University Medical School, University of Aberdeen, and Aberdeen Centre for Trauma Research
Aberdeen Centre for Trauma Research, Aberdeen
Correspondence: Professor David A. Alexander, Aberdeen Centre for Trauma Research, Bennachie, Royal Cornhill Hospital, Aberdeen AB252ZH, UK
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ABSTRACT |
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Aims To describe the likely effects of a terrorist incident involving biochemical agents and to identify important response issues.
Method Literature survey.
Results Observations following conventional terrorist incidents and other major trauma, including biochemical and nuclear accidents, suggest that a biochemical terrorist incident would have widespread public effects. The mental health services should play a major role in designing an effective multi-disciplinary response, particularly with regard to the reduction of public anxiety, identifying at-risk individuals and collaborating with medical and emergency services, as well as providing care for those who develop post-traumatic psychopathology.
Conclusions We should not feel helpless in the face of a biochemical threat; there is considerable knowledge and experience to be tapped. Awell-designed, well-coordinated and rehearsed strategy based on empirical evidence will do much to reduce public anxiety and increase professional confidence.
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INTRODUCTION |
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BACKGROUND |
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the unlawful use of force or violence against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives (US Department of Justice, 1996).
What we consider to be unjustifiable and repugnant acts of terrorists are viewed by the perpetrators as rational and may be allied to cherished martyrdom. Post (2002) has argued that an understanding of the motivations of terrorists can help their victims to make some sense of their suffering.
The authorities are not able to calculate accurately the risk of such terrorist activity, but it is important that forewarning and preparation are not on such a scale that massive public anxiety is created, because this would serve well the aims of the terrorists by creating a nation of terro-phobes. To achieve a balanced approach, and to design an effective strategy for responding to biological or chemical terrorism, the mental health services have much to offer because, as will be argued below, biochemical terrorism is quintessentially psychological warfare (Wessely et al, 2001).
Historically, terror has proved to be an effective instrument of coercion and intimidation for state organisations such as the Tzarist Okrahana, the Nazi Geheime Staatspolizei (the Gestapo), and the East German Ministerium fur Staatssicherheit für (the Stasi) and other groups with a specific agenda, such as the Mafia and the Ku Klux Klan. The political activities of the Baader-Meinhof Group, the Irish Republican Army, the Algerian Salafis, the Basque Homeland and Liberty Group (ETA) and the al Qa'ida have underscored just how effective the use of terror can be, at least in the short term. Most recently, suicide terrorism has caused profound fear and social disruption (Salib, 2003). However, we must maintain a realistic perspective; sometimes their efforts are not successful and may be counterproductive (Laqueur, 1999).
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AIMS OF BIOCHEMICAL TERRORISM |
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The aims of terrorism do not require massive casualties for their fulfilment: death and physical damage is a means to an end, not an end in itself. Following the two attacks using the nerve gas sarin in the Japanese cities of Matsumoto (1994) and Tokyo (1995), carried out by the Aum Shinrikyo cult, only 19 deaths occurred but the psychological, social and economic effects of these incidents were enormous (Knudson, 2001).
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ATTRACTION OF BIOLOGICAL AND CHEMICAL AGENTS |
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PSYCHOLOGICAL PSYCHOLOGICAL REACTIONS TO A BIOCHEMICAL INCIDENT |
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Community reactions
Tyhurst (1951) suggested
that, following a major trauma, there is likely to be a triphasic response. In
the initial impact, survivors will be preoccupied with their
present situation and most will be stunned and numbed. Up to about 15% will
still be able to retain their ability to think rationally, to evaluate the
level of risk and to take appropriate action. During the recoil
phase, survivors will want to talk to others and seek support. The reality of
what has occurred becomes irresistibly obvious to survivors at the
post-trauma phase. It is similar to the
post-honeymoon phase described by Raphael
(1986) that follows major
trauma. During this phase survivors are likely to display a number of
emotional reactions, including depression, anxiety and anger (particularly if
they consider that their legitimate needs have not been met).
