After the fire: the mental health consequences of fire disasters

Jonathan Laugharne, Gill Van de Watt and Aleksandar Janca

Community, Culture and Mental Health Unit, School of
Psychiatry and Clinical Neurosciences, University of
Western Australia, Perth, Western Australia, Australia
Correspondence to Dr Aleksandar Janca, Winthrop
Professor and Head, School of Psychiatry and Clinical
Neurosciences, University of Western Australia,
Medical Research Foundation Building, 50 Murray
Street, Perth, WA 6000, Australia
Tel: +61 8 9224 0293; fax: +61 8 9224 0293;
e-mail: aleksandar.janca@uwa.edu.au
Current Opinion in Psychiatry 2011, 24:72–77
Purpose of review
This article aims to summarize recent findings relating to the impact of fire disasters
on the mental health of victims, responders, families and communities within the context
of the existing literature.
Recent findings
Recent studies support previous findings that fire disasters are associated with a
negative impact on the mental and physical health of victims, their families and
professional and voluntary responders to the disasters. These effects can be delayed in
onset and can persist over at least several years, although long-term follow-up studies
over 20 years or more indicate that the psychological effects on victims are minimal
relative to controls by this stage.
Summary
Fire disasters, like other natural or man-made disasters, can have significant mental
health impact on individuals directly and indirectly affected and on communities caught
up in the events.

Keywords
fire disaster, mental health, posttraumatic stress disorder

Curr Opin Psychiatry 24:72–77

ß 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
0951-7367

health impact was most pronounced for residents and

Introduction
In recent years there has been considerable international
media interest in the wildfires which devastated homes
and lives in the USA and in Australia [1]. Such events are
rare, but when they occur can have devastating psycho-
social as well as physical impact on individuals, families
and communities.
In terms of the psychological trauma literature fire dis-
asters are one of a list of possible traumatic stressors, often
being conflated with other disasters both natural and
man-made.
This article aims to summarize the findings from recent
publications relating to the impact of fire disasters on the
mental health of victims, responders, families and com-
munities within the context of the existing literature.
Prevalence and risk factors
In a study of the mental and physical health of 3792
people involved in an explosion at a fireworks factory in
The Netherlands in 2000, van Kamp et al. [2] found that
30% of respondents had serious physical and mental
health problems 2–3 weeks after the explosion. High
scores were found for somatic symptoms, sleeping pro-
blems and restrictions in daily functioning owing to
anxiety, depression and feelings of insufficiency. The
0951-7367 ß 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
passers by and for rescue workers living in the affected
area, but to a lesser degree. The level of involvement
with the explosion was related to the negative health
consequences. In a follow-up study of 662 victims from
the same fireworks explosion van der Velden et al.
[3] investigated the predictive value of peritraumatic
dissociation for posttraumatic stress disorder (PTSD).
The authors reported that peritraumatic dissociation
measured at 2 to 3 weeks after the disaster was not a
strong independent predictor for intrusions and avoid-
ance reactions and PTSD symptom severity at 18 months
or 4 years postdisaster above initial intrusions, avoidance
reactions and psychological distress. However, whilst
dissociation may not be independently predictive, it
may be worthy of special attention in terms of interven-
tion immediately following such a disaster. A study
following the Oakland/Berkeley firestorm found that
dissociative symptoms in the immediate aftermath were
significantly related to contact with the fire, sex and
stressful life events and were associated with behaviours
such as trying to get closer to the fire, going into blocked-
off areas and crossing police barricades [4].
Marshall et al. [5] investigated the estimated prevalence
of psychopathology in 357 individuals seeking assistance
following the California wildfires in 2003. They found
that 33% showed evidence of probable major depression
and 24% of probable PTSD at 3 months after the fire.
DOI:10.1097/YCO.0b013e32833f5e4e

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 The mental health consequences of fire disasters Laugharne et al. 73
Property damage and physical injury were the best multi-
variate predictors of psychopathology and no additional
items provided a significant incremental improvement in
prediction. The authors also found that a short two-item
screener assessing fire exposure severity holds promise
for aiding the early identification of those at risk of
postfire psychopathology.
In an earlier study of the impact of the 1983 Ash
Wednesday bushfires in Australia, the authors found that
42% of victims were identified as potential psychiatric
cases using the General Health Questionnaire (GHQ)
12 months after the fire, indicating a significantly higher
level of morbidity than in communities not affected by
such an event [6]. At 20 months postfire, 23% of a sample
that had experienced major losses in the fire were defined
as ‘cases’. The 28-item GHQ was found to be a valid
instrument for defining the presence of psychiatric dis-
order in a disaster-affected community when evaluated
against the Diagnostic Interview Schedule. The authors
conclude that the findings demonstrate that lasting psy-
chiatric morbidity is associated with natural disasters.
