Skip to main content

First Responders after Disasters: A Review of Stress Reactions, At-Risk, Vulnerability, and Resilience Factors

  • David A. Alexander (a1) and Susan Klein (a2)

Disasters are widely reported, commonplace events that characteristically leave an enormous legacy of human suffering through death, injury, extensive infrastructural damage, and disorganization to systems and communities.The economic costs may be almost incalculable. Professional and civilian first responders play a vital role in mitigating these effects. However, to maximize their potential with the minimum health and welfare costs to first responders, is important to have a good understanding of the demands of such work on them, how they cope, and what enables them to fulfi ll their roles.This review will explore these themes by highlighting important findings and areas of uncertainty.

Corresponding author
Aberdeen Centre for Trauma Research Faculty of Health and Social Care The Robert Gordon University Garthdee Road Aberdeen AB10 7QG Scotland, UK E-mail:
Hide All
1. Sundnes, KO, Birnbaum, ML (eds): Health and Disaster Management Guidelines for Evaluation and Research in the Utstein Style. Prehospital Disast Med 2003;17(Suppl 3):1177.
2. Raphael, B: When Disaster Strikes. How Individuals and Communities Cope with Catastrophe. New York: Basic Books, 1986.
3. Dyregrov, A, Kristoffersen, JI, Gjestad, R: Voluntary and professional disasterworkers: Similarities and diffe rences in reactions. J Trauma Stress 1996;9:541555.
4. McFarlane, AC, Bryant, RA: Post-traumatic stress disorder in occupational settings: Anticipating and managing the risk. Occup Med 2007;57:404410.
5. Palm, KM, Polusny, MA, Follette, VM: Vicarious traumatization: Potential hazards and interventions for disaster and trauma workers. Prehospital Disast Med 2004;19:7378.
6. McCann, L, Pearlman, LA:Vicarious traumatisation: A framework for understanding the psychological effects of working with victims. J Trauma Stress 1990;3:131–49.
7. Figley, CR: Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder in Those Who Treat the Traumatized. New York: Brunner/Mazel, 1995.
8. Maslach, C, Jackson, SE: Burnout in Health Professions. In: Sanders, GS, Suls, J (eds), Social Psychology of Health and Illness. 3rd ed. Hillside NJ: Lawrence Erlbaum, 1982, pp 227251.
9. Ozen, S, Sir, A: Frequency of PTSD in a groups of search and rescue workers two months after 2003 Bingol (Turkey) earthquake. J Nerv Ment Dis 2004;192:573575.
10. Viel, JF, Curbakova, E, Dzerve, B, et al. : Risk factors for long-term mental and psychosomatic distress in Latvian Chernobyl liquidators. Environ Health Perspect 1997;105:15391544.
11. Nickeil, LA, Crichton, EJ, Tracy, CS, et al. : Psychosocial effects of SARS on hospital staff: Survey of a large tertiary care institution. Can Med Assoc J 2004;170:793798.
12. Armagan, E, Engindeniz, Z, Devay, AO, et al. : Frequency of post-traumatic stress disorder among relief force workers after the tsunami in Asia: Do rescuers become victims? Prehospital Disast Med 2006;21:168172.
13. Bilal, MS, Rana, MH, Rahim, S, et al. : Psychological trauma in a relief worker –A case report from earthquake-struck areas of Northern Pakistan. Prehospital Disast Med 2007;22:458461.
14. Klein, S, Alexander, DA: Post-Disaster Research Issues. In: Niaz, U (ed), Pakistan Earthquake 2005:The Day the Earth Move d. Karachi: Sama Publishing and Editorial Services, 2007, pp 233263.
15. Stewart, SH, Mitchell, TL, Wright, KD, et al. : The relations of PTSD symptoms to alcohol use and coping drinking in volunteers who responded to the Swissair Flight 111 airline disaster. J Anxiety Disord 2004;18:5168.
16. Alexander, DA, Walker, LF, Sinclair, SD, et al. : Police Stress at Work. London: Police Foundation, 1993.
17. Boxer, PA, Wild, D: Psychological distress and alcohol use among fire fighters. Scand J Work Environ Health 1993;19:121125.
