Psychiatric Dimensions of Disaster: Patient Care, Community Consultation, and Preventive Medicine
Robert J. Ursano, M.D. Carol S. Fullerton, Ph.D. Ann E. Norwood, M.D.
The majority of persons exposed to a disaster do well and have only mild, transitory symptoms. However, some individuals develop psychiatric illness postdisaster. Such illnesses include those that are secondary to physical injury and sickness as well as specific trauma-related psychiatric disorders such as acute stress disorder. The extent of the psychiatric morbiditv and mortality that develops in individuals in the community depends on the type of disaster, the degree of injury sustained, the amount the type of disaster, the degree of injury sustained, the amount of life threat, and the duration of community disruption. In this paper we examine the posttraumatic responses of direct concern to psychiatrists working in a community exposed to a disaster. We review the epidemiology of posttraumatic responses, the interface of psychiatry and traumatic stress, the psychiatric disorders associated with trauma, and psychiatric consultation to the disaster community. Overall, psychiatric intervention after a disaster is based on the principles of preventive medicine and includes community consultation and outreach programs with the goals of identifying high-risk groups, promoting community recovery, and minimizing social disruption. (Harvard Rev Psychiatry 1995;3:196-209.)
Disasters are an all-too-common element of modern life in the United States and worldwide. The recent earthquake in Russia, the floods in Texas, the Midwest, and the South, and the bombing of the Murrah Federal Building in Oklahoma City are poignant reminders of this fact. Traumatic events (defined as experiences outside of the range of normal events, and including individual trauma such as victimization through violent crime or injury in a motor vehicle accident) and disasters (traumatic events that affect an entire community) occur more commonly than is generally appreciated. In a random sample of 1007 young adults from a large health maintenance organization, Breslau and colleagues1 estimated the lifetime prevalence of exposure to traumatic events in the United States to be 39.1%. Norris2 calculated that 6-7% of the U.S. population is exposed to a disaster or trauma each year, ranging firm motor vehicle accidents and crime to hurricanes and tornadoes.
"Disaster" has been defined in many ways. The word is derived firm the Latin dis I ("against") and astrum ("stars")-hence, "the stars are evil."3 More recently, definitions of disaster have emphasized the social disruption that accompanies them.4Eranen and Liebkind5 noted that the difference between an accident and a disaster is one of degree; a crucial distinction between them is that in a disaster, the social structure and processes are affected sufficiently to threaten the existence and functioning of the community. The resource needs are greater than the resources available.
Disasters can be natural or human-made. Human-made disasters such as industrial accidents, airplane crashes, terrorist acts, and war can be more deadly than natural ones. For example, the leak of poisonous gas from a Union Carbide Corporation plant in Bhopal, India, killed 3800 people and injured over 300,000 more. The effects of chronic stress resulting firm exposure to disaster, as seen in toxic accidents such as those at Three Mile Island6 and Chernobyl7 , 8 have only recently been studied. In some instances the growth of technology has blurred the distinction between natural and human-made disasters.9 For example, the 1988 earthquake in Armenia claimed 30,000 lives. The majority died because their homes were poorly constructed. From such a perspective, this disaster is both natural and human-made.7
Psychiatrists must use a wide spectrum of skills in providing care to disaster victims. They need to diagnose and treat the disorders associated with trauma (e.g., Posttraumatic stress disorder [PTSD], depression); they must also provide consultation to medical and surgical colleagues on these psychiatric disorders as they present in a general medical clinic among patients injured in the disaster. Psychiatrists are essential in educating other physicians and the community about the "normal" responses to "abnormal" events; they also assist in the development of disaster plans for hospitals and communities. Psychiatrists contribute to the primary prevention of psychopathology by using epidemiological training, as well as their traditional skills of diagnosis, treatment, and consultation.
In this paper we examine the psychiatric responses to disasters and discuss the psychiatric disorders associated with disaster trauma, the nature of the community affected by the disaster (here termed the "disaster community"), and high-risk groups for which the psychiatrist, as community consultant, may need to initiate outreach programs. We used Medline and PsycInfo to review the English-language literature from 1980 to 1995 on psychiatric responses to disaster and psychiatric interventions (search terms: disaster, psychiatry, psychology). In addition, we considered the classic publications in this field i.e., the initial studies that brought a topic to attention or that, because of their design, have been formative in understanding clinical interventions.Responses to Trauma and Disaster
The behavioral and psychological responses seen in disasters are not random; they frequently have a predictable structure and time course.10 For most individuals posttraumatic psychiatric symptoms are transitory.10 For some, however, the effects of a disaster linger long after its occurrence, rekindled by new experiences that remind the person of the past traumatic event.11 A rainstorm can become the reminder of a flood; the flash of lightning and the crash of thunder, the reminder of an explosion; a bumpy ride in an airplane, the reminder of a plane crash; and a small earth tremor, the reminder of a major earthquake. Even normal life events can cause anxiety and bring to mind a destroyed home or deceased loved ones. The factors influencing resilience and vulnerability to catastrophic events are only now being identified.12 Although several empirical studies have investigated psychiatric response to disaster, few have addressed interventions. Such studies are very difficult to do and will probably not be undertaken in sufficient number to guide clinical work. However, understanding responses to disaster can provide the basis for developing interventions.13
Although exposure to disasters and other trauma has been associated with debility that can persist for decades, the effects of traumatic events are not exclusively bad. For some people trauma and loss facilitate a move toward health.14 , 16 A traumatic experience can become the center around which a victim reorganizes a previously disorganized life, reorienting values and goals.14 , 17 Traumatic events may function as psychic organizers for memory i.e., psychic glue linking event-related feelings, thoughts, and behaviors that are later accessed en bloc following symbolic, environmental, or biological stimuli.11Many survivors of the 1974 tornado in Xenia, Ohio, experienced psychological distress, but the majority described positive outcomes: they learned that they could handle crises effectively (84%) and believed that they were better off for having met this type of challenge (69O/o).18 , 19 This "benefited response" is also reported in the combat trauma literature. Sledge and colleagues15 found that approximately one-third of U.S. Air Force Vietnam-era prisoners of war reported having benefited from their prisoner of war experience; they believed that they had developed an important reprioritization of their life goals, lacing new emphasis on the importance of family and country. The prisoners reporting these benefits tended to be the ones who had suffered the most-traumatic experiences.
The study of emotional reactions to disasters began with observations of the oldest human-made disaster, war. During the American Civil War, combat psychiatric casualties were thought to be suffering from "nostalgia," which was considered to be a type of melancholy, or mild type of insanity, caused by disappointment and longing for home.20 In World Wars I and II, terms such as "shell shock," "battle fatigue," and "war neuroses" were more common descriptors of the emotional responses to trauma.21 The "thousand mile stare" described the exhausted foot soldier on the verge of collapse. From these observations, the study of other disasters began. A number of modern disasters, including the 1942 Coconut Grove Nightclub Fire22 , 23 the 1972 Buffalo Creek Flood24 , 25 and the 1980 Mt. St. Helens volcanic eruption,26 , 27 have been studied in detail. An important advance in the scientific study of responses to disasters was the recognition of PTSD in DSM-III,28 published in 1980.
