Terrorism and weapons of mass destruction: managing the behavioral reaction in primary care. (Review Article).

Abstract: Any terrorist attack using weapons of mass destruction will result in substantial psychological trauma and stress. Primary care and emergency clinics will likely see patients who have stress-related emotional or physical symptoms, or exacerbations of preexisting health concerns. Significant psychological and behavioral reactions to an attack with weapons of mass destruction are certain, include both group and individual reactions, and will follow a predictable course. Possible group reactions include mass panic, acute outbreaks of medically unexplained symptoms, and chronic cases of medically unexplained physical symptoms. Possible individual reactions include psychiatric disorders such as posttraumatic stress disorder, which occurs in approximately 30% of people exposed to extreme trauma. Most people have symptoms of arousal that are normal reactions to abnormal events and that resolve with rest, reassurance, support, and education. Mandatory debriefings are not recommended, and medications may be used when more conservative measures are not sufficient.

Key Words: debriefing, posttraumatic stress disorder, trauma, terrorism, weapons of mass destruction

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Weapons of mass destruction (WMD) are used to kill large numbers of people, destroy large amounts of property, achieve political goals, and create terror, chaos, and social disruption. WMD include biologic or chemical agents, nuclear weapons, conventional bombs contaminated with radioactive materials, large conventional or "truck" bombs, and surprising sources such as hijacked airplanes. Significant psychological and behavioral reactions to such an attack are predictable. Primary care and emergency clinics will likely see many patients who have stress-related emotional or physical symptoms, or exacerbations of preexisting health concerns that will stress the health care delivery system. For example, after the Tokyo sarin attack, 5,510 people sought medical attention at more than 200 hospitals and clinics in Tokyo within several hours of the incident. Approximately 25% of those seen were hospitalized; the remainder had no signs of exposure and were sent home. (1) Medical and rescue personnel may experience impaired performance and have a high rate of "bum-out" related to stress, fatigue, and resisting treatme nt for themselves as they did after the Oklahoma City bombing. (2)

Behavioral Response to an Attack

The psychological and behavioral reactions to WMD attacks may be separated into group and individual responses. For the most part, the range of psychological reactions will be similar regardless of the type of weapon used.

Group Responses

Collective or group reactions to WMD, attacks include symptoms of emotional distress, misattribution of physical symptoms, and social symptoms such as loss of confidence in government, anger at authority figures, scapegoating, social isolation, and demoralization. (3-5) Three specific group responses warrant further discussion: mass panic, acute outbreaks of medically unexplained symptoms, and chronic cases of medically unexplained physical symptoms.

Mass panic is characterized by intense contagious fear whereby individuals behave with reference only to self. There may be flight in a desire to escape, or alternatively, people may become behaviorally "frozen" or paralyzed. Mass panic leads to a loss of social organization and social roles as well as substantial community chaos. One might anticipate that mass panic would be a common problem after a devastating attack, yet this did not occur after the Tokyo sarin attack, the Israeli SCUD missile attacks, the Oklahoma City bombing, or the Hiroshima and Nagasaki nuclear attacks. Although mass panic does occur, it is actually rare after disasters. Instead, prosocial, adaptive, and helpful behavior is the norm. (3) Risk of mass panic is reduced by providing accurate knowledge (even if the information is disturbing) and advanced training and disaster simulation (risk factors for mass panic are listed in Table 1). Mass media communication can either serve as a vector for propagating distress and misperceptions, or can be an effective tool for educating the public and promoting responsible behaviors. Physicians may be the front-line experts interviewed by reporters and may either fuel panic or calm and reassure the public. (3)