In regard to the risk of developing psychopathological
reactions after a fire relative to other types of trauma, the
existing literature, mainly based on studies in adults,
suggests that fire and other natural disasters pose a lower
risk than traumas involving interpersonal abuse or vio-
lence [7,8]. There has been little research in this area in
children, a population at increased risk of PTSD owing to
their age. A recent study of 157 help-seeking children in
New York City confirms the findings of adult studies that
interpersonal traumas have greater psychosocial con-
sequences than other types of trauma, including being
involved in a fire [9].
Impact on fire victims
Following the Ash Wednesday bushfires in South Aus-
tralia, McFarlane and Raphael [10] emphasized the need
to assess the various components of such a disaster to
understand the immediate and long-term impact from
the psychological perspective. In the inventory phase
much of the symptomatic disturbance is different from
that seen in psychiatric clinic populations and is best
dealt with in the early stages using a consultation model.
Providing information about the nature of these reactions
is helpful for those affected and for service personnel
managing disaster relief. In the reconstruction phase, the
authors suggest, it is important for relief agencies to be
aware of the ways in which grief and psychological
morbidity can interfere with people’s ability to make
decisions and carry out practical tasks.
Keane et al. [11] note that residential fires result in loss of
life, property and displacement from one’s neighbour-
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hood. It would be expected that grief experienced in the
aftermath of residential fires has a significant impact on
survivors’ recovery and reintegration into the community.
The authors point out that, although there is some
research on psychological responses to community-wide
fires and large-scale disasters, little is known about such
responses among survivors of home fires that occur epi-
sodically and that appropriate interventions cannot be
developed until more is learned about variables influen-
cing survivors’ psychological response to a residential fire.
The literature on adult trauma survivors indicates that
those exposed to traumatic stress have a poorer physical
health status than nonexposed individuals. Studies on
physical health effects in adolescent trauma survivors, in
contrast, are scarce. Dorn et al. [12] hypothesized that
adolescents who have been involved in a mass burn
incident (n ¼ 124) will demonstrate more physical and
mental health problems than an unaffected cohort from
the same community (n ¼ 1487). Health data were
extracted from electronic medical records, covering 1 year
prefire and 4 years postfire. When compared with the
prefire baseline, survivors showed significantly larger
increases in mental, respiratory and musculoskeletal pro-
blems than community controls during the first year after
the fire, but not during the later years.
In a follow-up study to severe wildfires in Florida,
Langley and Jones [13] studied 206 ninth-grade high
school students affected by the fires. The researchers
were particularly interested in coping processes in the
mediation of psychological distress. Results indicated an
important role for exposure/loss, coping efficacy and
coping strategy as they related to PTSD symptomatology
in adolescents at both 3 months and 10 months postwild-
fire. Although relationships between the proposed vari-
ables and PTSD did not interact with sex, acculturation,
socioeconomic status or ethnicity, there was a significant
interaction between acculturation and ethnicity, signify-
ing that, for African–American youth, high acculturation
levels were predictive of less PTSD symptomatology.
Reijneveld et al. [14] have reported a study in which they
were able to access prospective prefire data on a group of
adolescents. In January 2001, a fire in a café in Volendam,
The Netherlands, wounded 250 adolescents and killed
14. In the 15 months before the disaster, all grade
2 students (aged 12–15 years) from a school in Volendam
(of whom 31 were in the café during the fire), and from
two other schools, had been selected as controls for a
study. One hundred and twenty-four Volendam students
and 830 from the other two schools had provided data for
substance use and completed the youth self-report (YSR)
questionnaire about behavioural and emotional pro-
blems. Five months after the disaster, the authors
obtained follow-up data from 91 Volendam adolescents
 74 Personality disorders and neurosis
and 643 controls from the other two schools. Volendam
adolescents had larger increases in clinical scores than
controls for total problems and excessive use of alcohol,
but not for smoking or use of marijuana, MDMA (ecstasy)
and sedatives. Increases in YSR scores were largest for
being anxious or depressed, incoherent thinking, and
aggressive behaviour. Intention-to-treat analyses showed
significantly larger increases in rates of excessive drinking
and YSR symptom subscales in Volendam adolescents
than controls. Effects were mostly similar in victims and
their classmates. The authors concluded that mental
health interventions after disasters should address
anxiety, depression, thought problems, aggression and
alcohol abuse of directly affected adolescents and their
peer group.