PTSD, however, is not the only psychiatric disorder associated with disasters. Major depression, substance abuse, generalized anxiety disorder, and adjustment disorder have also been diagnosed in individuals exposed to a disaster.29 In addition, psychological reactions to physical injury and illness as well as psychological resiliency are important postdisaster responses (see Table 1).
DSM-IV30 has added a new disaster-related diagnosis, acute stress disorder (ASD). This diagnosis is applicable soon after a traumatic event. In addition, DSM-IV changed the criteria for PTSD. Recognizing that traumatic stressors are all too often a part of everyday life, it deleted the DSM-III-R31 requirement that the stressor be "outside the range of usual human experience"; DSM-IV further restricted the diagnosis of PTSD by requiring that the individual respond to the stressor in ways involving intense fear, helplessness, or horror. DSM-IV also moved the physiological symptoms related to reminders of the traumatic event from the arousal criteria (criteria D) to the remembering criteria (criteria B). This change reflects recent advances in understanding the biology of PTSD and its relation to memory.32 Lastly, for a diagnosis of PTSD, DSM-IV requires the therapist to document that the patient's symptoms have caused clinically significant distress or impairment.
Preexisting psychiatric illness or symptoms are not necessary for psychiatric morbidity after a traumatic event, nor are they sufficient to account for it.14 , 33- 35 The less severe the disaster or traumatic event, the more important predisaster variables such as neuroticism or a history of psychiatric disorder appear to be.36 - 39 The more severe the stressor, the less pre-existing psychiatric disorders predict outcome.
The effects of chronic stress include physiological changes,6 as well as such mental health problems as fear, demoralization, increased symptom reporting, anxiety, and depression. Symptoms associated with chronic stress may be exacerbated by continued apprehension about possible risk.40
The severity of a disaster is perhaps the single best predictor of both the probability and the frequency of postdisaster psychiatric illness. Physical injury - the number of injured and the type of injury - is one indicator of the severity of a disaster. Shore and colleagues26 , 27 found that the intensity of disaster exposure following the Mt. St. Helens volcanic eruption predicted psychiatric outcome. They documented higher rates of postdisaster psychiatric illnesses, including PTSD, generalized anxiety disorder, and depression, in those who lived closer to the volcano.
Physical injury also appears to increase the risk of psychiatric disorder. Although no studies of physical injury and risk of psychiatric illness are available in the disaster literature. data are available from studies of veterans of combat trauma. The Epidemiologic Catchment Area study of Vietnam veterans41 documented a higher rate of PTSD in wounded than in nonwounded veterans. Similar findings were noted in the Veterans Affairs study.42 , 43
Additional evidence for the importance of the severity of the trauma to the risk of psychiatric illness is seen in the study of war trauma. Greater exposure to combat in Vietnam was significantly related to higher rates of PTSD, depression, and alcohol abuse.42 In an interesting investigation, Goldberg and colleagues44 studied monozygotic twins discordant for service in Vietnam. PTSD was nine times as common in the twins who had been exposed to a high level of combat in Vietnam as it was in those who had not served in Southeast Asia.
Acute Stress Disorder
Curiously absent from DSM-IV and DSM-III-R was a diagnostic category for acute responses to trauma and disaster events. With the new diagnosis of ASD (see Table 2), DSM-IV acknowledges a broader spectrum of responses to traumatic events. ASD symptoms begin within 4 weeks of a traumatic event and last between 2 days and 4 weeks. The symptoms cannot be due to the direct effects of a substance, a general medical condition, or an exacerbation of a psychiatric disorder present before exposure to the event.
Since ASD is a new diagnosis, no specific investigations are available on its course or outcome.45 However, recent studies of war suggest that acute combat-related stress reactions (which could now be thought of as representing an ASD) predict an adverse outcome46 and are associated with increased rates of somatic complaints.47 , 48 Numerous investigations also document that acute symptoms of intrusion, avoidance, and dissociation,49 part of the symptom complex of ASD, predict the development of later psychiatric disorders, particularly PTSD.50 , 51
PTSD has been widely studied following both natural and human-made disasters.26 , 27 , 39 , 45 , 53 The diagnostic criteria for PTSD (see Table 2) closely resemble those of ASD, with the primary difference being time course: for a diagnosis of ASD the symptoms must occur within 4 weeks of the traumatic event and resolve within 4 weeks. The diagnosis of PTSD applies to a similar constellation of symptoms if the symptoms persist longer than 1 month or if the onset of symptoms begins later than 1 month after the traumatic event. Studies have examined posttraumatic psychiatric responses in survivors of airplane crashes, volcanic eruptions, tornadoes, floods, and other disasters.
ASD PTSD
Nature of the trauma\reaction to the trauma
Individual experienced, witnessed, or was confronted with
an event that involved actual or threatened death or serious injury, X X
or a threat to the physical integrity of self or others. X X
Individual's response involved intense feelings of fear,
horror, or helplessness. X X
Symptom criteria
Persistent re-experiencing of the trauma X X
Persistent re-experiencing of the trauma X X
Avoidance of reminders of the trauma X X
Physical symptoms of hyperarousal X X
Symptoms of dissociation during or immediately after the trauma X
Clinically significant distress or impairment X X
Time requirements
Duration of symptom constellation 2 Days to 4 Weeks >1 Month
Onset of symptoms in relation to trauma Within 4 weeks of the trauma Anytime Following Trauma
Research on Vietnam War veterans42 , 43 , 56 has contributed greatly to our understanding of PTSD. Other investigations have examined PTSD-like disorders resulting from such disasters as the Coconut Grove fire22 and the Buffalo Creek dam collapse.57 The most frequent predictor of PTSD is the degree of exposure to the disaster. Although the prevalence of PTSD after a disaster varies greatly depending on the type of disaster and the degree of exposure, well-controlled studies51 , 58 , 59suggest that 10-30% of highly exposed individuals develop the disorder. The greatest risk is in persons exposed to life threat, the grotesque (for example, handling human remains or viewing mangled bodies), or similar situations evoking intense, overwhelming revulsion or fear.53 , 60 - 64 Persons who are injured are at higher risk, reflecting both their high level of exposure to life threat and the added persistent reminders and additional stress burden accompanying an injury.
Treatment of PTSD, when it has become persistent, can be complicated,12 and several different approaches have been used. Psychopharmacological and behavioral techniques have been reported to be successful in treating PTSD symptoms; less-studied interventions such as cognitive therapy, psychodynamic therapy, and hypnosis also hold promise.65 Shalev and colleagues66 have described a multidimensional approach that targets treatments at various layers of biological and psychological dysfunction. Little is known about treating ASD.