Pennebaker & Harber (1993) describe a social stage model of collective coping: one that emphasises how the need of individuals to talk about their experiences varies over time. Immediately after such an event there is an enthusiasm for sharing views, but that stage is followed by an inhibition phase during which they are more likely to reflect on than talk about the incident.
Panic describes a group response in which the impulsive flight reaction is acute and intense, for example when individuals feel completely trapped and lacking control of the situation (Pastel, 2001). It is contagious and results in individuals looking after their own safety and welfare. Panic should not be confused with mass anxiety because the latter can lead to constructive action. To what extent mass panic is likely to occur after a major biochemical terrorist incident remains unconfirmed (Wessely, 2000). In relation to most major catastrophes this has not been shown to be a characteristic reaction (e.g. Quarantelli, 1960; Durodié & Wessely, 2002). Glass & Schoch-Spana (2002) also challenge the pessimistic view of community reactions. They argue that the general public are likely to display adaptive, collective action. They advocate that the community should be acknowledged as a key partner in the planning and execution of the medical and public health response to a terrorist incident. More specifically, they propose five guidelines regarding public involvement. These are: treat the public as a competent ally; involve community organisations in public health operations; anticipate the need for home-based patient care and control of infection; invest in public outreach programmes and communication strategies; and ensure that the response strategy reflects the values and attitudes of the communities affected by the incident.
None the less, a biochemical terrorist incident would involve a number of elements that could conduce to overwhelming anxiety and subsequent panic. Ramalingaswami (2001) reported that after the 1994 outbreak of suspected pneumonic plague in Surat, India, there was widespread panic such that overnight approximately 600 000 citizens (including medical staff) fled the region.
The short-term effects of a biochemical incident require the authorities to plan for the provision of medical resources, including psychological services. In the longer term a terrorist incident is likely to have more chronic medical and psychiatric sequelae and substantial political and socio-economic effects. Terrorist action in New York and in Bali demonstrate how events on that scale can jeopardise the tourist trade, compromise financial markets and cause governments to review their political agenda. Several authorities have suggested that the longer-term consequences of a biochemical assault may be the more devastating and pernicious (e.g. Becker, 2001; Wessely et al, 2001).
Individual reactions
Observations following natural and human-induced major trauma describe a
miscellany of individual reactions, although much would depend on the
incubation period, virulence and toxicity of the agents used
(Holloway et al,
1997). However, these reactions are likely to include the
following:
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MASS PSYCHOGENICILLNESS |
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the rapid spread of illness signs and symptoms affecting members of a cohesive group, originating from a nervous system disturbance involving excitation, loss or alteration of function whereby physical complaints that are exhibited unconsciously have no corresponding organic aetiology (Bartholomew & Wessely, 2002).
In an excellent review they emphasise the influence of sociocultural factors. Following the events of 11 September 2001, the threat of biochemical terrorism sired the anthrax scares and the World Trade Center syndrome (widespread reports of chest pain and respiratory problems).
A concern is that the medical and welfare services would be overwhelmed in the wake of a major biochemical incident, primarily by many anxious individuals and not just those who had been exposed to contaminants (e.g. Tucker, 1997; Knudson, 2001), as occurred after the radiological contamination incident in Goiania, Brazil, in 1987 (Petterson, 1988). Of the first 60 000 screened, 5000 had not been contaminated but all had presented with symptoms of vomiting, diarrhoea and rashes, all of which are consistent with acute radiation sickness. Ultimately, 125 800 persons had to be screened but only 249 of them had been contaminated. Knudson (2001), with regard to the Aum Shinrikyo incident in 1995, reported that the ratio of those who sought medical help to those who required immediate medical care was approximately 450:1.