18. North, CS, Tivis, L, McMillen, JC, et al. : Psychiatric disorders in rescue workers after the Oklahoma City bombing. Am J Psychiatry 2002;159:857859.
19. American Psychiatric Association: Diagnostic and Statistical Manual (4th Edition). Washington DC: American Psychiatric Association, 1994.
20. World Health Organization: The ICD-10 Classification of Mental and Behavioural Disorders. Geneva:World Health Organization, 1992.
21. Engelhard, IM, van den Hout, MA, Weerts, J, et al. : Deployment-related stress and trauma in Dutch soldiers returning from Iraq: Prospective study. Br J Psychiatry 2007;191:140145.
22. Morren, M Yzermans, CJ, van Nispen, RMA, et al. : The health of volunteer fire fighters three years after a technological disaster. J Occup Health 2005;47:523532.
23. Norris, FH, Friedman, MJ, Watson, PJ: Disaster victims speak: Part I. An empirical review of the empirical literature, 1981–2001. Psych i a try 2002;65:207260.
24. Alexander, DA: Trauma research: A newera. J Psychosom Res 1996;41:15.
25. Klein, S, Alexander, DA: Epidemiology and presentations of post-traumatic disorders. Psychiatry 2006;5:225227.
26. Sims, A, Sims, D: The phenomenology of post-traumatic stress disorder. A symptomatic study of 70 victims of psychological trauma. Psychopathology 1998;31:96112.
27. Galea, S, Nardi, A, Vlahov, D: The epidemiology of post-traumatic stress disorder after disasters. Epidemiol Rev 2005;27:7891.
28. Liao, SC, Lee, MB, Lee, YJ et al. : Association of psychological distress with psychological factors in rescue workers within two months after a major earthquake. J Formos Med Assoc 2002;101:169176.
29. Fullerton, CS, Ursano, RJ, Wang, L: Acute stress disorder, posttraumatic stress disorder, and depression in disaster or rescue workers. Am J Psychiatry 2004;161:13701376.
30. Huizink, AC, Slottje, P, Witteveen, AB, et al. : Long term health complaints following the Amsterdam Air Disaster in police officers and fire fighters. Occup Environ Med 2006;63:657662.
31. Dowling, FG, Moynihan, G, Genet, B, et al. : A peer-based assistance program for officers with the New York City Police Department: Report of the effects of Sept. 11, 2001. Am J Psychiatry 2006;163:151153.
32. Yeh, CB, Leckman, JF, Wan, FJ, et al. : Characteristics of acute stress symptoms and nitric oxide concentration in young rescue workers in Taiwan. Psychiatry Res 2002;112:5968.
33. Morren, M, Dirkz, Wager AJE, Kessels, FJM, et al. : The influence of a disaster on the health of rescue wo rkers: A longitudinal study. CMAJ 2007;176:12791283.
34. Marmar, CR, McCaslin, SE, Metzler, TJ, et al. : Predictors of posttraumatic stress in police and other first responders. Ann NY Acad Sci 2006;1071:118.
35. Marmar, CR, Weiss, DS, Metzler, TJ, et al. : Stress responses of emergency services personnel to the Loma Prieta earthquake Interstate 880 freeway collapse and control traumatic incidents. J Trauma Stress 1996;9:6385.
36. Hagh-Shenas, H, Goodazi, MA, Dehbozorgi, G, et al. : Psychological consequences of the Bam earthquake on professional and non-professional helpers. J Trauma Stress 2005;18:477483.
37. Paton, D: Training disaster workers: Promoting wellbeing and operational effectiveness. Disaster Prevent Manag 1996;5:1118.
38. Eidelson, RJ, D'Alessio, GR, Eidelson, JI: The impact of September 11 on psychologists. Profess Psychol: Research and Practice 2003;34:144150.
39. Leffler, CT, Dembert, ML: Posttraumatic stress symptoms among US Navy divers recovering TWA flight 800. J Nerv Ment Dis 1998;186:574577.