Figure 1 summarizes a conceptual framework with which to understand individual psychological and physiological responses to a disaster. Often overlooked after a disaster are the psychiatric disorders attributable to head trauma and metabolic disturbances following crush injuries and burns. Co-occurring psychological symptoms are frequently seen in injured victims who may be dealing with the stress of their injury, the loss of family members, and an absence of resources and social supports with which to plan recovery. Since most studies indicate a high rate of psychiatric disorder in the physically injured, a proactive consultation liaison plan is a necessary part of a hospital emergency response plan.
Figure 1. Psychological and Physiological Responses to Disaster
Stress Mediators
Individual Developmental History
Biological Givens
Preexisting Illness
Previous Exposure Social Supports
Sociocultural Context
Meaning
Appraisal
Attributution
Health Outcome
Major Depression,
Generalized Anxiety Disorder,
Substance Abuse,
Family Violence,
Sleep Disturbance,
Somatization,
Adjustment Disorders
Major depression, generalized anxiety disorder, substance abuse, and adjustment disorders in disaster victims have been
less often studied than ASD and PTSD, but available data suggest that these disorders also occur at higher than average
rates.,26 , 27 , 42 , 56 Major depression, substance abuse, and adjustment disorders (anxiety and depression) may be relatively
common in the 6-12 months after a disaster and may reflect survivors' reactions to their injuries, to affects and feelings
stimulated by the disaster, and/or to their attributions of the cause of the disaster. The occurrence of these psychiatric
disorders may also be mediated by secondary stressors (i.e., the problems associated with disaster recovery, such as
negotiations with insurance companies for reimbursement, or unemployment secondary to destroyed businesses) following
a disaster. Major depression and substance abuse (drugs, alcohol, and tobacco) are frequently comorbid with PTSD and
warrant further study.29 , 56 , 57 , 68
Other symptoms and psychosocial problems may warrant psychiatric attention and intervention. Grief reactions are common after all disasters. Available studies of grief reactions following trauma do not greatly aid our understanding of who is at risk for persistent depression. One investigation indicated that single parents may be at high risk for developing psychiatric disorders since they often have few resources to begin with, and they lose some of their social supports after a disaster.67
Over time, when resources remain limited and employment and financial resources are scarce in the community, family violence, spouse abuse, and child abuse increase,69 with high morbidity and significant mortality. Primary care and emergency room services must remain alert to these problems for many months after a disaster.
Postdisaster chronic sleep disturbances are common clinical problems that may require treatment. Sleep difficulties can be due to anxiety related to recurrent disaster events (e.g., aftershocks) or to underlying psychiatric disease such as depression or PTSD.70 These disorders must be considered in the differential diagnosis and appropriate treatments initiated as indicated.
Somatization is common after a disaster and must be managed both in the community and in individual patients.71 Primary care providers must recognize that somatization is a frequent presentation of anxiety and depression in patients seeking care in medical clinics. Such recognition can help in the appropriate diagnosis and treatment of these psychiatric disorders, thereby minimizing inappropriate medical treatments.
Hostility, with its accompanying social disruption, feelings of frustration, and perception of chaos, is also common.60 , 72Although in some cases it is helpful for individuals to recognize that the return of anger can be a sign of a return to normal (i.e.,it is again safe to be angry and express one's losses, disappointments, and needs), in others hostility should remind the care provider to assess the risks of family violence and substance abuse.
Although individual patterns of response vary, several phases generally emerge over time.72 Cohen and colleagues73 have identified four phases in the response to disaster.
The first, immediately following a disaster, generally consists of strong emotions, including feelings of disbelief, numbness, fear, and confusion. People tend to cooperate, and heroic deeds are sometimes seen. These reactions are best understood as "normal responses to an abnormal event." Rescue personnel, family, and neighbors are generally the support systems that are most heavily used.
The second phase usually lasts from a week to several months after the disaster. At this juncture assistance flows in from agencies external to the community, and the cleanup/rebuilding process begins. In this phase of adaptation, denial alternates with intrusive symptoms. The intrusive symptoms generally arise first and consist of unbidden thoughts and feelings accompanied by autonomic arousal (e.g., a heightened startle response, hypervigilance, insomnia, and nightmares). Toward the end of the adaptation phase, denial is more prominent. This is often accompanied by an increase in visits to physicians for complaints of somatic symptoms such as fatigue, dizziness, headaches, and nausea.74 Anger, irritability, apathy, and social withdrawal are often present.
The third phase lasts up to a year and is marked by disappointment and resentment when expectations of aid and restoration are not met. During this period the strong sense of community may weaken as individuals focus on their personal concerns.
The final phase, reconstruction, may last for years. During this period disaster survivors gradually rebuild their lives, making homes and finding work. Recovery from a disaster involves the resolution of the initial psychological and somatic symptoms17 through reappraisal of the event, assignment of meaning, and integration into a new concept of self.
To understand the nature and degree of trauma sustained by patients, it is also useful to examine the mediating
characteristics of disasters along the following dimensions:74
In addition to these dimensions, another important factor influencing individuals' responses to a disaster is the degree to which the disaster disrupts their community. The community serves as the person's physical and emotional support system. The larger the scale of the disaster, the greater the potential disruption of the community. It is instructive to contrast the challenges facing the hypothetical survivor of an airplane crash with those confronting the victim of a larger-scale disaster such as a tornado or flash flood. If family members were not on the same aircraft, the plane crash survivor can return home to family, friends, and coworkers. He or she will most likely go back to a structurally intact house, to a community unaffected by the accident, to the same job with the same financial security, and so forth. By contrast, a tornado involves additional factors that amplify the trauma. Although the tornado survivor may experience and witness comparably gruesome sights, the recovery environment is markedly different: home and work site may have been destroyed, and relatives, friends, and coworkers may be dead, injured, or displaced. Thus, in considering the impact of a trauma, the degree to which the community is affected is an important consideration in estimating potential psychiatric morbidity.51 , 76
In every disaster, stressors unique to the specific situation-for example, the exposure to extreme heat or noise, the lack of housing or safe havens, and the possibility that the disaster will recur-are also important to psychiatric morbidity.77 Technological disasters may bring specific psychiatric concerns about normal life events-for example, fear of flying after a plane crash or claustrophobia after a mine accident. Each of these requires evaluation and intervention to treat the specific phobia and limit generalization to other areas of life (e.g., "I cannot cook anymore because the boiling water reminds me of the explosion").
Clinical studies suggest that the meaning ascribed to the disaster by individuals, families, and communities influences its psychiatric consequences.11 , 77 , 78 Beliefs Community Consultation, Treatment, and prevention about the cause of the disaster and the ramifications of these beliefs (such as self-blame, the shattering of assumptions about human nature, and rage at "those responsible" when the event is viewed as preventable) are important to assess in psychiatric evaluation and represent potential areas for intervention. Therapists can assist patients in modifying distorted attributions (e.g., "It's all my fault; if only I had insisted that we not go away for the weekend, we wouldn't have been caught in the tornado and my wife would still be alive"). Some events are more likely than others to shatter one's faith in a just and safe world.79Consider the implications of the following scenarios: An individual has survived an airplane crash in which many people were injured and killed. Various explanations or the crash exist; each would stimulate a different meaning and emotional response. The plane may have crashed because of sudden and unexpected wind shears, because of uncomplicated pilot error, or because of "complicated" pilot error (e.g., the pilot was under the influence of drugs or alcohol). At the far end of this continuum would be a crash caused by an act of terrorism or greed in which the plane was destroyed to further the interests of a group or an individual.
