Post-traumatic stress disorder following disasters:
a systematic review
Y. Neria1,2*, A. Nandi3and S. Galea2,4,5
1Department of Psychiatry, College of Physicians and Surgeons, Columbia University Medical Center, New York, NY, USA
2Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, NY, USA
3Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
4Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
5Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York City, NY, USA
Background. Disasters are traumatic events that may result in a wide range of mental and physical health
consequences. Post-traumatic stress disorder (PTSD) is probably the most commonly studied post-disaster psychiatric
disorder. This review aimed to systematically assess the evidence about PTSD following exposure to disasters.
Method. A systematic search was performed. Eligible studies for this review included reports based on the DSM
criteria of PTSD symptoms. The time-frame for inclusion of reports in this review is from 1980 (when PTSD was first
introduced in DSM-III) and February 2007 when the literature search for this examination was terminated.
Results. We identified 284 reports of PTSD following disasters published in peer-reviewed journals since 1980.
We categorized them according to the following classification: (1) human-made disasters (n=90), (2) technological
disasters (n=65), and (3) natural disasters (n=116). Since some studies reported on findings from mixed samples
(e.g. survivors of flooding and chemical contamination) we grouped these studies together (n=13).
Conclusions. The body of research conducted after disasters in the past three decades suggests that the burden of
PTSD among persons exposed to disasters is substantial. Post-disaster PTSD is associated with a range of correlates
including sociodemographic and background factors, event exposure characteristics, social support factors and per-
sonality traits. Relatively few studies have employed longitudinal assessments enabling documentation of the course
of PTSD. Methodological limitations and future directions for research in this field are discussed.
Received 27 February 2007; Revised 25 July 2007; Accepted 26 July 2007
Key words: Disaster, post-traumatic stress disorder (PTSD), trauma.
Exposure to traumatic events is common. Studies
have shown that more than two thirds of the general
population are likely to be exposed to trauma in their
lifespan and up to one fifth of Americans may experi-
ence traumatic events in the USA in any given year
(Breslau et al. 1991, 1998; Norris, 1992; Resnick et al.
1993; Kessler et al. 1995). However, there is substantial
heterogeneity worldwide in the distribution of ex-
posure to traumatic events. Research suggests that
there are certain geographical areas where large
populations are consistently exposed to large-scale
traumatic events such as wars, organized violence,
terrorism, and natural disasters. Therefore, the overall
exposure to trauma worldwide may exceed rates
previously reported in the USA (Kessler, 2000;
Brunello et al. 2001).
Exposure to disasters is particularly common. A
national survey in the USA suggested that more than
15% of females and 19% of males were exposed to
disasters at some time in their lifetime (Kessler et al.
1995). Although the consequences of disasters may
include a wide range of psychopathology (Norris
et al. 2002; Neria et al. 2006a), previous systematic
reviews have documented that post-traumatic stress
disorder (PTSD) is the most commonly studied psy-
chopathology in the aftermath of disasters (Norris
et al. 2002; Galea et al. 2005) and is likely the central
psychopathology after such events (Breslau et al. 2002).
The purpose of this article is to review the liter-
ature on PTSD following disasters starting from 1980,
when PTSD was first presented in DSM-III (APA,
1980) as a psychiatric condition to February 2007,
when this review was terminated. This review builds
on previously published reviews related to the topic
(Norris et al. 2002; Galea et al. 2005), updates and
* Address for correspondence: Dr Y. Neria, Columbia University,
College of Physicians and Surgeons, Department of Psychiatry,
1051 Riverside Drive, Unit 69, New York, NY 10032, USA.
Psychological Medicine, Page 1 of 14.
f 2007 Cambridge University Press
Printed in the United Kingdom
expands this prior work, and aims to identify key
challenges in the extant literature.
The sampling frame for this review can be summar-
ized based on exposure, outcome, and time-frame.
There is little consensus in the literature about what
constitutes a disaster. For the purpose of this review,
following the example established in a previous re-
view (Galea et al. 2005), we considered studies about
disasters that were defined as such by their authors.
Studies assessing the impact of chronic exposure to
trauma (e.g. war) were generally not included in
this review. For the outcome, studies eligible for
this review included reports based on DSM criteria
of PTSD symptoms. Therefore, studies of other psy-
chiatric disorders (e.g. depression, substance abuse)
or psychological problems (e.g. unresolved grief) were
not included in this review. The time-frame for
inclusion of reports in this review was between 1980
(when PTSD was first introduced in DSM-III) and
February 2007 when the literature search for this
examination was terminated.
We obtained papers for this review using a four-step
procedure. First, we performed a systematic search
of the peer-reviewed literature using the Medline,
PsycINFO, and PILOTS databases and identified
potential studies for inclusion using the following
keywords: ‘PTSD’, ‘posttraumatic stress disorder’,
‘disaster’, ‘mental health’, ‘trauma’. Second, we
analyzed abstracts for all studies identified and ex-
cluded papers that did not satisfy selection criteria.