The concept of the worried well appears in the literature (Knudson, 2001) but this term is inaccurate and unhelpful (Pastel, 2001). Such individuals have cause to be anxious and, moreover, the level of anxiety may be such that they are not well, at least in psychological terms. Moreover, other authorities (e.g. Engel, 2001) have cautioned against dismissing such health concerns because this is likely to raise suspicions of a conspiracy or of an uncaring or incompetent authority. Hadler (1996) has also suggested that a dismissive approach could result in a contest in which survivors redouble their efforts to persuade doctors of the legitimacy of their symptoms. Engel (2002) refers to a similar dynamic in relation to medically unexplained physical symptoms whereby patients and medical staff can become locked in debate over contested causation.
Engel (2001) has offered some guidelines as to how such individuals should be dealt with. These include the need to offer an empathic, non-judgemental, collaborative approach to help these ailing individuals achieve a better level of adjustment. It is important to note the conclusion of Bartholomew & Wessely (2002) that none of us is immune from such reactions because there are no clearly defined predispositions to mass psychogenic illness.
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PSYCHIATRIC/PSYCHOLOGICAL SYMPTOMS |
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THE MEDIA |
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The media must be embraced by the authorities as allies because, particularly in the early stage after a terrorist incident, they can play a helpful role by broadcasting to an anxious population accurate information about, for example:
In addition, the authorities can, through the media, address important matters relating to, for example, decontamination and isolation procedures, restriction on travel and the disposal of dead bodies. In any multi-racial society the last issue is likely to be a delicate one, particularly if cremation and a prohibition on access to the deceased is required, on health grounds, because this may transgress religious and cultural beliefs and values (Speck, 1978; Gibson, 1998).
After so-called silent disasters involving radiation, there has been a temptation for the authorities to avoid releasing information (Green et al, 1994). It was not until 28 April 1986 that the Russian authorities admitted that there had been a nuclear accident at Chernobyl 2 days earlier. Similarly, they displayed a reluctance to give out accurate information after the sinking of their nuclear submarine, the Kursk, in 2001. The Japanese authorities behaved in a similar fashion after the accident at the nuclear fuel processing facility at Tokaimura (International Atomic Energy Agency, 1999). Denial and duplicity by the authorities are likely to carry penalties and a serious loss of confidence in them is the probable result (Tønnessen et al, 2002).
Two further observations about communicating with the general public after a major incident are that statistics are less persuasive than are case studies, and that individuals are less influenced by statistical probabilities than they are by perceived outcomes (American Psychological Association, 2001). Education a key element of any public campaign following a biochemical incident would have an impact on how a community viewed the impact of such an occurrence.
Efforts should be made to develop non-adversarial and collaborative relationships with media personnel before a crisis. As Quigley (2001) has put it most graphically, if you don't engage and feed the beast, the beast will eat you.
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THE MENTAL HEALTH SERVICES SERVICES |
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According to DiGiovanni (1999) there are a number of key roles that the mental health professionals could be expected to fulfill:
However, mental health personnel need to broaden their concept of trauma to include the physical effects of likely toxic agents and their management, involving the use of decontamination procedures. Similarly, they need to know of the psychological effects of barrier environments and of the wearing of personal respirators and protective clothing.
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FORMAL METHODS OF INTERVENTION |
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There is already evidence that those subject to such a regimen may react adversely even if that incident proves subsequently to be a hoax (Norwood, 2001), and Barbera et al (2001) explore in detail the implications of large-scale quarantine.
Crisis intervention
The general principles of crisis intervention provide an obvious foundation
for an intervention strategy, and subsequent models of early intervention have
embraced many of them while extending the intervention strategy.
First used in relation to military combat, psychological first aid has been proposed by Raphael (1986) as an appropriate response in the first phase following major civilian trauma. It represents a coordinated strategy designed to reduce suffering and uncertainty and to harness the healing resources of the survivors without causing iatrogenic harm. Some of these key elements are:
The implementation of psychological first aid will generally rest with the emergency services, the military and hospital personnel. Everly & Mitchell (2001) present a response strategy, following a terrorist incident, in the fashion of the Ten Commandments. These include: setting up walk-in centres and crisis hotlines; collaboration with the media; enlisting the support of key representatives of political, medical, religious, economic and educational domains; using symbols (e.g. flags and stickers) as a means of enhancing community cohesiveness; and initiating rituals to honour the dead, rescuers and helpers and the survivors. Their final commandment is a familiar one, namely, the Galenic principle of First, do no harm. An argument could be advanced for elevating this to the first principle, in deference to recent evidence and concerns about the psychonoxious potential of inappropriate early intervention (e.g. Wessely et al, 1999). Harm can innocently and inadvertently be caused by, for example, retraumatising individuals by premature and/or insensitive re-exposure to reminders of the trauma, by medicalising or pathologising what are normal acute stress responses and by compromising the natural healing potential of individuals, families and communities. With regard to an employer being concerned about liability for negligent intervention, a legal authority has emphasised particularly that the debriefer should be adequately trained and reputable and that those to be debriefed should be fully aware of the precise nature and purpose of the debrief (Wheat, 2002: p. 156).
Critical incident stress debriefing was initially introduced as a group method of enabling emergency personnel to adjust to particularly disturbing events and to reduce their likelihood of developing post-traumatic stress disorder (Mitchell & Everly, 1996). Its popularity resulted in it being widely used for civilians as a single-session intervention following traumatic experiences, a development far removed from the original model. However, its therapeutic or prophylactic value has been questioned (e.g. Wessely et al, 1999; van Emmerick et al, 2002). Evaluative studies are limited in number and can be criticized on methodological grounds, as the review by the British Psychological Society (2002) confirmed. None the less, certainly on the basis of these findings, mandatory debriefing cannot be justified. The debate must be pursued further because there are significant arguments both for and against this intervention (Wessely & Deahl, 2003) and there are many unanswered questions (Raphael & Wilson, 2000). There is also a need to evaluate other models of intervention.
Blythe (2002) has produced a helpful manual to assist organisations prepare their staff for a major incident. This is a largely atheoretical practical approach, supplemented with a number of checklists covering a range of communication, health, safety, legal and humanitarian matters. Shielding also has been introduced as a practical public health intervention (Everly, 2002) offering a model for individuals, organisations and communities to minimise the impact of a biochemical terrorist incident, particularly through a self-imposed isolation. The concept of stepped care (Engel et al, 2003) is particularly attractive because it combines the benefits of population-based and individual-based levels of care. Simple community interventions are provided first and, for those individuals with particular medical and specific needs, specialist care is made available later. In other words the psychiatric/psychological interventions are not offered indiscriminately. A peer support system, the Trauma Risk Management Programme, evolved from the Royal Marines' Stress Trauma Project; this is of particular relevance to hierarchical organisations. It is based on a system of self-help strategies, education, risk assessment and mentoring (C. March, personal communication, 2003).
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FIRST RESPONDERS AND CARE-GIVERS: THEIR PREPARATION AND WELFARE |
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As was described above by Glass & Schoch-Spana (2002), the general public also must be considered as key partners in the overall response to a biochemical incident. Similarly, Durodié & Wessely (2002) and Rowan (2002) advocate that governments should encourage the active cooperaton of the general public (including lay and voluntary bodies) in the preparation of emergency plans. Weaknesses in major incident plans for biochemical attacks have been revealed in field exercises in the USA and following hoaxes (Tucker, 1997). Ashraf (2002) highlighted the fact that, following the terrorist events of 11 September 2001, there were 7622 postal threats involving anthrax throughout Europe. Although anthrax was not used in any of these events, he claimed that they demonstrated that Europe was not fully prepared for widespread terrorist incidents.
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POSITIVE OUTCOMES AFTER TRAUMA |
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Clinical Implications and Limitations |
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LIMITATIONS
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Received for publication February 19, 2003. Revision received July 21, 2003. Accepted for publication July 31, 2003.