The construction of meaning is an active process that appears to affect the outcome of the traumatic experience and recovery.80 , 81 The meaning of a disaster to any one person results from the interaction of his or her past history, present context, and physiological state. The ascribed meaning will then direct individual behaviors of what to do, what to fix, and whom or what to blame. It is important to remember that meaning is dynamic, not static: it changes over time as the individual's psychosocial context changes. Such alterations can aid or inhibit recovery. For example, immediately following the crash of an Air Force C-141 cargo plane, the remaining members of the squadron were convinced that the accident was caused by aircraft failure. However, this belief was modified as the date grew nearer for the squadron members to fly the same type of plane again. By that time, the squadron's belief had changed, and members thought that the crash must have
been caused by human error. If it were human error, one could feel safe: "I would never do that."
Epidemiological Model
For many psychiatrists, disaster psychiatry requires a shift from the traditional focus on psychopathology. Preventive medicine's epidemiological model offers a useful paradigm for psychiatric assessment and intervention as it does for other medical responses to disaster.82 The epidemiological model is a traditional medical model used to investigate outbreaks of infectious disease. Adapting this model to understanding the mental health effects of disasters includes determining the individual's level of exposure to the toxins (e.g., was there exposure to the dead and the gruesome, were family members killed), identifying individuals at higher risk for illness, and monitoring behavioral and psychological responses over both the short and the long term. Recovery from a disaster often takes months or years rather than days.83
Consultation to the community can facilitate recovery and limit disability. In the wake of a disaster, the psychiatric consultant attempts to identify high-risk groups and behaviors, foster recovery from acute stress, decrease the development of persistent disorders, and minimize pain and suffering. Both acute and long-term effects of the disaster must be considered. Initial interventions include consultation to the disaster community's leaders, teachers, and care providers to maximize their understanding of the responses to trauma and disaster. Because disaster victims rarely present to traditional mental health services, psychiatric care must be organized around outreach programs into the community.84 Identifying high-risk groups (those most likely to develop psychiatric disorders) is one of the most important aspects of the consultation to the disaster community.85
After a disaster, consultation teams must mobilize quickly, often without prior warning. Frequently, they must carry their own resources.86 Even before beginning the consultation, the psychiatric consultant must design the team. Its composition is usually based on many factors, including the availability of trained consultants. the need to train new ones, characteristics of the disaster (e.g., scope, type of community affected), and financial resources. Ideally, the team is multidisciplinary, including psychiatrists, psychologists, social workers, psychiatric nurses, chaplains, and/or mental health paraprofessionals. When the consultation team comes from a distant site, practitioners from the affected community must be included; this facilitates entree into the community as well as continuity of care.
The initial tasks of the team are to gain an understanding of the disaster and to establish contacts for collaboration. The team must integrate smoothly into the disaster environment at a time when outsiders are often experienced as intrusive. Liaison with primary care providers and disaster workers is critical for effective intervention.87 A consultation team can be seen as "wanting something" from an environment in which the resources are already insufficient. The consultants must be knowledgeable of the culture and customs of the group they wish to help,87whether that be a hospital, a school system, the police, firefighters, disaster workers, community leaders, or a foreign nation. Usually, the state mental health system and federal health care units (Veterans Affairs or Department of Defense hospitals) are important programs to contact in order to coordinate efforts.
Members of a consultation team, like other disaster workers, experience the stresses of the disaster. The team leader must stay alert to the signs of stress in the team to maintain its health and functioning. Team leaders regulate the working hours and ensure adequate rest and respite for team members and themselves. Excessively long work hours are to be avoided if at all possible. Dedication to the mission is important, but over dedication-working extraordinarily long hours or exposing oneself to extreme psychological and physical suffering -is a problem. It is useful to alert team members to the potential for over dedication. Since recognizing over dedication in oneself may be difficult, training should emphasize "buddy care." Behaviors that suggest over dedication include skipping meals, working well beyond the end of a shift, providing others opportunities to rest yet not availing oneself of similar respite, and comparable patterns of ignoring physical and emotional limits. The team leader must recognize that asking a team member to take time out may cause him or her to feel devalued but may be necessary.
Disaster sites can look remarkably calm shortly after the event, even when the destruction and loss have been intense. Individuals feel chaos around them and can experience dissociation and a pervasive sense of unreality.88 During this time, rest and respite can be importantly.10 The initial interventions following a disaster must focus on the establishment of safety, the provision of food and water, and protection from the environment. As Kingston and Rosser89 noted, in times of disaster, "the most important aspect of psychological care is the social provision of physical care: i.e., physical care is psychological care, and this is the prime and essential function of relief organizations." Fears of loss and separation should be addressed by establishing reliable communications and casualty identification and notification procedures. Table 3 summarizes important interventions to consider during the early phases of disaster response. In a large-scale disaster, physicians will first intervene using public health and medical skills, such as their knowledge about sanitation and injury care.
Table 3. Immediate Postdisaster Psychiatric Interventions
Establishing safety, respite, and physiological recovery for victims
Relieving symptoms of postdisaster stress
Prescribing sleep medication
Providing reality orientation
Encouraging ventilation of feelings
Establishing outreach programs to provide community support and social-intervention programs to decrease chronicity
Fear of loss of control is not uncommon in individuals who experience major disaster. Disasters make one feel that the normal rules of life are not operating. The stress on families, particularly the persistent problems of loss of housing, income, and employment secondary to a disaster, results in increased rates of child and spouse abuse.90 Educating primary care providers about these problems is important to case identification. Establishing caretaker respite services-child care and elder care-may decrease the incidence of such violence and warrants scientific investigation.
Within the first hours or days, psychiatrists located in a hospital setting should begin a consultation-liaison outreach program to injured victims who are at increased risk of PTSD. The psychiatric consultant and treating psychiatrists need to be alert to the physical health effects of any disaster (crush injuries, burns, head trauma, metabolic disturbances due to poor food and water intake, and infections, for example) and to problems caused by such issues as lost medications. Symptoms that need to be recognized and monitored vary greatly: in an industrial accident at a fertilizer plant, organic mental disturbances due to toxic fumes may be the most important differential diagnosis; 3 months after a hurricane in the southern United States that destroys the water and sanitary systems, the differential diagnosis of mental disturbances related to infection and vector-borne diseases takes precedence.91 , 92
Often other psychiatric interventions, such as debriefing, have been inappropriately attempted at this early stage of a disaster.93 In general, debriefing is a group intervention in which members are guided dough a chronological reconstruction of the traumatic event. (See Shalev93 for an excellent review.) The goal is better understanding of and response to the events that have transpired. This process can only be effective when individuals are able to listen, express their feelings, and cognitively reorganize the experience.
The initial impact of a disaster is often much wider than anticipated. Those affected by a disaster may be widely dispersed.94 One cannot think of the disaster community as including only those directly affected. Modern transportation and information flow by telephone, television, and radio often help the disaster community to span the globe. For example, following the Los Angeles earthquake, telephone lines into Los Angeles immediately became tied up as news of the earthquake spread; residents and visitors to the city had concerned relatives throughout the world. The recent Kobe earthquake and Oklahoma City bombing provide additional illustrations of the worldwide impact of major disasters.
In a review of the literature on disaster responses, several groups (including rescue workers, the injured, heroes, and children) emerge as being at greater risk for traumatic stress-related sequelae. Children are a unique population during times of disaster.95 - 98 Often community leaders and teachers notice how wonderfully quiet children are being and are thankful, given their own level of distress. However, tile inhibition of children's normal activity is an indicator of their degree of stress. Teachers must be alert to social withdrawal in their students as a possible sign that the stress is continuing. Sometimes, children's distress may be more evident. Following the earthquake in Armenia, elementary school students jumped out of first floor school windows whenever a large truck rolled by and shook the ground. The distress of parents increases the distress of their children.99 Interventions with parents and families are directed at assisting the child to regain a sense of safety, validating the child's emotional reactions rather than discouraging or minimizing them, anticipating and providing additional support during times of heightened distress (such as anniversaries of the event), and minimizing secondary stresses.100
Exposure to death and the dead is part of most disasters and one of the risk factors for the development of psychiatric illness.60 , 61 , 64 , 79 , 101 , 103 The number of dead and injured and the sight and smell of dead bodies were among the most stressful aspects of the Granville, Australia, rail disaster.104 Identification with the victims-"It could have been me" appears to be a risk factor for increased psychiatric symptoms.84 Often those exposed to death and the dead experience an aversion to meat or a need to wash frequency. Usually these symptoms abate over several weeks or months.
The loss of a child in a disaster carries particular meaning and brings high risk. Following the rail accident in Australia, Singh and Raphael105 observed Blat among the bereaved, parents who lost children experienced the most severe symptoms. During a satellite telemedicine consultation following the 1988 earthquake in Armenia, victims described the of Heir children as the loss of "the future." Their distress was further exacerbated by a rumor that spread through the community, stating that youngsters were being kidnapped by parents whose children had died. Child victims of trauma universally evoke powerful emotional responses and generally create troublesome memories for witnesses. It is difficult to forget the image of the rescue worker carrying the infant's body from the rubble of the Murrah Building.
Disaster and rescue workers often experience the symptoms of PTSD or ASD and other psychiatric illnesses.94 , 104 , 106 - 109 Such workers can become forgotten victims of a disaster. They are repeatedly exposed to mutilated bodies, mass destruction, and life-threatening situations while doing physically demanding work that in itself creates fatigue, sleep loss, and often great danger. Workers also experience the stresses of their role as help providers.104 They often must exercise their long-practiced skills while ignoring their own risk. At times, they are forced to abandon pleading victims when their skills are needed elsewhere to assist a greater number of individuals. Such conflict is inherent in the job but can become a source of guilt or the focus of persistent feelings of helplessness or incompetence.
Lifton110 described the psychological distress of rescue workers in Hiroshima. Fear, anger, hatred, and resentment often diminished their effectiveness. Rescue workers in the 1977 Australian train crash reported feeling helpless and overwhelmed by the magnitude and unexpectedness of the disaster, the anguish of the relatives, the suffering of the injured, and the extreme pressure of the work.105 Approximately 20% of them were suffering from depression, anxiety, and insomnia 1 month following the disaster. McFarlane35 , 36 conducted a long-term study of psychiatric morbidity in firefighters exposed to the Ash Wednesday bushfires in South Australia in 1983. Twenty-nine months after the bushfires, 21% of the 459 firefighters were still experiencing recurrent imagery that interfered with their lives. Repeated exposure to disaster trauma may put first responders such as firefighters and police officers at a particularly increased risk of developing PTSD.1 , 37 , 107 , 109 , 111 ill In the United States alone, over 650 firefighters are forced to retire each year due to occupational illness including psychological stress112 , 114
Disaster workers who do not participate directly in the disaster recovery are also frequently overlooked. These include medical personnel and individuals who staff telephone hotlines. Other often-forgotten persons are those who handle the personal effects (such as wallets, photographs, and jewelry) of the dead - a task that is particularly stressful because of constant reminders of the victims' lives. Supervisors and community leaders also experience great stress in a disaster. They must make rapid decisions with little or no information and provide hope no matter what they fear. Interacting with the media may also be stressful for community leaders following a disaster.10 Having one appointed individual manage the media can substantially decrease this strain.
Heroes are part of nearly every disaster. Empirical observations suggest that they are often overlooked as a highly stressed group.114 Heroes are expected to carry the burden of idealization placed on them by the community. They are required to be away from their homes and families, always to be good, and to be able to tell a story that brings hope and courage to those around them. They are rarely allowed to express their own despair, worry, and fear or to recall the feelings that they overlooked in order to perform their heroic acts.
Community Consultation
The psychiatrist can play an important role in community wide recovery through consultation with community leaders and the media based on knowledge of community responses to disaster. Rumors are prominent in disaster communities and represent the community's attempt to understand events that are not fully explained or do not fit previous patterns. Rumor management is an important task of community leaders and an area in which the psychiatric consultant can assist. Recognizing rumors as the attempt of the community to explain the disaster and its aftermath can assist a community leader in responding appropriately. Community leaders should actively provide information and their interpretation of events in order to quell rumors and assist the disaster victims in recovery through managing the meaning of the event for the community.
After the initial impact of the disaster is over, those involved in rescue operations should be given time off and encouraged to talk. The psychiatric consultant can provide assistance in helping these individuals to process the meaning of their experiences. Rescue workers must feel free to discuss their experiences (see Table 4). Symbols are an important part of the recovery process. Commendations and awards to rescue workers and to those who have distinguished themselves are important components of the community recovery process. Memorials to the victims or the heroes of the disaster are part of the healing process and should be encouraged. Leaders are powerful symbols themselves. Leaders should be encouraged to express their own grief in order to lead the community in recognizing the appropriateness of grieving losses.
Table 4. Later Postdisaster Psychiatric Interventions
The recognition of a disaster by outside authorities, such as the president or the governor, is an important part of recovery. When a community is recognized and its distress acknowledged, it often feels less alone and more joined by others. These "others" offer the hope of additional resources as well as emotional support. The consultant, who may at first feel like an "outsider," fills some of these same functions, serving as an indicator of outside concern, providing hope for the return of "normal" life, and allowing a brief respite from the ongoing issues of disaster stress and recovery.