Third, we analyzed the full-text version of all remain-
ing studies and excluded those that did not satisfy
selection criteria. Finally, we compared our final
sample to previous review papers (Brewin et al. 2000;
Norris et al. 2002; Galea et al. 2005) to verify that
our search was successful and its results were com-
Our search identified 284 reports of PTSD following
disasters published since 1980. The earliest disaster
included in this review was the 1963 Vajont landslide
and tidal wave flood disaster in Northeast Italy,
which was studied retrospectively 36 years after and
reported in 2004 (Favaro et al. 2004), and the latest
disaster studied was Hurricane Katrina in 2005,
most recently described in a report by the Centers
for Disease Control and Prevention (CDC, 2006). We
categorized studies according to the following classi-
fication: (1) human-made disasters (n=90), (2) tech-
nological disasters (n=65), and (3) natural disasters
(n=116). Because some studies reported on findings
from mixed samples (e.g. survivors of flooding and
chemical contamination) we grouped these studies
together (n=13). Hence, the results of this review are
presented in four Appendix tables (Tables A1–A4,
available in the online version of this paper). Each
table provides a summary including lead author and
year of publication, study design (cross-sectional,
prospective cohort), population studied (survivors,
responders, community or the general population,
mixed), subjects’ roles (e.g. disaster workers), sam-
sample), time-frame of data collection, PTSD instru-
ment, and main findings. Key reports that made use
of a random or systematic sample and that studied
at least 500 participants are summarized by disaster
type in text Tables 1–3. These tables aim to provide the
reader with main findings and comparisons between
disaster types, populations studied, and time-frames
of assessments to facilitate the most meaningful con-
clusions from the numerous studies conducted in
almost three decades of research.
Although many reports of rates of post-disaster
PTSD can use the term ‘incidence’ rather than
‘prevalence’ due to the fact that in most cases the
exposure duration was brief and limited in time,
few studies were designed to ensure that the assess-
ment of incidence was carried out among persons
without previous PTSD. We therefore, and consistent
with a previous review (Galea et al. 2005), opted to
use the term ‘prevalence’ rather than ‘incidence’
throughout this article unless incidence of PTSD
was specifically assessed in individuals without pre-
Studies of human-made disasters
Table A1 presents data on human-made disasters
reviewed. We located 22 human-made disasters, on
which 90 reports have been published. The most fre-
quently studied events were the 11 September 2001
terrorist attacks (n=42) and the 1995 Oklahoma City
bombing (n=15). Of those studies, we present 12 key
studies in Table 1.
Most studies in this category assessed PTSD in adult
populations. The highest prevalence of PTSD was
2Y. Neria et al.
Table 1. Summary of key studies assessing post-traumatic stress after human-made disasters
StudySample type Sample size (n)
% T2% T3%
1992 Los Angeles County civil disturbances (29 April 1992)
Hanson et al. (1995)b
Communityn=1200 in LA County 6–8 months4.1%
2001 Terrorist attacks, New York City and Washington, DC (11 September 2001)
Galea et al. (2002)b
Schlenger et al. (2002)b
Nandi et al. (2005)b
Hoven et al. (2005)b
Galea et al. (2004)b
n=988 in Manhattan
n=2001 in NYC
n=8236 NYC students
n=2616 in NYC metropolitan area
11.2% in NYC, 4.3% nationally
5.2% (non-Hispanics), 14.3%
(Dominicans), 13.2% (Puerto
Ricans), 6.1% (other Hispanics)
6.5% (women), 5.4% (men)
Stuber et al. (2006)b
Silver et al. (2002)c
n=2752 in NYC metropolitan area
n=933 nationally at 2 months,
787 nationally at 6 months
n=988 in Manhattan at 1 month,
2001 in NYC at 4 months, 1570
in NYC at 6 months
n=2368 in NYC
2 months6 months5.8%
Galea et al. (2003)d
1 month7.5% 4 months1.7% 6 months0.6%
Adams & Boscarino (2005)b
Community1 year4% (Whites), 5.5% (African
Americans), 5.3% (Dominicans),
8.4% (Puerto Ricans), 5%
Neria et al. (2006c)b
Miguel-Tobal et al. (2006)b
n=930 NYC primary care patients
n=1589 in Madrid
aTiming of assessment(s) after the disaster.
bCross-sectional study design.
cProspective cohort study design.
dSerial cross-sectional study design.
PTSD following disasters: a systematic review
found among survivors and first responders. For
example, 1 month after exposure, PTSD prevalence
ranged from 20.3% among survivors of the 1993
Sivas religious uprisings in Turkey (Sungur & Kaya,
2001) to 29% among survivors of the 1991 mass
shooting episode in Killeen, Texas (North et al. 1994).
The prevalence of PTSD among first responders
assessed following involvement in rescue, recovery
and cleaning efforts were especially high. For example
44.3%of police officers
Hillsborough football stadium disaster in Sheffield,
UK, assessed 1–2 years after exposure (Sims & Sims,
1998), were classified with severe symptom severity
while 44.1% were classified with moderate symptom
severity. Similarly, 22.5% and 20% of disaster workers
were found to suffer from PTSD at 2 weeks and 10–15
months after the 9/11 terrorist attacks in New York
City and Washington, DC, respectively (CDC, 2004;
Fullerton et al. 2006).
There are relatively few examples of research based
on probability samples of the general population. Only
one such study preceded the attacks of 11 September
2001. Using a household probability sample of adults
from Los Angeles County (n=1200), Hanson and
colleagues (Hanson et al. 1995) estimated that the
prevalence of current (past 6 months) PTSD was 4.1%
6–8 months after the 1992 Los Angeles County civil
disturbances. Subsequent work including general
population samples of adults from New York City
and the New York City metropolitan areas after the
9/11 attacks (Galea et al. 2004; Adams & Boscarino,
2005; Nandi et al. 2005; Stuber et al. 2006) and from
Madrid after the 2004 train bombings (Miguel-Tobal
et al. 2006) showed comparable levels of PTSD symp-
toms within the first 12 months after these terrorist
Several studies after human-made disasters focused
on specific populations such as low-income subjects
and recent immigrants (Neria et al. 2006c), psychiatric
patients (Franklin et al. 2002), specific ethnic groups
(Murphy et al. 2003; Galea et al. 2004), and parents of
children exposed to disasters (Mirzamani & Bolton,
2002). Because there are not enough studies in each
group, it is not possible to compare between studies.
However, it is noteworthy that these studies suggest
that while the prevalence of PTSD is likely to decline
over time in the general population, the impact of the
trauma among high-risk groups may endure. For
example, while the prevalence of PTSD declined
among residents of Manhattan from 7.5% 1 month
after the 9/11 terrorist attacks to 1.7% and 0.6% at
4 and 6 months after the 9/11 attacks, respectively
(Galea et al. 2003), the prevalence of PTSD among low-
income minorities 1 year after the terrorist attacks was
substantially higher (10.2%) (Neria et al. 2006c).
involved inthe 1989
Only 18 studies focused on samples of children.
They studied samples exposed to the: 1984 school
playground sniper attack in Los Angeles; 1988 school
shooting in Winnetka, Illinois; 1993 World Trade
Center bombing; 1995 Oklahoma City bombing;
1998 American Embassy bombing in Nairobi, Kenya;
1998 discotheque fire in Goteborg, Sweden; and the
Washington, DC. Because the assessment measures
that were used in these studies were different, and
some studies chose to measure post-traumatic symp-
toms only, cross-study comparisons of the prevalence
of PTSD in children is limited. Yet, the evidence sug-
gests a particularly high prevalence of PTSD among
directly exposed children. For example, the prevalence
of PTSD among exposed children was 38.4% at
1 month after the 1984 school playground sniper attack
in Los Angeles (Pynoos et al. 1987), 27% at 3 months
(Koplewicz et al. 2002), and 18.4% at 6 months after the
9/11 terrorist attacks in New York City (Hoven et al.
Trade Center bombing
A number of studies examined PTSD longitudinally,
enabling documentation of the course of PTSD
in samples exposed to human-made disasters. All
studies provided evidence of a general decline in the
prevalence of PTSD over time. For example, data
from the 1991 mass shooting in Killeen, Texas, suggest
that the prevalence of PTSD decreased from 27.2% at
6–8 weeks to 17.7% at 13–14 months after the episode
(North et al. 1997). Findings from a large nationally
representative sample of adults residing outside of
New York City show that the prevalence of PTSD
decreased from 17.0% at 2 months after 9/11 to 5.8%
at 6 months after 9/11 (Silver et al. 2002). The same
pattern has been observed in a random sample of
adults living in Manhattan (Galea et al. 2003).
Similarly, research among children directly exposed
to the 1993 World Trade Center bombing suggests
that the prevalence of severe to very severe PTSD
symptomatology decreased from 27% at 3 months to
14% at 9 months (Koplewicz et al. 2002). It is note-
worthy that no study to date has assessed the course
of PTSD over a long enough period of time (e.g. years)
to reliably examine whether PTSD monotonically
declines over time or whether there is reliable evi-
dence for the late onset of PTSD.
