An Overview of Disaster Psychiatry

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Disasters are events that result in serious widespread disruption to the functioning of a society or community, whether on a local or larger scale, due to hazardous events. These events can be either natural or human made.¹ According to the World Health Organization, disasters are severe disruptions, ecological and psychosocial, which greatly exceed the coping capacity of the affected community.²

What Are the Impacts of Disaster?

Disasters’ impacts can be localized, but they are typically widespread and may persist for extended periods. The effects often challenge or exceed the resources available to a community and generally require assistance from external sources.^1,3 Disaster causes loss of human lives, physical illnesses, and property damage. Beyond the socioeconomic and physical toll, disasters also cause significant emotional and mental distress for the communities they affect. These effects may precipitate an increase in psychiatric disorders such as posttraumatic stress disorder (PTSD), anxiety, and depression.³

What Is Disaster Psychiatry?

Disaster psychiatry is defined as the understanding and treatment of the psychological impacts resulting from disaster, often using an epidemiological approach. It emphasizes the normality of acute stress responses following disaster event and strives to avoid psychopathologizing individuals. A key goal of disaster psychiatry is to provide interventions targeted at symptoms rather than focusing on syndromes. It aims to promote the overall health status and well-being of an affected community. This approach involves integration outside of traditional office settings, involving many organizations to ensure effective preparation and response.⁴ Although there are several important milestones in the development of disaster psychiatry, the 1942 Cocoanut Grove nightclub fire, which claimed nearly 500 lives, stands as a defining moment in the field’s development, particularly due to Erich Lindemann, MD, PsyD’s observations of survivors’ experiences.⁵

Psychological Effects of Disasters

Disasters differ in nature, each with unique characteristics that impact the psychological responses of survivors and communities. These elements can shape the type, intensity, and duration of stress experienced after the disaster.⁶ Disasters can have both short-term and long-term effects on mental health, despite a wide range of individual responses. While some individuals may develop chronic disorders such as PTSD, depression, or anxiety, the majority will experience stress responses that do not reach clinical levels. For many, these are appropriate responses to extreme circumstances.^7,8

A survivor’s response to and recovery from a disaster is shaped by various factors, some of which can be influenced or developed, while others are inherent traits.⁶ Genetic factors play a significant role in how individuals respond. Stress response is complex and regulated by multiple systems, including the sympathetic nervous system (SNS), the hypothalamic-pituitary-adrenal axis (HPA axis), neuropeptide Y, and serotonin, all of which vary genetically between individuals. Interestingly, neuropeptide Y, which is secreted from the hypothalamus and other areas of the brain, may serve as a protective factor from the effects of trauma.⁹

The body’s stress response involves 2 main components: an acute response mediated by the sympathetic-adreno-medullar system (SAM) and a long-term response mediated by the HPA axis. SAM activation triggers the adrenal medulla to release norepinephrine and epinephrine, which in turn activate a cascade of cellular responses such as vasoconstriction, increased blood pressure, heart rate, and many others. There is also behavioral activation such as enhanced vigilance, attention, and arousal.¹⁰ Long-term stress leads to sustained activation of the SNS and HPA axis. The hypothalamus releases corticotropin-releasing hormone, stimulating the anterior pituitary gland to release adrenocorticotropic hormone, which prompts the adrenal cortex to secrete glucocorticoid hormones like cortisol, further activating the stress response. Chronic elevation of stress hormones can have detrimental effects on health, including hypertension, immune suppression, insulin resistance, and cardiovascular disease.¹¹

Clinicians Role in Disaster Psychiatry and Disaster Management

Disaster psychiatry is unique from most practice settings as it is not office or hospital based. Clinicians typically work on-site. Clinicians' roles include planning and coordination during the predisaster, immediate response, and long-term care and support stages.^3,6,11

Taking a stepwise approach to the phases of a disaster can help clinicians prepare for and respond more effectively to these events. Phases of disaster management include: readiness (predisaster), response (immediate action), relief (sustained rescue work), rehabilitation (long-term remedial measures using community resources), recovery (returning to normalcy), and resilience (fostering).¹²

Predisaster: Preparation and Planning

Effective disaster preparation and planning are essential for communities to manage potential crises. Clinicians can work as liaisons between disaster response agencies and health care facilities, assisting with hospital and clinic disaster planning. Mental health clinicians in particular can advocate for the inclusion of mental health considerations in disaster preparedness, addressing the psychological impact on affected populations. Preparing for disasters has become increasingly important due to the growing frequency and intensity of disasters related to changes in climate, technology use, and geopolitical situations.⁴

Immediate Response: Psychological First Aid

An immediate response is crucial in mitigating long-term psychological effects and fostering resilience. This early response typically occurs at the disaster site, beginning as soon as possible and potentially lasting several days to weeks. Psychological first aid (PFA) is a key approach for reducing initial distress and supporting adaptive functioning and coping in both the short and long term.¹³ The primary goals of PFA are to improve mental health and functional responses by tending to basic needs, ensuring safety, promoting a sense of control, and fostering social connections.¹⁴ Key components of PFA include engaging with individuals, promoting safety, assessing needs, providing calming and stabilization, and encouraging connectedness.^{14, 15} Clinicians should engage survivors with respect and empathy, assess their medical and psychiatric needs to identify those requiring immediate care, and offer information and support to help stabilize emotions. Creating opportunities for social connection helps build a support network promoting resilience, problem-solving, and long-term recovery.

Key Interventions: The 5 Elements of Mass Trauma Response

There are 5 principles of intervention that serve as guidance for developing practices after disasters and mass violence.¹⁵ These principles are:

1. Promote a sense of safety.
2. Promote calming.
3. Promote sense of self and collective efficacy.
4. Promote connectedness.
5. Promote hope.