The psychiatrist should work closely with primary care physicians; following disaster trauma many patients with psychiatric disorders will present with somatic complaints. Family practitioners, internists, pediatricians, obstetrician/gynecologists, and other physicians need to be especially vigilant for symptoms of family violence, substance abuse, depression, and somatization. By making use of radio, newspapers, and television, psychiatrists can provide outreach to large segments of the population. Discussions of normal responses to disaster trauma as well as symptoms that should prompt medical attention can broaden outreach efforts substantially. When psychiatric disorders are identified, referrals should be made and the disorder-specific treatment(s) initiated.
The majority of persons exposed to a disaster will do well and will not develop psychiatric illness. The development of psychiatric disease depends on the type of disaster, the degree of injuries, the amount of life threat, and the duration of community disruption. Psychiatric intervention after disaster is based on the principles of preventive medicine and includes disaster consultation and outreach programs to identify high-risk groups, aid in community recovery, and minimize social disruption. High-risk behaviors (e.g., family violence, substance abuse, somatization) and inappropriate treatment must be assessed and remedied to decrease their impact on morbidity and mortality.
Further study of individual resilience after disasters will help to predict under what conditions and in which people posttraumatic psychiatric illness develops. The formal recognition of ASD in DSM-IV is an important step in this process and will facilitate the systematic study of the relationship between acute and chronic posttraumatic health outcomes. Long-term follow-up studies of posttraumatic grief reactions and depression are needed in order to clarify the natural course and duration of these syndromes. The design of future studies of any disaster-related disorder should include examining the time course of and differences between acute and chronic symptoms.
Adams PR, Adams GR. Mount Saint Helens's ashfall: evidence for a &aster stress reaction. Am Psychol 1984;39:252-60.
Adler A. NeuTopsychiatric complications in victims of Boston's Coconut Grove disaster. JAMA 1943;123:1098-101.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Press, 1994.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed. Washington, DC: American Psychiatric Association, 1980.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed revised. Washington, DC: American Psychiatric Association, 1987.
Bartone PT, Ursano RJ, Wright KM, Ingraham LH. The impact of a military air disaster on the health of assistance workers. J Nerv Ment Dis 1989;177:317-28.
Baum A, Gatchel RJ, Schaeffer MA. Emotional, behavioral, and physiological effects of chronic stress at Three Mile Island. J Consult Clin Psychol 1983;51:565-72.
Baum A. Toxins, technology, and natural disasters. In: Vandenbos GR, Bryant BD, eds. Cataclysms, crises, and catastrophes: psychology in action. Washington, DC: American Psychological Association, 1986:9-53.
BremnerJD, Davis M, Southwick SM, KrystalJH, Charney DS. Neurobiology of posttraumatic stress disorder. In: OldhamJM, Ribs MB, Tasman A, eds. Review of psychiatry. Vol 12. Washington, DC: American Psychiatric Press, 1993:183-204.
Breslau N. Davis GC, Andreski P. Peterson E. Traumatic events and posttraumatic stress disorder in an urban population of young adults. Arch Gen Psychiatry 1991;48:216-22.
Card JJ. Lives after Viet Nam. Lexington, Massachusetts: Lexington Books, 1983.
Cardena E, Spiegel D. Dissociative reactions of the San Francisco Bay area earthquake of 1989. AmJ Psychiatry 1993;150: 474-8.
Cohen R. Culp C, Genser S. Human problems in major &asters: a training curriculum for emergency medical personnel. Washington, DC: US Government Printing Office, 1987:1-23; DHHS publication no (ADM)88-1505.
Davidson JRT, FairbankJA. The epidemiology of Posttraumatic stress &order. In: Davidson JRT, Foa ED, eds. Posttraumatic stress &order: DSM-IV and beyond. Washington,DC: American Psychiatric Press, 1992:147-69.
Dolhnger SJ. The need for meaning following disaster: attributions and emotional upset. Pers Soc Psychol Bull 1986;12: 300-10.
Durham TW McCammon SL, Allison EJ. The psychological impact of disaster on rescue personnel. Ann Emerg Med 1985;14:664-8.
Eranen L, Liebkind K. Coping with disaster: the helping behavior of communities and individuals. In: Wilson JP, Raphael B. eds. International handbook of traumatic stress syndromes. New York: Plenum, 1993:957-64.
Erikson KT. Loss of commonality at Buffalo Creek. Am Psychiatry 1976;133:302-6.
Farber IJ. Psychological aspects of mass &asters. J Nad Med Assoc 1967;59:340-5.
Forster P. Nature and treatment of acute stress reactions. In: Austin LS, ed. Responding to &aster: a guide for mental health professionals. Washington, DC: American Psychiatric Press, 1992:25-51.
Frazer AG, Taylor AJW. The stress of post-disaster handling and victim identification work. J Hum Stress 1982;8(4):5-12.
FreedyJR, Resnick HS, Kilpatrick DG. Conceptual framework for evaluating disaster impact: implications for clinical intervention. In: Austin L, ed. Responding to &aster: a guide for mental health professionals. Washington, DC: American Psychiatric Press, 1992:3-23.
Fullerton CS, McCarrollJE, Ursano RJ, Wright KM. Psychological responses of rescue workers: fire fighters and trauma. Am J Orthopsychiatry 1992;62:371-8.
Gerrity ET, Steinglass P. Relocation stress following natural &asters. In: Ursano RJ, McCaughey BG, Fullerton CS, eds. Individual and community responses to trauma and disaster. London: Cambridge University Press, 1994:220-47.
Glass AJ, Army psychiatry before World War II. In: Anderson RS, Glass AJ, Bernucci RJ, eds. NeuT~psychiatry in World War II, zone of the interior. vol 1. Washington, DC: Office of the Surgeon General, Department of the Army, 1966:3-23.
Gleser GC, Green BL, Winget CN Prolonged psychosocial effects of disaster: a study of Buffalo Creek. New York: Academic, 1981.
Gleser GC, Green BL, Winget CN. PT~longed psychosocial effects of disaster: a study of Buffalo Creek. New York: Academic, 1981.
Goldberg J. True, Eisen SA, Henderson WG. A twin study of the effects of the Vietnam War on posttraumatic stress disorder. JAMA 1990;263:1227-32.
GoldbergJ, True WR, Eisen SA, Henderson WG. A twin study of the effects of the Vietnam War on posttraumatic stress disorder. JAMA 1990;263:122732.
Gordon R. Wraith R. Responses of children and adolescents to &aster. In: Wilson JP, Raphael B. eds. International handbook of traumatic stress syndromes. New York: Plenum, 1993:561-75.
Grace MC, Green BL, LindyJD, Leonard AC. The Buffalo Creek disaster: a 14-year follow-up. In: Wilson JP, Raphael B. eds. International handbook of traumatic stress syndromes. New York: Plenum, 1993:441-9.
Green BL, LindyJD, Grace MC. Psychological effects of toxic contamination. In: Ursano RJ, McCaughey BG, Fullerton CS, eds. Individual and community responses to trauma and disaster. London:,Cambridge University Press, 1994:154-76.