Studies of technological disasters
We identified 65 studies from 40 technological
disasters, starting with the 1966 Aberfan mining dis-
aster in South Wales and ending with the 2002 near
4 Y. Neria et al.
sinking of the USS Dolphin Navy research submarine
(Table A2). Of these studies, we present in Table 2
the three key studies based on probability samples
of the general population conducted following the
1986 Chernobyl nuclear reactor accident (Havenaar
et al. 1997), the 1989 Exxon Valdez oil spill (Palinkas
et al. 1993), and the 2001 chemical factory explosion
in France (Godeau et al. 2005).
Prevalence of PTSD
Many of the reports suggest a high prevalence of PTSD
when survivors or rescue workers involved in tech-
nological disasters were assessed for the first time
after exposure. The prevalence of PTSD following
technological disasters ranged from 15% to 75%. For
example, 15% of residents exposed to the 1991 toxic
chemical railroad spill in California had PTSD at 3–4
months after the disaster (Freed et al. 1998). Similarly,
26% of adult survivors from the buildings most
severely damaged by the 1992 Bijlmermeer plane
crash in The Netherlands were found to have PTSD
6 months after the disaster (Carlier & Gersons, 1997).
On the other extreme, 73% of survivors from the
1988 Piper Alpha oil rig disaster were found to have
PTSD when assessed 10 years after exposure (Hull
et al. 2002).
Course of PTSD
A number of studies have conducted longitudinal
assessments following exposure to technological
disasters, enabling documentation of the course of
PTSD symptoms. One study found a significant
decline from 54% in the first month after an air-
plane crash-landing in Alabama to 10–15% one year
after the disaster (Sloan, 1988). Similarly, rapid de-
clines in the prevalence of PTSD over time were
documented after the USS Iowa gun turret explosion
(Ursano et al. 1995), the Piper Alpha oil rig disaster
(Alexander, 1993), and the Lockerbie disaster (Scott
et al. 1995).
Studies of natural disasters
Observations of studies of natural disasters confirm
key observations from human-made and technologi-
cal disasters. Hence, we will summarize key findings
of PTSD after natural disasters while highlighting
the main differences between types of disasters. We
located 116 studies from 40 natural disasters starting
with the 1963 Vajont landslide and tidal wave flood
disaster in NortheastItaly
Hurricane Katrina in August of 2005 (see Table A3
for further details about individual studies). From
those studies we present in Table 3 findings from key
Prevalence of PTSD
Consistent with previous observations (Norris et al.
2002; Galea et al. 2005) we note that the prevalence
of PTSD documented in the aftermath of natural dis-
asters is often lower than the rates documented after
Table 2. Summary of key studies assessing post-traumatic stress after technological disasters
StudySample type Sample size (n)
1986 Chernobyl nuclear reactor accident, Ukraine (26 April 1986)
Havenaar et al. (1997)b
Communityn=1617 from Gomel
(near accident) and
n=1427 from Tver
(far from accident)
6.5 years 2.4% in Gomel,
0.4% in Tver
1989 Exxon Valdez oil spill, Alaska (24 March 1989)
Palinkas et al. (1993)b
Communityn=593 from variably
1 year 9.4%
2001 Chemical factory explosion, Toulouse, France (21 September 2001)
Godeau et al. (2005)b
Communityn=1477 students from
directly and indirectly
9 months44.6% (directly exposed 11- to 13-year-olds),
28.5% (directly exposed 15- to 17-year-olds),
22.1% (indirectly exposed 11- to 13-year-olds),
4.4% (indirectly exposed 15- to 17-year-olds)
aTiming of assessment(s) after the disaster.
bCross-sectional study design.
PTSD following disasters: a systematic review5
Table 3. Summary of key studies assessing post-traumatic stress after natural disasters
StudySample type Sample size (n)
1989 Newcastle earthquake, Newcastle, Australia (28 December 1989)
Carr et al. (1995)b
Communityn=3007 in Newcastle6 months 18.3% among highly
11% (low exposure),
19% (disruption), 23% (threat),
40% (disruption and threat)
Carr et al. (1997b)c
Communityn=845 in Newcastle6 months
2 years3% (low exposure), 8% (disruption),
13% (threat), 19% (disruption and
1998–1999 Floods, Hunan Province, China (1998–1999)
Liu et al. (2006)b
Communityn=33340 Within 2.5
1999 Turkey earthquakes, Marmara region, Turkey (17 August 1999 and 12 November 1999)
Basoglu et al. (2004)b
Communityn=530 near epicenter,
420 from 100 km away
Onder et al. (2006)b
Communityn=683 near epicenter
14 months 23% (near epicenter),
14% (100 km away)
19.2% (36 month prevalence),
1999 Mexican floods and mudslides, Mexico (October 1999)
Norris et al. (2004)c
Communityn=561 from two affected
2003 Wildfire disaster, Australia, 18 January 2003
Parslow et al. (2006)c
2004 Earthquake and tsunami, Asia (26 December 2004)
van Griensven et al. (2006)c
Communityn=371 displaced and 690
non-displaced from Phang
Nga, Krabi, and Phuket
provinces of Southern Thailand
2 months 11.9% (displaced in Phang Nga),
6.8% (non-displaced in Phang
Nga), 3.0% (non-displaced in
Krabi and Phuket)
9 months 7.0% (displaced in Phang Nga),
2.3% (non-displaced in Phang Nga)
aTiming of assessment(s) after the disaster.