In a further report of follow-up data at 12 months after the
Volendam fire, the same research group found differences
between students from the affected school and others for
excessive use of alcohol, but not for behavioural and
emotional problems and use of other substances. Effects
had decreased compared with those after 5 months [15].
The authors concluded that, in the long run, the effects
of such a disaster decrease regarding self-reported beha-
vioural and emotional problems, but they remain regard-
ing alcohol misuse among those present at the disaster
and their peers.
Two studies are of particular interest in terms of long-
term follow-up after fire disasters. A Swedish group
reported a 25-year follow-up of adolescent and young
adult survivors of a hotel fire which occurred in 1978 [16].
Results from the self-reported data showed low levels of
psychiatric illness. Moreover, the respondents reported a
low level of traumatic stress symptoms. More than 50% of
the participants, however, stated that the fire had a
determining effect on their lives. Sixteen (21.3%) respon-
dents indicated that the fire still had an impact on their
daily lives. Differences between men and women were
reported in most of the self-rating scales. The results
indicate that a traumatizing experience (such as a fire
disaster) still had a small effect on psychological health in
a long-term perspective. McFarlane and Van Hooff
[17], in a recent 20-year follow-up study of 1011 adults
exposed to the Ash Wednesday bushfires as children
utilizing a control group recruited at the time of the
original study, found only a small direct impact of
the fires on adult psychiatric morbidity and emphasized
the need to consider the significance of other lifetime
traumas.
Impact on responders
The prevalence and longitudinal course of posttraumatic
stress disorder were studied in a group of 459 firefighters
who were exposed to the 1983 Ash Wednesday bushfires
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in South Australia [18]. The main finding, that the level of
morbidity 4 months after the disaster remained almost
unchanged at 29 months, indicates the long-term nature
of posttraumatic stress disorder. Twenty-nine months
after the fire, 21% of the firefighters were continuing
to experience imagery of the disaster, in a way that
interfered with their lives. The authors emphasized
the need for disaster management plans to recognize
the psychological impact of natural disasters and the
long-term nature of posttraumatic stress disorder, and
the need for preventive mental health programmes to
minimize such morbidity is discussed.
Al Naser et al. [19] studied 108 Kuwaiti firefighters with a
focus on the relationship between cognitive interpret-
ations and the manifestations of symptoms of PTSD.
They found that those with positively valenced cogni-
tive interpretations had significantly lower posttraumatic
stress.
Several papers have been published which relate to the
effects of the 1992 cargo aircraft crash into apartments in
Amsterdam on responding professionals 8.5 years after
the event. An initial report [20] focused on the risk of bias
in recruitment into such a study, which the researchers
found could lead to overestimation of health effects by,
on average, a factor of 1.5–2. A further paper reported
on the psychological distress of 334 disaster-exposed
firefighters and 834 disaster-exposed police officers
compared with colleagues exposed to other duty-related
stressors [21]. On the standardized instruments of
psychological distress, exposed firefighters reported more
somatic complaints and fatigue, whereas exposed police
officers reported higher psychological distress on all
aspects. The degree and type of exposure at the disaster
site and other background factors, such as previous life
events and educational level, were associated with
several outcomes of psychological distress levels of
exposed rescue workers. The disasters’ aftermath of
rumors about potential health consequences owing
to toxic exposure is likely to have contributed to the
long-lasting psychological distress of some of the rescue
workers.
A further report on the same cohort found that exposed
workers reported a significantly lower physical health-
related quality-of-life (HRQoL) and vitality than non-
exposed workers [22]. Exposed police officers also
reported a lower mental HRQoL. Among exposed
workers, a lower HRQoL was reported significantly more
often by workers who had someone close affected by the
disaster; by firefighters who rescued people, cleaned up,
or witnessed the immediate disaster scene; and by police
officers who supported the injured. Exposed police
officers who perceived the disaster as ‘not bad’ reported
a lower HRQoL less often than those to whom it was ‘the
 The mental health consequences of fire disasters Laugharne et al. 75
worst ever’. This study indicates that professional dis-
aster assistance workers are at risk for a lower HRQoL,
even after several years.
The police officer cohort of responders was also studied
in regard to the use of healthcare after the air disaster in
Amsterdam. They completed questionnaires on disaster
involvement and healthcare in the preceding 12 months.