Green BL, Wilson JP, LindyJD. Conceptualizing post-traumatic stress disorder: a psychosocial framework. In: Figley CR, ed. Trauma and its wake. vol 1. The study and treatment of post-traumatic stress &order. New York: Brunner/Mazel, 1985:53-69..
Green BL. Evaluating the effects of disasters. PsycholAssessl991;3:538-46.
Green BL. Def~ning trauma: terminology and generic dimension. J Appl Soc Psychol 1990;20:1632-42.
HelzerJE, Robins LN, McEvoy L. Post-traumatic stress disorder in the general population. N EnglJ Med 1987;317:1630-4.
Hildebrand JF. Stress research: a perspective of need, a study of feasibility. Fire Command 1984;51:20-1.
HildebrandJF. Stress research (part 2). Fire Command 1948; 51:55-8.
Holloway HC, Fullerton CS. The psychology of terror and its aftermath. In: Ursano RJ, McCaughey BG, Fullerton CS, eds. Individual and community responses to trauma and disaster.
Holloway HC, Ursano RJ. The Vietnam veteran: memory, social context, and metaphor. Psychiatry 1984;47:103-8.
Horowitz MJ. Disasters and psychological responses to stress. Psychiatr Ann 1985;15:161-7.
Jones D. Secondary disaster victims: the emotional effects of recovering and identifying human remains. AmJ Psychiatry 1985;142:303-7.
KeatingJP, Blumenfield M, Reilly M, Pine VR, Mittler E. Post-&aster stress in emergency responders. Presented at the Annual Meeting of the American Psychiatric Association, Chicago, 1987.
Kinston W. Rosser R. Disaster: effects on mental and physical state. J Psychosom Res 1974;18:437-56.
Kulka RA, Schlenger WE, FairbankJA, Jordan BK, Hough RL, Marmar CR, et al. Trauma and~ the Vietnam War generation. New York: Brunner/Mazel, 1990.
Kulka RA, Schlenger WE, FairbankJA, Jordan BK, Hough RL, Marmar CR, et al. Assessment of posttraumatic stress disorder in the community: pn~spects and pitfalls from recent studies of Vietnam veterans. Psychol Assess 1991;3:54760.
Lee LE, Fonseca V, Brett KM, Sanchez J. Mullen RC, Quenemoen LE, et al. Active morbidity surveillance after Hurricane Andrew-Florida, 1992. JAMA 1993;270:591-4.
Lifton R. Death in life-survivors of Hiloshirna. New York: Random House, 1967.
Lima BR, Chavez H. Samaniego N. Pompei MS, Pai S. Santacruz H. Disaster severity and emotional disturbance: implications for primary mental health care in developing countries. Acta Psychiatr Scand 1989;79:74-82.
Lima -BR, Pal S. Santacruz H. Lozano J. Luna J. Screening for the psychological consequences of a major &aster in a developing country: Amero, Colombia. Acta Psychiatr Scand 1987; 76:561-7.
Lindemann E. Symptomatology and management of acute grief Am Psychiatry 1944;101:141-8.
LindyJD, Grace MC, Green BL. Survivors: outreach to a reluctant population. AmJ Orthopsychiatry 1981;51:468-78.
Lun& B. Mardberg B. Otto U. Chernobyl: nuclear threat as disaster. In: Wilson JP, Raphael B. eds. International handbook of traumatic stress syndromes. New York: Plenum, 1993: 431-9.
McCarrollJE, Ursano RJ, Fullerton CS. Traumatic responses to the recovery of war dead in Operation Desert Storm. AmJ Psychiatry 1993;150:1875-7.
McCarrollJE, Ursano RJ, Fullerton CS. Symptoms of PTSD following recovery of war dead: 13-15 month follow-up. AmJ Psychiatry 1995;152:939-41.
McFarlane AC, Raphael B. Ash Wednesday: the effects of a fire. Aust N Z J Psychiatry 1984;18:341-53.
McFarlane AC. Posttraumatic morbidity of a disaster: a study of cases presenting for psychiatric treatment. J Nerv Ment Dis 1986;174:4-14.
McFarlane AC. Long-term psychiatric morbidity after a natural disaster. MedJ Aust 1986;145:561-3.
McFarlane AC. The aetiology of post-traumatic morbidity: predisposing, precipitating and perpetuating factors. BrJ Psychiatry 1989;154:221-8.
McFarlane AC. The longitudinal course of posttraumatic morbidity: the range of outcomes and their predictors. J Nerv Ment Dis 1988; 176:30-9.
McFarlane AC. The phenomenology of post-traumatic stress disorders following a natural disaster. J Nerv Ment Dis 1988; 176:22-9.
Mellman TA, Kulick-Bel1 R. Ashlock LE, Nolan B. Sleep events among veterans with combat-related posttraumatic stress &order. AmJ Psychiatry 1995;152: 110-5.
Nader K, Pynoos R. School &aster: planning and initial interventions. J Soc Behav Pers 1992;8:1-21.
Noji EK. Natural disasters. Crit Care Clin 1991;7:271-92.
Noji EK. Disaster epidemiology: challenges for public health action. J Public Health Policy 1992;13:332-40.
Norris FH. Towards establishing a data base for the prospective study of traumatic stress. Presented at the National Institute of Mental Health workshop, Traumatic stress: defining terms and instruments. Rockville, Maryland: Uniformed Services University of the Health Sciences, November 20-21, 1988.
Parker G. Cyclone Tracy and Darwin evacuees: on the restoration of the species. BrJ Psychiatry 1977;130:548-55.
Perry S. DifedeJ, Musngi G. Frances AJ, Jacobsberg L. Predictors of Posttraumatic stress &order after burn injury. AmJ,Psychiatry 1992;149:931-5.
Pynoos RS, Nader K. Prevention of psychiatric morbidity in children after disaster. In: Shaffer D, Philips I, Enzer NB, eds. Prevention of mental disorders, alcohol and other drug use in children and adolescents. Washington, DC: US Government Printing Office, 1989:225-71; DHHS publication no (ADM)891646.
Pynoos RS, Nader K. Psychological first aid and treatment approaches to children exposed in community violence: research implications. J Traumatic Stress 1988;1:445-73.
Pynoos RS, Nader K. Issues in the treatment of posttraumatic stress in children and adolescents. In: Wilson JP, Raphael B. eds. International handbook of traumatic stress syndromes. New York: Plenum, 1993:535-49.
Pynoos RS. Grief and trauma in children and adolescents. Bereavement Care 1992;11:2-10.
Quarentelli EL. An assessment of conflicting views on mental health: the consequences of traumatic events. In: Figley CR, ed. Trauma and its wake. New York: Brunner/Mazel, 1985: 173-215.
Raphael B. Victims and helpers. In: Raphael B. ed. When disaster strikes: how individuals and communities cope with catastrophe. New York: Basic Books, 1986:222-4.
Raphael B. Wilson JP. Theoretical and intervention considerations in working with victims of disaster. In: Wilson JP, Raphael B. eds. International handbook of traumatic stress syndromes. New York: Plenum, 1993:105-17.