bCross-sectional study design.
cProspective cohort study design
Y. Neria et al.
human-made and technological disasters. Large-scale
natural disasters affect broad geographic areas, lead-
inginvestigators tostudy mixed populations that often
include both direct and indirect victims (Thompson et
al. 1993; Shannon et al. 1994; Carr et al. 1995).
Consequently, as previously suggested (Galea et al.
2005), the relatively low prevalence of PTSD among
populations studied after natural disasters compared
to human-made or technological disasters may stem
from a lower average dosage of exposure among
people exposed to the disaster. This is supported by
a study of the Turkey earthquakes that showed a
higher prevalence of PTSD closer to the epicenter
compared to 100 km away (Basoglu et al. 2004).
Overall studies of natural disasters report PTSD
prevalence ranging from 3.7% (Canino et al. 1990) to
60% (Madakasira & O’Brien, 1987) in the first 1–2
years after the disaster, with most studies reporting
prevalence estimates in the lower half of this range
(Norris et al. 2004; Liu et al. 2006; Parslow et al. 2006).
However, higher prevalence estimates of PTSD
have been reported in specific groups such as clinical
samples (Livanou et al. 2002; Soldatos et al. 2006)
and populations in areas heavily affected by the dis-
aster (Najarian et al. 2001; Finnsdottir & Elklit, 2002).
Moreover, a study based on a community sample
following the Turkey earthquakes estimated the pre-
valence of PTSD to be 11.7% even 3 years after
the disaster (Onder et al. 2006).
Few studies examined PTSD among first re-
sponders, particularly firefighters and police officers
in the wake of natural disasters (McFarlane, 1988;
McFarlane & Papay, 1992; Spurrell & McFarlane, 1993;
Chang et al. 2003; Ozen & Sir, 2004; Armagan et al.
2006; CDC, 2006). Those that did, generally showed
high-prevalence estimates of PTSD. For example, 21%
of firefighters responding to the 1999 Chi-Chi earth-
quake in Taiwan (Chang et al. 2005) and 22% of fire-
fighters responding to Hurricane Katrina in 2005
(CDC, 2006) had PTSD at 5 months and 2–3 months
after the disaster, respectively.
A number of studies investigated PTSD among
children following natural disasters. In the aftermath
of the 1988 Armenian earthquake, 95% of the children
from a severely exposed city and 26% of the children
from a mildly exposed city had severe levels of PTSD
symptoms 1.5 years after the event (Goenjian et al.
1995). The prevalence found among the mildly
exposed children is comparable to the prevalence
of PTSD among children exposed to the 1989 Loma
Prieta earthquake (Bradburn, 1991), 1992 Hurricane
Andrew (Vernberg et al. 1996), 1999 Hurricane Floyd
(Russoniello et al. 2002), 2002 Typhoon Rusa (Lee
et al. 2004), and the 2004 earthquake and tsunami
(Neuner et al. 2006).
Course of PTSD
Few studies have examined the course of PTSD after
natural disasters. A longitudinal study of firefighters
who participated in rescue efforts after the 1983
Australian bushfire found that more than one-fifth
of the sample (21%) had persistent PTSD over a 2-year
period (McFarlane, 1988). This study extended extant
knowledge about PTSD from human-made disasters
by examining multiple patterns of PTSD, including
acute onset (9.2%) and delayed onset (19.7%) PTSD.
In parallel to findings from studies of human-made
disasters, some longitudinal research of natural dis-
asters documented a decline in PTSD prevalence over
time (Carr et al. 1997a,b; van Griensven et al. 2006);
however, some studies also showed an increase in
PTSD prevalence over time. For example, a cohort
study of residents of Dade County, Florida exposed to
Hurricane Andrew in 1992 found that the prevalence
of PTSD increased from 26% to 29% between 6 and
30 months after the disaster. More specifically, this
study showed that while intrusion and arousal symp-
toms declined over time, avoidance symptoms in-
creased (Norris et al. 1999). Similarly, an increase in
prevalence of PTSD was observed between 3 and
9 months after the 1998 Zhangbei-Shangyi earthquake
in China (Wang et al. 2000).