Logistic regression showed that the disaster-involved
police officers more often used drugs on their own initia-
tive, including sleeping pills or tranquilizers, and con-
sulted a general practitioner or medical specialist, a
paramedical specialist, and a privately practicing psycho-
logist or psychiatrist. Thus, even after several years,
police officers involved in disaster work may use more
self-initiated healthcare [23]. Another Dutch study fol-
lowing a fireworks depot explosion made similar findings
regarding the long-term health of rescue workers and
emphasized that disaster-related health effects may not
emerge until a year or more after the event [24].
Probably the most widely reported fires in recent times
are those consequent to the terrorist attacks on the World
Trade Center (WTC) in New York on September 11
2001. In an interesting qualitative study of resilience
based on in-depth interviews with 9/11 ground zero first
responders, Freedman [25] concludes that concepts such
as posttraumatic stress may be too individually formu-
lated to take into account the factors that acted as the
basis for the resilience of these responders. The author
emphasizes that emotional numbing and psychological
distance are useful self-adaptive tools in such a situation,
that high-cohesion groups such as firefighters have their
own rituals for making meaning, reducing stress and
maintaining performance which clinicians can work with.
Furthermore, the heroizing of responders by public and
media can create emotional burden, adding to psychologi-
cal stress. The key helpers within the responder groups,
such as chaplains, can play a beneficial role in terms of
responders’ psychological adjustment, but may them-
selves become overwhelmed by their responsibilities.
A separate study compared rates of PTSD in relief
workers at the WTC collapse from two sources: direct
exposure to the disaster site and indirect exposure
through survivor narratives [26]. Standardized clinical
interviews for PTSD were conducted with 109 relief
workers 6–8 months after the September 11th terrorist
attacks. Rates of acute PTSD from direct and indirect
exposure to traumatic stressors were 6.4 and 4.6%,
respectively. The findings suggest that indirect expo-
sures can lead to PTSD even when criterion A1 of the
Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition-Text Revision (DSM-IV-TR; American
Psychiatric Association, 2000, p. 463) that is ‘experienced
by a family member or other close associate’ is not met.
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Further research is necessary to define precisely the
parameters of indirect traumatic exposure that may be
linked to the development of PTSD.
In a 2008 review of the 9/11 literature relating to the
psychological impact on disaster workers, Bills et al. [27]
reviewed all articles that examined the mental health
outcomes of workers at one of the three September 11th
crash sites or the Fresh Kills landfill in New York City. In
total, 25 articles met study inclusion criteria, often using
different methodologies. The articles described varying
degrees of mental health symptomatology, risk factors for
adverse mental health outcomes, and utilization of men-
tal health services.
The mental health needs of workers exposed to the
events of September 11th ranged from little to no care
to pharmacotherapy. A range of risk factors, including
exposures at the WTC site and occupational activities,
impacted on these needs, but the role of specific mental
health interventions was less clear. The authors comment
that these findings suggest the need for a future pro-
gramme for disaster workers consisting of an accessible
mental health treatment service supported by compre-
hensive postdisaster surveillance and emphasis on pre-
disaster mental wellness. A number of areas for further
consideration and study were identified, including the
need for a more diverse exploration of involved responder
populations as well as investigation of potential mental
health outcomes beyond PTSD.
Impact on families
Whilst the majority of studies in this review are con-
ducted in developed countries, Satapathy and Walia [28]
report on a school fire in India that resulted in the deaths
of 93 children. Fires that result in a large number of
deaths and injuries are quite common in India, presenting
many complex emergency management challenges.
Although significant improvement in disaster manage-
ment has been noted in recent years, full integration of
government emergency management initiatives at the
provincial level is still in its infancy. The purpose of the
study was to analyze the factors leading to the tragedy,
the response of the stakeholders, the relief and rehabi-
litation support provided to the affected families, and the
perceptions of the affected parents regarding their level
of satisfaction with the management of this disaster. The
study methodology included structured interviews to
determine the parents’ level of satisfaction with the
different elements of the response, participant obser-
vations, intensive interaction with the members of the
affected families, and focused group discussion with
different relevant government officials. The findings
indicate a high level of parent and stakeholder satis-
faction in the majority of response and relief efforts
 76 Personality disorders and neurosis
associated with the disaster. The effective provincial
level management of this fire, in the absence of a well
defined disaster management plan, was quite encoura-
ging according to the authors, and provides guidance for
other disaster managers in the country. Although the
participants in the study perceived the management of
the disaster as highly satisfactory, the authors comment
that several disaster management elements, particularly
disaster mental health services, require further attention
at all levels.