40. Alvarez, J, Hunt, M: Risk and resilience in canine search and rescue handlers after 9/11. J Trauma Stress 2005;18:497505.
41. Alexander, DA: Stress among body handlers: A long-term follow-up. Br J Psychiatry 1993;163:806808.
42. Tucker, P, Pfefferbaum, B, Doughty, DE, et al. : Body handlers after terrorism in Oklahoma City: Predictors of posttraumatic stress and other symptoms. Am J Psychiatry 2002;72:469475.
43. Taylor, A, Frazer, A: The stress of post-disaster body handling and victim identification. J Human Stress 1982;8:412.
44. Tedeschi, RG, Kilmer, RP: Assessing strengths, resilience, and growth to guide clini cal interventions. Professional Psychololgy: Research and Practice 2005;36:230237.
45. Summerfield, D: Survivors of the tsunami: Dealing with disaster. Psychiatry 2006;5:255256.
46. Tam, CWC, Pang, EPF, Lam, LCW, et al. : Severe acute respiratory syndrome (SARS) in Hong Kong in 2003: Stress and psychological impact among frontline healthcare workers. Psychol Med 2004;34:11971204.
47. McCarroll, JE, Ursano, RJ, Wright, KM, et al. : Handling bodies after violent death. Am J Orthopsychiatry 1993;63:209214.
48. Witteveen, AB, Bramsen, I, Twisk, JWR, et al. : Psychological distress of rescue workers eight and one-half years after professional involvement in the Amsterdam air disaster. J Nerv Ment Dis 2007;195:3140.
49. Alexander, DA, Atcheson, SF: Psychiatric aspects of trauma care: Survey of nurses and doctors. Psych Bull 1998;22:132136.
50. Alexander, DA, Klein, S: Ambulance personnel and critical incidents: Impact of accident and emergency work on mental health and emotional well-being. Br J Psychiatry 2001;178:7681.
51. Perilla, JL, Norris, FJ, Lavisso, E: Ethnicity, culture and disaster response: Identifying and explaining ethnic differences in rescue workers after the Oklahoma City bombing. Am J Psychiatry 2002;159:857859.
52. Maddi, SR, Kobasa, SC: The Hardy Executive: Health Under Stress. Homewood, III: Dow Jones-Irvin, 1984.
53. Roberts, SB, Flannelly, KJ, Weaver, AJ, et al. : Compassion fatigue among chaplains, clergy, and other respondents after September 11th. J Nerv Ment Dis 2003;191:756758.
54. Brown, J, Mulhern, G, Joseph, S: Incident-related stressors, locus of control, coping and psychological distress among fi re fighters in Northern Ireland. J Trauma Stress 2002;15:161168.
55. Cetin, M, Kose, S, Ebrinc, S, et al. : Identificationand posttraumatic stress disorder symptoms in rescue workers in the Marm a ra Turkey, earthquake. J Trauma Stress 2005;18:485489.
56. Ursano, RJ, McCarroll, JE: The nature of a traumatic stressor: Handling dead bodies. J Nerv Ment Dis 1990;178:396398.
57. Fullerton, CS, Ursano, RJ, Reeves, J, et al. : Perceived safety in disaster workers following 9/11. J Nerv Ment Dis 2006;194:6163.
58. Regehr, C, Goldberg, G, Hughes, J: Exposure to human tragedy, empathy, and trauma in ambulance paramedics. Amer J Orthopsychiatry 2002;72:505513.
59. Bryant, RA, Harvey, AG: Post-traumatic reactions in volunteer fire fighters. J Trauma Stress 1996;9:5162.
60. Ozer, EJ, Best, SR, Lipsey, TL, et al. : Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychol Bull 2003;129:5273.
61. Rundell, JR: Assessment and Management of Medical-Surgical Disaster Casualties. In: Ursano, RJ, Fullerton, CS, Weisaeth, L, Raphael, B (eds),Textbook of Disaster Psychiatry. Cambridge: Cambridge University Press, 2007, pp 164189.