Multiple disaster aggregate studies
We identified 13 studies that included samples from
more than one disaster (see Table A4 for a detailed
description of these studies). While some studies
investigated samples from the same disaster type,
such as survivors from multiple terrorist attacks
in France (Abenhaim et al. 1992; Verger et al. 2004),
survivors from earthquakes in Santiago, Chile, and
California, USA (Durkin, 1993), and survivors from
the Oklahoma City bombing and the Nairobi bombing
(North et al. 2005), other studies focused on survivors
of different types of disasters, including a study that
included subjects exposed to either a plane crash,
tornado or shooting spree (Smith et al. 1993) and a
study that included persons exposed to either a plane
crash or train collision (Chung et al. 2005). One ad-
vantage of these studies is that they used the same
instrument in different samples, facilitating compari-
sons. One study comparing different populations
exposed to terrorist bombings (North et al. 2005)
found lower rates of PTSD (22% among males and
40% among females) among survivors 6 months after
the Oklahoma City bombing compared to survivors
8–10 months after the Nairobi bombing (34% among
males and 49% among females). Only one study
assessed the course of PTSD over time. Interestingly,
while the prevalence of PTSD decreased over time
PTSD following disasters: a systematic review7
among earthquake survivors, it increased among sur-
vivors of political abuse between 1.5 and 4.5 years
after exposure (Goenjian et al. 2000).
Classification of disasters
The trauma literature has yet to provide a consistent
distinction between individual traumatic events and
disasters (which arguably are best considered as
collectively experienced, or mass traumas), leaving
the question what qualifies a traumatic event to meet
criteria for a disaster open (Quarantelli, 1995). Earlier
work in sociology and hazard and risk management
has attempted to address this problem (Quarantelli,
1998; Mileti, 1999). It has been suggested that an
incident is a disaster if it is extremely harmful and
disruptive (Tierny et al. 2001). However, definitions
of ‘extremely’ vary and there remains no universal
or even widely used definition of disasters making
for inconsistencies between studies in which events
are considered as disasters by some studies, but not
by others. For example, while massive loss of life
seems to be central for an event to be classified as a
disaster, some of the most studied disasters (e.g.
Three Mile Island) did not result in any loss of life.
Similarly, while the literature is generally unified in
classification of events as disasters if they are dis-
ruptive events and restricted in time (e.g. plane
crash, flood, fire), the status of ongoing repeated
Holocaust, ongoing ethnic cleansing, and genocide)
is not clear. Although this review was not committed
to a single definition of disaster, we suggest that a
definitive definition of a disaster would need to ac-
count for at least two dimensions: scale and outcome
(Norris et al. 2002; Galea & Resnick, 2005; Neria et al.
2006b). Hence, an incident may be appropriately
classified as a disaster if its scale is ‘large’, i.e. it has
affected a considerable number of people regardless
of loss of life, and its consequences are ‘significant’,
i.e. it has resulted in quantifiable mental and/or
physical health outcomes among the affected popu-
Measurement of PTSD
The classification of PTSD has been modified since
it was first introduced in DSM-III in 1980. For example,
in DSM-IV the definition of the A criterion was
changed to include both exposure (A1) and the sub-
jective response to the exposure (A2), and specifically
whether the exposed person experienced horror and
helplessness facing the exposure. Notably, compared
to previousDSM editions,the recentDSM-IV
definition of exposure is broader and provides a list of
potential examples, which includes a sudden death
of a close relative. Changes in definitions of PTSD
may influence rates, correlates and course of PTSD
as documented across studies over time. Moreover,
while PTSD is a clinical condition, regularly assessed
by clinical interviewers, many post-disaster studies
have utilized screening instruments administered
by laypersons or well trained research assistants.
Although most screening instruments showed suf-
ficient psychometric properties there is no evident
agreement in the PTSD literature in general and the
disaster literature in particular about what is the best
screening instrument that can be reliably administered
by laypersons in the aftermath of disasters. Similarly,
there is a lack of consensus of whether a face-to-face
interview is needed for a reliable assessment of post-
disaster psychopathology or alternatively whether
telephone-based (Galea et al. 2002) or internet-based
(Schlenger et al. 2002; Silver et al. 2002; Neria et al.
2007) surveys are similarly qualified to assess disaster-
Exposure and post-disaster PTSD
The role of event exposure in the development of
PTSD has received considerable attention across
studies. A wide range of potential types of exposure
has been studied. Importantly, the risk of PTSD has
been repeatedly shown to be associated with severity
of exposure to the disaster across numerous studies
(Durham et al. 1985; Green et al. 1990, 1994; Abenhaim
et al. 1992; Joseph et al. 1994; Tyano et al. 1996; Cwikel
et al. 2000; Tucker et al. 2000; Sungur & Kaya, 2001;
Galea et al. 2002; Neria et al. 2006c). As we already
noted above, the prevalence of PTSD is higher among
persons who were directly exposed to the disaster
(often referred as the ‘victims’ of a disaster in disaster
studies), lower among rescue workers and first re-
sponders, and yet even lower in the general popu-
lation. These three types of samples studied are
likely to represent different levels of severity of dis-
aster exposure, with direct victims having the highest
exposure and associated PTSD prevalence and people
in the general population having the lowest levels of
exposure and PTSD prevalence. Studies that focused
on several groups, with different levels of exposure
enabled direct comparisons between people with
different levels of disaster exposure. For example,
studies that assessed areas close and distant from a
disaster site have repeatedly showed that the preva-
lence of PTSD is higher among persons closer to the
disaster than among those who are in distant areas
(Havenaar et al. 1997; Schlenger et al. 2002; Jordan
et al. 2004; Neria et al. 2006c).
8 Y. Neria et al.
Disasters frequently involve populations which
are not directly exposed to the trauma such as people
who experience loss of family members or friends
or colleagues, or those who suffered property loss,
were forced to relocate, or were exposed to the event
through the media. This raises two critical points
about the burden and the nature of post-disaster
sequences of such events among those indirectly
exposed to a disaster may well exceed the mental
health consequences among those who were directly
exposed or close to the disaster epicenter. Although,
as we note in this review, there is little question that
there is a dose–response relationship between the
extent of trauma and the mental health burden of
disasters, this relation may not necessarily mean that
the principal population mental health burden of a
disaster is among those who were most directly
affected by the disaster (Galea et al. 2005). Second, the
extant post-disaster literature provides an oppor-
tunity to assess the relation between indirect exposure
to a trauma and risk of PTSD. The literature reviewed
here is mixed on this latter point. For example, while
Neria and colleagues, in their study of primary-care
patients exposed to the 9/11 terrorist attacks in
Northern Manhattan, found that indirect exposure to
the attacks on the World Trade Center was not asso-
ciated with risk of PTSD (Neria et al. 2006b), other
studies conducted in national samples after the same
attacks (Schlenger et al. 2002; Silver et al. 2002) and in
distant areas after the Oklahoma City bombing
(Pfefferbaum et al. 1999) provide evidence for a
probable relation between indirect exposure and
PTSD. These findings may challenge one of the core
criteria of PTSD according to DSM-IV (Criteria A).
Most of the persons interviewed in post-9/11 national
surveys reported an indirect exposure to the attacks,
mostly through TV broadcasts. The inclusion of this
type of exposure is certainly new to the discipline of
trauma research and deserves further attention
(Ahern et al. 2002). The events of 9/11 and the recent
terrorist attacks in Europe and Asia, as well as
recent major natural disasters, all provide an oppor-
tunity to examine whether direct exposure to trauma
is a necessary condition for PTSD, or whether
alternatively, an interaction between a ‘sufficient’
level of exposure (even indirect), and certain risk
factors (e.g. genetic susceptibility) can result in true
Burden of PTSD in the aftermath of disasters
A large body of research conducted after disasters in
the past three decades suggests that the burden of
PTSD among persons who were exposed to disasters
is significant. The post-disaster PTSD literature
suggests that there are fairly consistent estimates of
PTSD that can be expected in the first year after
exposure among specific risk groups. Specifically, the
prevalence of PTSD among direct victims of disasters
ranges between 30% and 40%; the range of PTSD
prevalence among rescue workers is lower, ranging
between 10% and 20%, while the range of PTSD rates
in the general population is the lowest and expected
to be between 5% and 10%. The most consistently
documented determinants of the risk of PTSD across
studies are measures of the magnitude of the ex-
posure to the event. Particularly, degree of physical
injury, immediate risk of life, severity of property
destruction and frequency of fatalities are especially
predictive of high rates of PTSD. Therefore, across
samples and studies, survivors and direct victims of
a disaster are consistently shown to have increased
risk of PTSD than persons in the general population,
regardless of the national or political consequences
of a particular disaster. Aside from the observation of
the centrality of trauma exposure as a determinant
of PTSD, as previously noted (Galea et al. 2005), many
post-disaster studies vary considerably in the range
of correlates tested and the model-building tech-
niques used to assess statistically significant corre-
lates, suggesting the need for caution when drawing
inferences about associations of PTSD with correlates
in post-disaster research. For example, while it is
generally true to suggest that direct victims or females
are at higher risk for PTSD in the wake of disasters,
it is sometimes unclear whether the lack of significant
associations between proximity of exposure and
PTSD, or gender and PTSD are due to specific disaster
type and its consequences or the mediating role of
other variables (e.g. relationship with deceased, social
support) which obscure the exposure–PTSD and
gender–PTSD associations in multivariate analyses.
Most of the studies in the wake of disasters have
used cross-sectional designs. The relatively small
body of research on the course of PTSD over time is
complicated by major methodological limitations.
Variability in sample types, sample sizes, point of
times of assessments, screening or diagnostic instru-
ments, reduction is sample size over time, are only
some of the differences noted between studies as-
sessed here, limiting comparability and the drawing
of definitive inference about the course of PTSD.
The aim of the current review was to build on and
update previous work and to systematically review
up-to-date evidence regarding post-disaster PTSD.
Several decisions made in the conduct of this review
PTSD following disasters: a systematic review9
need to be borne in mind when interpreting the results
we present here. First, we opted to include a wide
range of PTSD studies, with notable differences in
sampling and measurements methods. Consequently,
we included studies with different levels of research
quality. Moreover, the studies reviewed here come
from different disciplines and frequently present
results quite differently, limiting our capacity to
employ uniform principles of study inclusion. Second,
there may be cross-cultural factors that limit the
validity of instruments applied in different countries
when these instruments were primarily designed to
assess psychopathology in developed countries, or
majority populations. This suggests caution in inter-
preting data from studies across countries. Third, this
review summarizes the published English-language
peer-reviewed literature. Hence, we do not here pro-
vide information about PTSD across the entire uni-
verse of disasters that do happen worldwide. There is
likely a substantial imbalance between studies that
are carried out and where disasters do actually occur.
Cross-cultural differences between rich and poor
countries may mean that the epidemiology of PTSD
in less rich countries may be different than that docu-
mented here, arising from the available literature.
Fourth, given the complexity of defining traumatic
event exposure, as noted above, we are not able, in
this review, to systematically shed much light on the
conditional probability of PTSD differential on specific
traumatic event exposure. Fifth, following previous
lines of work (Brewin et al. 2000; Galea et al. 2005)
we decided to include findings of studies which
specifically assessed PTSD in the wake of disasters.
We did not include studies of depression, complicated
grief or substance abuse in the wake of disasters and
as such, we may be limiting our appreciation of the
centrality of co-morbidity to the burden and trajectory
of PTSD after disasters. Similarly, our review did not
describe studies which assessed changes in service
utilization or mental health treatment-seeking and
the relations between such behaviors and PTSD;
service utilization and mental health treatment-
seeking are of considerable interest to public mental
health planners and not including consideration of
these subjects may be underrepresenting the social
and economic burden of PTSD after disasters. Service
utilization and treatment may fruitfully be considered
as subjects of study in future work.
Conclusion and implications for future disaster
three decades, combined with improvements in
communication and transportation enabling access to
areas where disasters occur, have enabled mental and
public health researchers, around the globe, to exam-
ine various aspects of the associations between ex-
posure to disasters and PTSD. The evidence suggests
that the burden of PTSD among populations exposed
to disasters is substantial. Post-disaster PTSD is as-
sociated with a range of correlates including socio-
demographic and background factors, event exposure
characteristics, emotional states, social support fac-
tors and personality traits. Relatively small numbers
of studies have employed longitudinal assessments
enabling documentation of the course of PTSD.
However, the review of the literature reveals that
several areas remain underexplored and limit the
extent to which the wealth of available data may fruit-
fully guide intervention. We hope that future research
will provide better guidance with regard to at least
two key questions. First, the course of PTSD after dis-
asters remains unclear. Our review indicates that in
order to provide reliable estimates of course of post-
disaster psychopathology and to enable comparisons
between studies, substantial progress is needed in all
areas of measurement (e.g. instruments and methods
of administration), time-frames for follow-ups and
sampling procedures. Notably, a clearer understand-
ing of the trajectory of PTSD and the determinants of
this trajectory, including the groups among whom
PTSD resolves spontaneously, those among whom it
persists in the long-term, and those with more com-
plicated lapsing/relapsing pattern will be invaluable
in guidingthe implementation of effectiveintervention
strategies. Second, future development of interven-
tions would benefit from work that more explicitly and
clearly identifies populations at risk (e.g. minorities,
elderly, children, direct victims, first responders). Our
review suggests that while it is safe to expect a signifi-
cant decline in psychopathology in the general popu-
lation, a number of groups remain highly vulnerable to
PTSD in the short-term and may well have a different
long-term course of PTSD and bear the brunt of the
social and economic consequences associated with this
condition. The literature to date has yet to compre-
hensively discuss what the psychological, cultural,
to traumatic events. It is our view that such progress
is critical to highlight the needs of high-risk popu-
lations, and is necessary for tailoring appropriate
interventions to the right people in the wake of
Supplementary information accompanies this paper
on the Journal’s website (http://journals.cambridge.
10 Y. Neria et al.
Partial funding was received from the MIMH:
MH72833 (Y.N.); Spunk Fund Inc. (Y.N.); NIH: DA
017642, MH 078152 (S.G).
Declaration of Interest
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