In relation to a major US wildfire, Jones et al. [29] found
that members of ‘high-loss’ families reported slightly
higher levels of PTSD symptoms and significantly higher
scores on the Impact of Events Scale. PTSD symptoms
reported by parents were generally significantly corre-
lated with (but not concordant with) PTSD symptoms
reported by their children. The ‘high-loss’ group scored
significantly higher on the Resource Loss Index than did
the low-loss group.
The research group that focused on psychological out-
comes from the café fire at Volendam in the Netherlands
also assessed impact on the families of victims over a
4-year follow-up period. They found that parents of burn
victims were more likely to present mental health pro-
blems during the first 2 years after the incident, when
compared with the baseline. Moreover, they were more
likely to present cardiovascular health problems in every
year following the disaster, compared with the baseline.
Risk factors for presenting mental health problems were
female sex of the parent and a large burn size in the child.
Lower socioeconomic status and female sex of the parent
predicted cardiovascular health problems [30]. A separ-
ate report [31] showed the odds of developing new
hypertension were 1.48 times higher in parents of fire
victims than in control parents during the follow-up
period. All analyses controlled for age, sex, socioeco-
nomic status, family practice, history of chronic disease,
and number of contacts with the family practitioner
during follow-up. Because hypertension is an important
risk factor for cardiovascular morbidity, the authors
emphasize that it is important to provide interventions
that help people fight the negative effects of disaster-
related stress.
Menendez et al. [32] conducted semi-structured focus
groups of women whose firefighter husbands were
directly involved in rescue efforts at Ground Zero. An
analysis of transcripts from interviews reveals the nature
and extent of the impact of the trauma on these women,
their husbands, and their children. There were two
recurring themes that were apparent from the interview
data. Women used patterns of connectedness to other
spouses to cope with the emotional impact of the event.
In addition, participants reported a constant need to be
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
vigilant in helping their families cope. The authors dis-
cuss issues related to the family’s physical, mental, and
spiritual health in the context of nursing practice.
Impact on community
As well as considering the impact of fire disasters on
family members, researchers have also studied the effects
on the wider community. In their review of the human
disaster and hazards literature in an attempt to discover
lessons applicable to understanding the social impacts of
fire in the residential/wildland interface, Kumagai et al.
[33] argue that those literatures are potentially very
useful in developing an understanding of wildland fire
as a human event. A number of lessons are derived,
including why people tend to be unduly optimistic in
the face of environmental hazards such as fire and why
the characteristics of the affected community are at least
as important as those of the fire in understanding social
impacts. In a study of the impact of an Arizona wildfire in
2002, Carroll et al. [34] note the emergence of both
cohesion and conflict in the communities in the study
area. The authors discuss the findings in terms of attribu-
tion theory and structuration theory. The social conflicts
generated in such circumstances are further discussed in a
paper by the same research team including an analysis of
the resistance shown by locals to solutions imposed by
outside agencies [35].
McCool et al. [36] point out that public concern over the
consequences of forest fire to wildland interface commu-
nities has led to increased resources devoted to fire sup-
pression, fuel treatment, and management of fire events.
The social consequences of the decisions involved in these
and other fire-related actions are largely unknown, but do
occur at a variety of temporal and social organizational
scales. Preparation for the possibility of a fire, actions that
suppression agencies take during a fire, and postfire
decisions all have consequences, though poorly under-
stood. The article aims to present an ‘event-based’
approach that can be useful for constructing and system-
atizing discussion about the consequences of wildland
fire to human communities.
Conclusion
Current evidence strongly suggests that the victims of fire
disasters are at increased risk of adverse psychological
effects, including PTSD and depression, and also adverse
physical health effects, although current evidence
suggests attenuation over time. Responders to these
disasters, such as firefighters and police, are also at
increased risk of mental and physical health problems.
These may be delayed in onset for a year or more.
Responders with more positive cognitions in regard to
the disaster seem more likely to remain healthy.
 The mental health consequences of fire disasters Laugharne et al. 77
Close family of fire disaster victims, such as parents, are
also at increased risk of deteriorating mental and physical
health, including cardiovascular health, for at least several
years after the event. Mothers and those of low socio-
economic status are at particular risk in this regard.
Finally, there is increasing evidence to highlight the
importance of social cohesion in limiting psychological
distress within communities affected by fire or other
disasters.
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:
 of special interest
 of outstanding interest
Additional references related to this topic can also be found in the Current
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