RundellJR, Ursano RJ. Psychiatric responses to trauma In: Ursano RJ, Norwood AK, eds. Emotional aftermath ofthe Persian GulfWar: veterans, communities, and nations. Washington, DC: American Psychiatric Press pn press].
RundellJR, Ursano RJ, Holloway HC, Silberman EK. Psychiatric responses to trauma. Hosp Community Psychiatry 1989; 40:68-74.
Shalev A, Bleich A, Ursano RJ. Posttraumatic stress &order: somatic comorbidity and effort tolerance. Psychosomatics 1990;31:197-203.
Shalev AY, GaW T. Eth S. Levels of trauma: a multidimensional approach to the treatment of PTSD. Psychiatry 1993; 56:166-77.
Shalev AY. Debriefing following traumatic exposure. In: Ursano RJ, McCaughey BG, Fullerton CS, eds. Individual and community responses to trauma and disaster. London: Cambridge University Press, 1994:201-19.
Shore JH, Vollmer WM, Tatum EL. Community patterns of posttraumatic stress disorders. J Nerv Ment Dis 1989;177: 681-5.
ShoreJH, Tatum EL, Vollmer WM. Psychiatric reactions to disaster: the Mount St Helens experience. Am PsychiatTy 1986;143:590-5.
Singh B. Raphael B. Post&aster morbidity of the bereaved: a possible role for preventive psychiatry. J Nerv Ment Dis 1981;169:203-12.
Sledge WH, BoydstunJA, Rahe AJ. Self-concept changes related to war captivity. Arch Gen Psychiatry 1980;37: 430-43.
Smith E, North C. Posttraumatic stress &order in natural disasters and technological accidents. In: Wilson JP,Raphael B. eds. International handbook of traumatic stress syndromes. New York: Plenum, 1993:405-19.
Smith EM, North CS, McCool RE, SheaJM. Acute post&aster psychiatric &orders: identification of those at risk. AmJ Psychiatry 1989;147:202-6.
Solomon S. Gerrity ET, MuffAM. Efficacy of treatment for posttraumatic stress disorder. JAMA 1992;268:633-8.
Solomon SD, Smith EM, Robins LN, Fischbach RL. Social involvement as a mediator of disaster-induced stress. J Appi Soc Psychol 1987;17:1092-112.
Solomon SD, Smith EM. Social support and perceived control as moderators of responses to dioxin and flood exposure. In: Ursano RJ, McCaughey BG, Fullerton CS, eds. Individual and community responses to trauma and &aster. London: Cambridge University Press, 1994:179-200.
Solomon SD, Gerrity ET, MuffAM. Efficacy of treatments for Posttraumatic stress &order: an empirical review. JAMA 1992;268:633-8.
Solomon SD. Mobilizing social support networks in times of disaster. In: Figley CR, ed. Trauma and its wake. vol 2. Traumatic stress theory, research andintervention. NewYork: Brunner/Mazel, 1986:232-63.
Solomon Z. Mikulincer M, Kotler M. A two year follow-up of somatic complaints among Israeli combat stress reaction casualties. J Psychosom Res 1987;31:463-9.
Solomon Z. Mikulincer M. Combat stress reactions, posttraumatic stress disorder, and social adjustment: a study of Israeli veterans. J Nerv Ment Dis 1987;175:277-85.
Spiegel D, Cardena E. Disintegrated experience: the dissociative disorders revisited. J Abnorm Psychol 1991;100:366-78.
Steinglass P. Gerrity E. Natural disasters and post-traumatic stress disorder: short-term versus long-term recovery in two disaster-affected communities. J Appl Soc Psychol 1990;20: 1746-65.
Taylor V. Good news about disaster. Psychol Today 1977;11 :93-4, 124-6.
Titchener JL, Kapp FT. Family and character change at Buffalo Creek. AmJ Psychiatry 1976;133:295-9.
Turner S. Thompson J. Rosser RM. The Kings Cross fire. In: Wilson JP, Raphael B. eds. International handbook of traumatic stress syndromes. New York: Plenum, 1993:451-9.
Ursano RJ, BoydstunJA, Wheatley RD. Psychiatric illness in US Air Force Vietnam prisoners of war: a five-year follow-up. Am Psychiatry 1981;138:310-4.
Ursano RJ, McCarrollJE. The nature of the traumatic stressor: handling dead bodies. J Nerv Ment Dis 1990;178:396-8.
Ursano RJ, Fullerton CS, Wright KM, McCarrollJE, Norwood AK, Dinneen MM, eds. Disaster workers: trauma and social support. Bethesda, Maryland: Uniformed Services University of the Health Sciences, 1992; DTIC publication no ADB 165599.
Ursano RJ, Kao TC, Fullerton CS. Posttraumatic stress disorder and meaning. structuring human chaos. J Nerv Ment Dis 1992;180:756-9.
Ursano RJ, McCaughey BC, Fullerton CS. The structure of human chaos. In: Ursano RJ, McCaughey BG, Fullerton CS, eds. Individual and community responses to trauma and disaster: the structure of human chaos. London: Cambridge University.Press, 1994:3-27.
Ursano RJ, Fullerton CS, Bhartiya V, Kao TC. Longitudinal assessment of Posttraumatic stress &order and depression after exposure to traumatic death. J Nerv Ment Dis 1995;183: 36-42.
Ursano RJ, Holloway HC. Military psychiatry. In: Kaplan HI, Sadock BJ, eds. Comprehensive textbook of psychiatry. 4th ed. Baltimore: Williams & Wilkins 1985:1900-9.
Ursano RJ, Fullerton CS. Cognitive and behavioral responses to trauma. J Appl Psychol 1990;20:1766-75.
Ursano RJ. Commentary. Posttraumatic stress disorder: the stressor criterion. T Nerv Ment Dis 1987;175:273-5.
Ursano RJ. The Vietnam era prisoner of war: precaptivity personality and development of psychiatric illness. AmJ Psychiatry 1981;138:315-8.
Van der Kolk BA, Van der Hart 0. Pierre Janet and the breakdown of adaptation in psychological trauma. AmJ Psychiatry 1989;146:1530-40.
Weisaeth L. A study of behavioral responses to an industrial disaster. Acta Psychiatr Scand Suppl 1989;80:13-24.
Weisaeth L. Psychological and psychiatric aspects of technological disasters. In:Ursano RJ, McCaughey BC, Fullerton CS, eds. Individual and community responses to trauma and disasters: the structure of human chaos. London: Cambridge University Press, 1994:72-102.
Weisaeth L. The stressors and the post-traumatic stress syndrome after an industrial disaster. Acta Psychiatr Scand Suppl 1989;80:25-37.
World Health Organization, 1991; Psychosocial guidelines for preparedness and intervention in disaster. Geneva: World Health Organization, 1991: MNH/PSF/91.3.
Wright K, Ursano P.J, Bartone P. Ingraham L. Individual and community responses to disaster: victim classification. AmJ Orthopsychiatry 1990;60:35-42.