy cries between shifts or after a disaster. We see and experience some horrible things – and it doesn’t have to be all blood and death, either… seeing entire neighborhoods wiped out by some calamity is akin to a knife in your soul. Or sometimes it’s the small things that trigger a response in someone. Just because we are exposed more often than others to these things doesn’t make us immune.

    First responders are starting to realize that mental health care isn’t the ‘touchy-feely’ stuff they often joke about. It’s a very necessary component of disaster management – for victims, families of victims, and responders… the important thing to realize in that system though is that they all need to be treated differently. I’ve heard of disastrous group sessions where first responders were brought into community discussions. That should never happen!

    Good work as always, Doc!

    • disasterdoc says:

      Thank you for sharing your experiences – so many do not have hands on experience, and even in non-disaster settings, very few understand the stresses of emergency responders. The importance of mental health care for responders really hit me during a class on Global Disaster relief. One teacher was a psychiatrist who spends his volunteer time travelling to different relief areas around the world, not to help local populations, but to help the healthcare volunteers. I figure if a psychiatrist goes to Africa just for the volunteers, it must be pretty important! He also pointed out the value of mental health workers specifically trained for responder care – both the psychological issues and the experience of working in a disaster setting are far removed from a generic psychiatry or counselling practice. It’s on my wish list as I develop our local MRC!

  2. Monika Lenz says:

    Excellent. I often think about the first responders and how they will deal with long term stress after a horrible situation. It has long been known that police have higher divorce rates. Children who were abused are more likely to abuse their children. Even seemingly mild episodes of trauma can stay with a person. Example: I had my old dog destroyed three weeks ago. The veterinary staff was very supportive, the veterinarian suggested he euthanize rather than treat and I knew that was the right decision but I am still dealing with that day emotionally. Now if I was a parent of a child who had died how long would I suffer? Probably the rest of my life. I know one such parent who, after 50 years, still relates her child’s death to everyone she meets. Your post is helpful in that it shines a light into the dark aspects of post traumatic stress. As much as we want to look away from such darkness it might be better to turn a bright beam of light on it.

    • disasterdoc says:

      Thank you for commenting, Monika. I can’t understand the reluctance of people to accept mental health issues as equal to physical health issues. Can you imagine your health insurer saying they only pay for 12 doctor visits in two years for heart disease? People would be up in arms. Yet insurance often limits mental health care this way (if they cover it at all), and no one blinks an eye!

      My years of hospice work really taught me the importance of handling grief proactively, no matter what the setting. Not everyone needs the same interventions, but everyone needs options. Family support and time are adequate for many, but some people like reading materials, some benefit from group sessions, some need counselling, and some just want a volunteer to check in and ask how they are doing. By addressing grief openly and ongoing, it is less likely to become permanently disabling. If we need all these options to handle grief from “expected” deaths (not that death is ever truly expected), how much more should be needed in a disaster setting!

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