Of the potential psychological responses to WMD attacks, the physical responses to stress create the greatest initial burden to primary care. In response to terror and trauma, individuals experience a number of symptoms of arousal and anxiety as a normal survival reaction. Many individuals may mistakenly attribute these physiologic reactions to the effect of some WMD agent or medical illness. Sometimes, these symptoms affect an entire group of people and present as mass outbreaks of medically unexplained symptoms (OMUS). (6) These outbreaks are manifested by contagious physical symptoms in a group of people with no identifiable cause. They rapidly affect an entire group and spread by sight and sound whether on-site or via media and are characterized by rapid onset and rapid remission. (7-14) Frequently, symptoms include hyperventilation, dyspnea, dizziness, nausea, headache, syncope, abdominal distress, and agitation. Symptoms often mimic the reported effects of an infectious or chemical agent. (9) Common set tings are schools, factories, sporting events, and other social groupings. False reports of poisonous gas have resulted in notable epidemics of somatization in adults and children in the United States and in the West Bank. (15) For example, in 1973 a ship containing 50 drums of a harmless organophosphate defoliant docked in Auckland, New Zealand. Workers noticed a foul odor and saw the word "poison" on the drums. Miscommunication about the ship's cargo ensued, and as concern mounted, a crisis developed. Even though no one was physically affected by the organophosphates, 643 people sought medical care for symptoms consistent with anxiety and somatoform reactions. (15, 16)

Although these acute outbreaks rapidly remit, entire groups of people may develop physical symptoms that become chronic. Medically unexplained physical symptoms (MUPS) have occurred after World War I (WWI), Vietnam, the Three-Mile Island nuclear catastrophe in 1979, industrial exposures at Love Canal in the 1970s and 1980s, and military activities in the Balkans and the Persian Gulf. (17) MUPS are usually labeled as somatoform disorders, a label that may alienate patients and blur the vision of physicians. These patients may eventually become quite disabled, convinced of the medical nature of their symptoms, and search desperately for a cure. Physicians, on the other hand, may take the position of diagnostic skepticism and send patients the message that their symptoms are not real. This amounts to a doctor-patient standoff in which the doctor stops searching for potential medical problems and the patient becomes more interested in finding a cause for his or her suffering. This tension between doctor and patie nt may lead to substandard medical care. (17) In this situation, the physician must always show respect, empathy, and validation for the patient's concerns.

Individual Responses to Traumatic Stress

Our understanding of individual psychological reactions to WMD attacks is drawn primarily from military and disaster psychiatry. Although individual patterns of response to large-scale traumatic events vary, several phases generally emerge over time. (4)

Phase 1: Immediate Response. Strong emotions, disbelief, numbness, fear, and confusion are common in the immediate aftermath of an attack. Signs and symptoms of anxiety and autonomic arousal are considered normal responses to an abnormal event (Table 2). Biologic responses immediately after a traumatic event include the release of stress hormones and peripheral catecholamines. These changes usually result in improved cognitive performance. However, as stress persists, behavior and thinking may become narrowly focused with a loss of flexibility. Thinking may eventually become disorganized, resulting in either a fight or flight response or a freeze response. (18) During this phase, the risk of mass panic or acute outbreaks of medically unexplained symptoms is at its peak.

Phase 2: Intermediate Response--Adaptation, Arousal, and Avoidance. Phase two of the traumatic response occurs from 1 week to several months after the event. Intrusive symptoms such as recollections of the event with increased autonomic arousal (eg, startle response, hypervigilance, insomnia, and nightmares) are common. Increased visits to primary care for somatic symptoms such as dizziness, headache, fatigue, and nausea are also commonly seen. In fact, clinics may be overwhelmed with patients reporting new somatic symptoms or a worsening of existing health problems. Stress may even precipitate early labor in pregnant women or cause fetal distress. Some may develop psychiatric disorders during this phase. In addition, anger, irritability, apathy, grief and mourning, and social withdrawal are common.

Phase 3: Long-term Response--Recovery, Impairment, and Change. Phase three may last up to a year or more. During this stage, victims may experience feelings of disappointment and resentment if initial hopes for aid and restoration are not met. The sense of community may be weakened as individuals focus on their personal needs. Some individuals may experience continued posttraumatic psychiatric symptoms as well as extended grief and mourning for years after the attack. The majority will rebuild their lives and focus on future challenges.

Psychiatric Disorders

After traumatic stress, most people will experience acute symptoms that dissipate over time. However, some will develop psychiatric disorders, most commonly posttraumatic stress disorder (PTSD), which occurs in as many as 30% of exposed individuals. (4,19,20) The cardinal features of PTSD include intrusive reexperiencing of the trauma via nightmares or flashbacks, avoidance of reminders of the trauma along with emotional numbing, and persistent symptoms of autonomic hyperarousal. The best predictor of PTSD is the degree of exposure to the traumatic event. Those whose lives are directly threatened, who are physically injured, or who are exposed to extremely horrifying or grotesque events are at greatest risk. (4) However, all who have exposure to the event are at potential risk, including immediate victims, family members and friends, rescue workers, health care workers, and any others in the local community. PTSD symptoms may persist for months or even years after the traumatic event. (19) Other psychiatric p roblems such as depression, somatoform disorders, other anxiety disorders, bereavement, and grief often arise as individuals struggle with the loss and pain associated with the event. Furthermore, there may be increased reports of substance use and domestic violence.

Reactions to Biologic and Chemical Attacks

Several unique features of biologic and chemical agents make them especially terrifying. (5,20) Like radiation, they are frequently invisible and odorless. With certain agents, exposed or infected individuals may initially develop symptoms of common illnesses and therefore avoid early detection. Most of these agents are unfamiliar to American doctors, and treatment may not be readily available. Some agents cause gross deformities such as the lesions of smallpox or the severe blisters of mustard gas. The unseen and mysterious nature of these agents may lead to situations like the MUPS mentioned above or the so-called gas hysteria seen during WWI. In WWI, there were twice as many gas hysteria cases as there were actual gas exposure cases. (20) Other likely syndromes include conversion reactions with respiratory features or gas mask phobia, which was a significant problem during the Persian Gulf War. (19) The protective gear worn during chemical and biologic attacks increases one's sense of isolation, decreases intragroup communication, and may increase the incidence of psychiatric casualties. (21,22)

The behavioral response to biologic agents will differ from that of chemical agents. (5) There is usually a time delay between initial exposure to a biologic agent and the development of symptoms. The first responders to a biologic attack will be emergency department staffs, clinics, and public health officials rather than firemen and emergency medical technicians who are the first responders to a chemical attack. If the attack is covert, it may not even be identified as such but will appear to be a natural outbreak. On the other hand, a natural outbreak may be claimed by terrorists to further their agenda. Furthermore, people may fear the contagious spread of disease across a region or nation, especially when there is uncertainty about the attack or questions about the effectiveness of treatment. Attempted quarantine, infection control, and vaccination and treatment programs may be accompanied by unfounded rumor and also present an opportunity to do real harm. This may create a public opinion backlash agains t government and public health officials.

Prevention of Psychiatric Casualties

A lack of social preparedness makes community chaos and behavioral problems more likely after WMD attack. Hospitals and communities must develop emergency and disaster plans and repeatedly practice them. These plans must include realistic scenario simulation and robust and redundant communication systems and receive adequate funding. Such efforts will reduce a community's sense of helplessness before and after an attack occurs. (4) If leaders, first responders, and other members of the community are prepared for their roles before a WMD event, energy can be directed at providing social support to victims rather than wasting time sorting out roles and responsibilities during the postevent confusion.

After the Attack

Initial Assessment and Treatment. Hospitals, clinics, and emergency rooms may be overwhelmed with persons seeking medical treatment. Numerous patients may present with physical symptoms that either reflect the direct effect of a biologic or chemical agent or the psychological response to the attack. Biologic and chemical agents directly affect the central nervous system and cause symptoms such as lethargy, depression, disorientation, and psychosis (Tables 3 and 4). (15,23) Rapid diagnosis and prompt treatment minimize both medical and neuropsychiatric complications. Once a medical diagnosis is made, individuals requiring medical treatment should be cared for appropriately. Those who have completed treatment or require no medical treatment fall into two groups: those who are emotionally distressed and those who are not. The non- distressed people may be discharged with education and reassurance. Those who are emotionally upset by the trauma may require further intervention. The mainstay of treatment for emotio nally distressed individuals is rest, reassurance, education, and support. They should be placed in a location where any disruptive behaviors can be monitored. This location should be sufficiently removed from high-tempo triage activity, yet close enough to the main emergency room to permit further medical treatment if needed. Patients should be reassured that symptoms of autonomic arousal and anxiety are normal responses to an abnormal situation. This reassurance, combined with support and rest, is often enough to diminish symptoms.

Treating Medically Unexplained Symptoms. In the case of acute OMUS, a few additional measures are required. Lengthy incident scene investigations and elaborate searches for the offending agent may worsen and prolong the event. The group should be informed about the scope of the problem, and the role of the offending agent should be minimized. Leaders should be calm, authoritative, supportive, and nonconfrontational. Individuals should be separated to minimize the spread of symptoms by sight and sound. Repetitive questioning about symptoms and use of language suggestive of infection or exposure should be avoided. (7, 9) The treatment of chronic MUPS is more problematic. An empathic, supportive, and collaborative stance combined with minimizing unnecessary medical tests and procedures is key. (17)

Medications. Although most patients will respond to a conservative and supportive approach, some may require medications for agitation, psychosis, or insomnia. (23, 24) Antipsychotic medications such as haloperidol are effective for delirium or psychosis resulting from WMD agents. Complications of antipsychotic use include parkinsonism, akathisia, and dystonias. Anticholinergic medications such as benztropine or diphenhydramine are useful for treating these side effects. Benzodiazepines like lorazepam, clonazepam, or diazepam may be used for severe anxiety or insomnia. Patients treated with benzodiazepines should be cautioned about sedation and possible impairment in driving and decision-making. [beta]-blockers such as propranolol and [alpha]-agonists such as clonidine may be useful for decreasing autonomic arousal as a result of their antiadrenergic activity. Trazodone, zolpidem, or zaleplon are often the preferred choices for insomnia because they preserve sleep architecture.

Debriefing. Group debriefing techniques have been used in the aftermath of natural disasters and terrorist events. Debriefings offer affected persons an opportunity to join others in a group review of the traumatic event, share emotional reactions, and give their chaotic experience a sense of structure. Most debriefing models are designed for use with first responders such as firemen and emergency medical technicians but debriefing may also be used for victims. Although there is no convincing evidence that such debriefings reduce the incidence of PTSD, debriefings may foster group cohesion and help individuals deal with the postattack chaos. Debriefings may help sustain performance, reduce the sense of isolation, and facilitate identification of those who need further mental health treatment. (25, 26) Unfortunately, encouraging intense emotional expression after a recent trauma may be harmful and even retraumatize some individuals. (25, 27, 28)

If such group debriefings are conducted, it is important that the group is composed of persons linked socially (by virtue of working relationships or prior friendships) rather than haphazardly assembled groups of people linked only by geographic proximity at the time the debriefing is scheduled. Open and frank discussions among care providers or persons concerned with the well being of others within the group may foster a sense of cohesion and reduce individual isolation. The focus of the debriefing should be the creation of a cognitive historical narrative of the event, ie, "what happened." Participants should be allowed to express their feelings about what happened if they choose, and such emotions should be supported. However, any attempt to extract the real or underlying emotions is strongly discouraged. Those with prior abusive experience, minimal ability to regulate affect, limited ego-functioning, or serious preexisting mental illness may be harmed by being forced to participate in highly emotional, m andatory debriefings.