62. Alexander, DA, Wells, A: Reactions of police officers to body-handling after a major disaster: A before-and-after comparison. Br J Psychiatry 1991;159:547555.
63. Thompson, J, Solomon, M: Body recovery teams at disasters: Trauma or challenge? Anxiety Res 1991;4:234244.
64. McCaslin, SE, Jacobs, GA, Meyer, DL, et al. : How does negative life change following disaster response impact distress among Red Cross responders? Profess Psychol: Research and Practice 2005;36:246253.
65. Arata, CM, Picou, JS, Johnson, G, et al. : Coping with technological disaster: An application of the conservation of resources model to the Exxon Valdez oil spill. J Trauma Stress 2000;13:2339.
66. Mitchell, J:When disaster strikes: The critical incident stress debriefing procedure. J Emerg Med Serv 1983;8:3639.
67. National Institute for Clinical Excellence: Post-traumatic Stress Disorder (PTSD): The Management of PTSD in Adults and Children in Primary and Secondary Care. London: National Collaborating Centre for Mental Health, 2005.
68. Raphael, B, Wooding, S: Debriefing: Its evolution and current status. Psychiatr Clin North Am 2004;27:407423.
69. Gray, MJ, Maguen, S, Litz, BT: Acute psychological impact of disaster and large-scale trauma: Limitations of traditional interventions and future practice recommendations. Prehospital Disast Med 2004;19:6472.
70. Everly, GS, Mitchell, JT: Critical Incident Stress Management (CISM): A New Era and Standard of Care in Crisis Management. Ellicott City, MD: Chevron, 1997.
71. Greenberg, N, Cawkill, P, March, C, et al. : How to TRiM away at post traumatic stress reactions: Traumatic risk management—Now and the future. J R Nav Med Serv 2005;91:2631.
72. Elhai, JD, Jacobs, GA, Kashdan, TB, et al. : Mental health service use among American Red Cross disaster workers responding to the September 11, 2001 U.S. terrorist attacks. Psychiatry Res 2006;143:2934.
73. Bryant, RA, Moulds, ML, Nixon, RVD: Cognitive behaviour therapy of acute stress disorder: A four-year follow-up. Behav Res Ther 2003;41:489494.
74. Harvey, AG, Bryant, RA, Tarrier, N: Cognitive behaviour therapy for posttraumatic stress disorder. Clin Psychol Rev 2003;23:501522.
75. Walser, RD, Ruzek, JI, Naugle, AE, et al. : Disaster and terrorism: Cognitivebehavioural interventions. Prehospital Disast Med 2004;19:5463.
76. Seidler, GH, Wagner, FE: Comparing the efficacy of EMDR and traumafocused cognitive-behavioural therapy in the treatment of PTSD: A metaanalytic study. Psychol Med 2006;36:15151522.
77. Dominici, F, Levy, JI, Louis, TA: Methodological challenges and contributions in disaster epidemiology. Epidemiol Rev 2005;27:912.
78. Griffin, MG, Resick, RA, Waldrop, AE, et al. : Participation in trauma research: is there evidence of harm? J Trauma Stress 2003;16:221227.
79. Huizink, AC, Smidt, N, Twisk, JWR, et al. : Epidemiologi caldisaster research: The necessity to include representative samples of the invo lved workers. Experience from the epidemiological study air disaster Amsterdam—ESADA. J Epidemiol Community Health 2006;60:887889.
80. Keane, T, Fairbank, J, Caddell, K, et al. : Clinical evaluation of a measure to assess combat exposure. J Consult Clin Psychol 1989;1:5355.
81. Wessely, S, Unwin, C, Hotopf, M, et al. : Stability of recall of military hazards over time. Br J Psychiatry 2003;183:314322.
82. Summerfield, D: Cross-Sectional Perspecti veson the Medicalization of Human Suffering. In: Rosen, GM (ed), Posttraumatic Stress Disord er: Issues and Controversies. New York: Wiley, 2004, pp 233245.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Prehospital and Disaster Medicine
  • ISSN: 1049-023X
  • EISSN: 1945-1938
  • URL: /core/journals/prehospital-and-disaster-medicine
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed