Disasters and Mental Health
The ability to measure psychological and behavioral responses to disasters has become very important given our global, social, and climate instability. The measures reported below have been successfully used in large probability-based representative samples of U.S. Americans in national and regional studies.
Here we highlight several validated measures that have been used in various disasters, such as 9/11, the Boston Marathon Bombing, hurricanes, war, and pandemics (Ebola and COVID). We first review five types of measures. As an addendum, we follow with a literature review of how these measures have been used in various disasters. We list two measures for each of the areas. When measuring disaster responses, it is important to tailor the measures, which is why we provide examples.
Measuring direct exposure as a covariate will always be important. For population-based researchers, measures of exposure and acute stress are important for predicting health outcomes. If you want to identify the early predictors of cardiovascular disease risk following a disaster, relevant measures would be high media exposure, acute stress, and worry. These are likely to be stronger predictors than a general measure of exposure. For example, for 9/11, media exposure predicted subsequent physical health problems. Common mental health outcomes of disasters include acute stress, PTSD symptoms, general psychological distress, and worry about the future. In addition, it may be helpful to examine risk factors, such as chronic stressors, and protective factors, such as community-level social assets (which are described in the literature review attached below).
Below we provide a short review of each of these measures:
There are many ways to measure exposure, and most commonly it is dichotomized as direct exposure versus none. Disaster exposure measures aim to capture the degree to which participants or participants’ close others were exposed to the specific type of disaster. Disaster exposure can be assessed in terms of proximity, such as no first-hand exposure, witnessing the disaster in person or having a closed other exposed, to being directly at the site of the disaster (Holman et al., 2014; Lowe et al., 2015; Lowe et al., 2013; Silver et al., 2002; Thompson et al., 2019).
Here are two examples of disaster exposure measures by Holman et al. (2014), and by Lowe et al. (2015)
2. Disaster media exposure
Disaster media exposure assesses the degree to which participants have been exposed to disaster-related information via traditional (e.g., TV, radio, online news sources) or social (e.g., Facebook, Twitter) media. This is typically done in two ways. One approach asks participants to estimate hours spent consuming disaster-related information from different media outlets (e.g., television, social media, news sites) in a given time frame such as 7 days after the 9/11 attacks (Silver et al., 2002; Silver et al., 2013) or Boston Marathon Bombings (Holman et al., 2014). Another way involves presenting and asking participants how frequently they have seen a series of disaster-related images, such as those from the Iraq War (Silver et al., 2013; e.g., military equipment, bombs exploding, injured/dead soldiers), Boston Marathon Bombings (Holman et al., 2020a), or the 9/11 attacks (Ahern et al., 2002).
Please see examples of time-oriented measure here (Holman et al., 2014; Silver et al., 2013) and exposure to disaster-related images here (Ahern et al., 2002; Holman et al., 2020a; Silver et al., 2013).
3. Acute stress response (stress-related symptoms soon after exposure)
During and/or shortly after a disaster, people may experience symptoms of acute stress disorder such as anxiety or dissociation symptoms. One way to measure these symptoms is with the 30-item Stanford Acute Stress Reaction Questionnaire (SASRQ; Cardena et al., 2000). The SASRQ has been used to measure acute stress symptoms within a one to three weeks after 9/11, the Iraq War, and the Boston Marathon Bombings (Holman et al., 2014; Silver et al., 2013). Another way to measure acute stress symptoms is with the 14-item Acute Stress Disorder Scale (ASDS; Bryant, Moulds, Guthrie, 2000) that was developed as a self-report version of the Acute Stress Disorder Interview, a structured clinical interview based on the DSM-IV criteria. The ASDS has been used to identify acute stress disorders after the Orlando mass shooting (Thompson et al., 2019a) and COVID-19 outbreak (Holman et al., 2020b).
Here is a copy of the ASDS and the SASRQ.
4. Worry about future disasters
Fears and worry about the possibility of a disaster reoccurring is an important psychological outcome and mediator of psychological and physical health. A face valid, two-item measure modified from the Vaughan Perceived Risk Scale (Vaughan & Wong, unpublished data, 2002) is typically used that asks the extent a participant is fearful and worried the specific disaster will occur in the future. A modified version of the two-items has been used to measure fear and worry after 9/11 (Holman et al., 2008; Silver et al., 2002), the Boston Marathon Bombings (Holman et al., 2020), and the 2014 Ebola public health crises (Thompson et al., 2017). Additional face-valid items have been used to assess participants’ fear and worry that community violence, weather-related disasters, exposure to environmental hazards, and economic hardship will occur in the future (Thompson et al., 2019a, 2019b).
Please see examples of the two-item measure here (Holman et al., 2008; Silver et al., 2002)
5. PTSD symptoms
Posttraumatic stress symptoms, such as intrusive memories and hyperarousal , are those persisting a month or more after a disaster. The 22-item Impact of Events Scale-Revised (IES-R; (Weiss & Marmar, 1997) and the 17-item PTSD Checklist Civilian (PCL-S; Blanchard et al., 1996) are widely used, well-validated, reliable measure to assess posttraumatic stress symptoms. The PTSD Checklist can also be modified for specific disasters such as Hurricane Ike (Lowe et al., 2015). To assess PTSD symptoms with fewer items, the 4-item Primary Care PTSD Screen has been used after the Boston Marathon bombings (PC-PTSD-4; Prins et al., 2004) which focuses on hallmark constructs of PTSD such as re-experiencing, avoidance, numbing, and hyperarousal. A modified 5-item Primary Care PTSD Screen (PC-PTSD-5; Prins et al., 2016) that now includes an item on negative alterations in mood and cognitions consistent with the DSM-5 can also be used. View the IES-R here.
View the PCL-S here and a distinction of different versions here. View the PC-PTSD-4 and PC-PTSD-5 here.
Authors and Reviewer(s):
This summary was prepared by Alison Holman, & Roxane Cohen Silver and reviewed by Aoife O’Donovan, Sandro Galea, Sarah Lowe, Elissa Epel, and Darwin A. Guevarra. Updated October 7th, 2021.
Garfin, D. R., Fischhoff, B., Holman, E. A., & Silver, R. C. (in press, 2021). Risk perceptions and health behaviors as COVID-19 emerged in the United States: Results from a probability-based nationally representative sample. Journal of Experimental Psychology: Applied. doi.org/10.1037/xap0000374
Holman, E. A., Garfin D. R., Lubens, P., & Silver, R. C. (2020a). Media exposure to collective trauma, mental health, and functioning: Does it matter what you see? Clinical Psychological Science, 8, 111-124. DOI: 10.1177/2167702619858300
Holman, E. A., Garfin, D. R., & Silver, R. C. (2014). Media’s role in broadcasting acute stress following the Boston Marathon bombings. Proceedings of the National Academy of Sciences of the USA, 111, 93-98. doi/10.1073/pnas.1316265110
Holman, E. A., Silver, R. C., Poulin, M., Andersen, J., Gil-Rivas, V., & McIntosh, D. N. (2008). Terrorism, acute stress, and cardiovascular health: A 3-year national study following the September 11th attacks. Archives of General Psychiatry, 65, 73-80. doi: 10.1001/archgenpsychiatry.2007.6
Holman, E. A., Thompson, R. R., Garfin, D. R., & Silver, R. C. (2020b). The unfolding COVID-19 pandemic: A probability-based, nationally representative study of mental health in the United States. Science Advances, eabd5390. DOI: 10.1126/sciadv.abd5390.
Jones, N. M., Garfin, D. R., Holman, E. A., & Silver, R. C. (2016). Media use and exposure to graphic content in the week following the Boston Marathon bombings. American Journal of Community Psychology, 58, 47-59. DOI 10.1002/ajcp.12073
Lowe, S. R., Joshi, S., Pietrzak, R. H., Galea, S., & Cerdá, M. (2015). Mental health and general wellness in the aftermath of Hurricane Ike. Social Science & Medicine, 124, 162-170. doi: 10.1016/j.socscimed.2014.11.032
Silver, R. C., Holman, E. A., McIntosh, D. N., Poulin, M., & Gil-Rivas, V. (2002). Nationwide longitudinal study of psychological responses to September 11. JAMA: The Journal of the American Medical Association, 288, 1235-1244. doi:10.1001/jama.288.10.1235
Silver, R. C., Holman, E. A., Andersen, J. P., Poulin, M., McIntosh, D. N., & Gil-Rivas, V. (2013). Mental- and physical-health effects of acute exposure to media images of the September 11, 2001, attacks and the Iraq War. Psychological Science, 24, 1623-1634. doi.org/10.1177/0956797612460406
Thompson, R. R., Garfin, D. R., Holman, E. A., & Silver, R. C. (2017). Distress, worry, and functioning following a global health crisis: A national study of Americans’ responses to Ebola. Clinical Psychological Science, 5(3), 513-521. doi.org/10.1177/2167702617692030
Thompson, R. R., Jones, N. M., Holman, E. A., & Silver, R. C. (2019a). Media exposure to mass violence events can fuel a cycle of distress. Science Advances, 5(4), eaav3502. DOI:10.1126/sciadv.aav3502
Thompson, R. R., Holman, E. A., & Silver, R. C. (2019b). Media coverage, forecasted posttraumatic stress symptoms, and psychological responses before and after an approaching hurricane. JAMA Network Open, 2(1), e186228-e186228. doi:10.1001/jamanetworkopen.2018.6228