The Physician and Community Resources. In the wake of an attack, additional community and regional resources will be required. (4) These resources include the Red Cross, community mental health centers, social workers, and hospice care providers as well as teachers and religious officials. Schools, churches, synagogues, and mosques may serve as additional locations for psychosocial treatment. Incorporation of these resources into the response plan strengthens the community's social organization, enlists a larger portion of the community in a prosocial behavioral response, and decreases the burden on primary care facilities. In addition, by including these agencies in the disaster planning process, the confusion that arises when well-intentioned but poorly trained volunteers arrive on the scene is minimized. Such offers of help can unintentionally create more confusion and make an already difficult situation worse. In addition to personal liaison with various agencies, several Internet sites provide useful in formation. Sites sponsored by the Red Cross (http://www.redcross.org/), the Centers for Disease Control and Prevention (http://www.cdc.gov/), and the Uniformed Services University for the Health Sciences (http://www.usuhs. mil/psy/disasteresources.html) provide excellent printable handouts and articles free of charge. These and other resources are essential aids to physicians, local officials, and disaster planners.

Table 1

Risk factors for mass panic (3)

Belief that there is a small chance of escape from the agent
Perceived high risk
Available but limited treatment resources
No perceived effective response
Loss of credibility of authorities

Table 2

Symptoms of anxiety and autonomic arousal

Anorexia
Chest pain/tightness
Diaphoresis
Diarrhea
Dizziness
Dry mouth
Dyspnca
Faintness
Flushing
Hyperventilation
Light-headedness
Muscle tension/aches
Nausea
Pallor
Palpitations
Paresthesias
Tachycardia
Urinary frequency
Vomiting

Table 3

Neuropsychiatric effects of selected chemical agents (20)

Chemical agent           Syndrome or symptoms

Organophosphates         Depression, sleep
  (nerve agents such       disturbance, impaired
  as Sarin, Soman,         cognition, delirium
  VX, and Tabun)

Atropine (treatment for  Blurred vision, tachycardia,
  organophosphates)        dry mouth, suppression
                           of sweating, urinary
                           retention, cognitive
                           impairment, psychosis,
                           and delirium

Cyanide                  Early symptoms of cyanide
                           exposure are anxiety,
                           confusion, giddiness,
                           and hyperventilation

Blistering agents,       Cause blindness and burns,
  mustard gas,             psychologic distress over
  phosgene                 disfigurement, phosgene
                           inactivates charcoal
                           and causes suffocating
                           sensation like lungs
                           filling with fluid

Table 4

Neuropsychiatric syndromes or symptoms in selected biologic agents
(5, 20)

Biologic agent        Syndrome or symptoms

Anthrax               Meningitis
Brucellosis           Depression, irritability,
                        headaches, death
Q fever               Malaise, fatigue, encephalitis,
                       hallucinations
Botulinum toxin       Depression caused by
                        lengthy recovery time
Viral encephalitides  Depression, cognitive
                        impairment
All biologic agents   Delirium

Acknowledgment

I thank Katha Lacy for editorial and manuscript assistance.

Accepted August 26, 2002.

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RELATED ARTICLE: Key Points

* Significant psychological and behavioral reactions to an attack with weapons of mass destruction are certain, include both group and individual reactions, and will follow a predictable course.

* Possible group reactions include mass panic, acute outbreaks of medically unexplained symptoms, and chronic cases of medically unexplained physical symptoms.

* Possible individual reactions include psychiatric disorders such as posttraumatic stress disorder, which occurs in approximately 30% of people exposed to extreme trauma.

* Most people have symptoms of arousal that are normal reactions to abnormal events and that resolve with rest, reassurance, support, and education.

From the Department of Psychiatry, Uniformed University of the Health Sciences, Bethesda, MD.

No financial support was received for this work.

Neither author has any proprietary or commercial interest related to this work.

The views expressed in this article are those of the author and do not reflect the official policy of the Department of Defense or other departments of the U.S. government.

Reprint requests to Timothy J. Lacy, MD, Lt Col, USAF, MC, Department of Psychiatry, Uniformed Services University of the Health Sciences, Building B3068, 4301 Jones Bridge Road, Bethesda, MD 20817. Email: [e-mail]

Copyright [c] 2003 by The Southern Medical Association

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