Promote a sense of safety: Disasters force people to respond to events that threaten their lives or the individuals and things they care most about.¹⁵ As a result, it is common to see large percentages of disaster-affected populations with negative posttraumatic reactions. When threat or danger conditions are ongoing, these negative posttrauma responses persist. However, these reactions show a gradual reduction over time once safety is introduced, even when the threat continues.^16,17

Promote calming: Calming interventions help to counteract the heightened emotionality often seen after mass trauma exposure. While an initial arousal response can be adaptive, heightened emotional responses when prolonged can result in mental health issues such as depression and PTSD.¹⁸

Promote sense of self and collective efficacy: Self-efficacy is the belief that one's actions are likely to lead to positive outcomes, while collective efficacy is the confidence that a group can achieve positive outcomes together. This sense of control over positive outcomes is especially important when coping with trauma-related challenges.¹⁹

Promote connectedness: Social connectedness is important in combating stress and trauma. It supports resilience by encouraging knowledge sharing and increasing opportunities for social support activities. Examples of such activities are discussing traumatic experiences in safe environments with adequate support.¹⁵ Moreover, this can lead to a sense of community efficacy.

Promote hope: Disaster tends to be an experience individuals are not trained for and do not have the learned coping strategies to combat. As a result, disaster is often followed with a “shattered worldview,” which undermines hope and leads to despair.²⁰ However, those who retain hope and remain optimistic about their future after experiencing disaster are likely to have more favorable outcomes.²¹ Fostering hope is essential for recovery in disaster situations.

Long Term Care and Support

Following PFA, long-term care and support are essential to sustained recovery. Key objectives include effective triage and screening, restoration of daily functioning, development of self-regulation techniques for managing emotional responses, and improvement of problem-solving abilities to manage ongoing challenges. Long-term care and support also focuses on strategies for risk reduction, resilience-building to withstand stressors caused by disasters, and long-term recovery to support mental well-being.¹³

Challenges in Disaster Psychiatry

Disaster psychiatry encounters several significant challenges. Rapid mobilization of mental health resources is essential for effective intervention, yet time constraints pose a challenge. Limited access to insurance or inadequate coverage can prevent individuals from receiving necessary care. The complexity of disaster response also brings role conflicts, particularly regarding leadership and decision-making. Additionally, many lack preparedness for handling disasters, highlighting the need for predisaster training and planning.²² Even disaster workers are at risk of acute stress disorder, PTSD, and depression.²³

Concluding Thoughts

Disaster psychiatry plays a crucial role in mitigating the impact of disaster, promoting an environment where survivors can move forward with resilience. Clinicians who are interested in learning more about disaster psychiatry can find more resources through the American Psychiatric Association’s Disaster Mental Health webpage. This page provides position statements, literature, and resources related to the field. Additionally, it provides information regarding volunteer opportunities.²⁴ Clinicians can also find resources through the Substance Abuse and Mental Health Services Administration’s webpage on Disaster Behavioral Health Resources. This page provides literature and guides which are designed for both responders and survivors.²⁵

Ms Filippi is a medical student at Penn State College of Medicine. Dr Pratt is a resident physician in the Department of Psychiatry at Yale School of Medicine. Dr Khan is an associate clinical professor in the Department of Psychiatry at Yale School of Medicine and serves as a staff psychiatrist at VA Connecticut Healthcare System.

References

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3. Makwana N. Disaster and its impact on mental health: a narrative review. J Family Med Prim Care. 2019;8(10):3090-3095.

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5. History of disaster mental health. University of Nebraska. Accessed February 24, 2025. https://www.disastermh.nebraska.edu/wp-content/uploads/2021/05/History_of_Disaster_Mental_Health.pdf

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13. Psychological First Aid (PFA) Field Operations Guide: 2nd Edition. The National Child Traumatic Stress Network. 2018. Accessed February 24, 2025. https://www.nctsn.org/resources/psychological-first-aid-pfa-field-operations-guide-2nd-edition

14. Stoddard F Jr, Pandya A, Katz C, eds. Disaster Psychiatry: Readiness, Evaluation, and Treatment. American Psychiatric Publishing; 2011.

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16. Ozer EJ, Best SR, Lipsey TL, Weiss DS. Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychol Bull. 2003;129(1):52-73.

17. Bleich A, Gelkopf M, Solomon Z. Exposure to terrorism, stress-related mental health symptoms, and coping behaviors among a nationally representative sample in Israel. JAMA. 2003;290(5):612-620.

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19. Benight CC, Harper ML. Coping self-efficacy perceptions as a mediator between acute stress response and long-term distress following natural disasters. J Trauma Stress. 2002;15(3):177-186.

20. Janoff-Bulman R. Shattered Assumptions: Towards a New Psychology of Trauma. Free Press; 1992.

21. Carver CS, Scheier MF. On the Self-Regulation of Behavior. Cambridge University Press; 1998.

22. Farokhzadian J, Mangolian Shahrbabaki P, Farahmandnia H, et al. Nurses’ challenges for disaster response: a qualitative study. BMC Emerg Med. 2024;24(1):1.

23. Fullerton CS, Ursano RJ, Wang L. Acute stress disorder, posttraumatic stress disorder, and depression in disaster or rescue workers. Am J Psychiatry. 2004;161(8):1370-1376.

24. Disaster mental health.American Psychiatric Association. Accessed February 25, 2025. https://www.psychiatry.org/psychiatrists/practice/professional-interests/disaster-and-trauma

25. Disaster behavioral health resources.Substance Abuse and Mental Health Services Administration. Accessed February 25, 2025. https://www.samhsa.gov/technical-assistance/dtac/resources