Center for the Study of Traumatic Stress
CSTS | Department of Psychiatry | Uniformed Services University | 4301 Jones Bridge Road, Bethesda, MD 20814-4799 | www.CSTSonline.org

Psychological and Behavioral Issues
Healthcare Providers Need to Know
when Managing a Chemical, Biological,
Radiological, or Nuclear (CBRN) Event
symptoms may be amplified if
Introduction
Following
widespread
exposuretoathose affected believe something
An event involving exposure or
could have been done to prevent
potential exposure to CBRN agents
CBRN agent, the management of acutethe exposure or that concerns
will create fear and uncertainty.
psychologicalandbehavioral
responses
willraised about exposure were not
While CBRN agents havebe as important as the treatment of any
adequately addressed in a timely
occasionally been used for malicious
manner. Psychological distress after
purposes, such as by terrorists, most
CBRN-related injuries and illnesses.
a CBRN incident may also manifest
exposures are unintentional andas somatic complaints for which
result from the failure of or damage
no diagnosis can be found (often referred to as “MIPS” —to man-made systems designed to contain and safeguard
Multiple Idiopathic Physical Symptoms). These patientsthe population. The man-made nature of a CBRN event
should be managed by general health care providers. Some
often increases the likelihood and severity of adverse
individuals will manifest changes in their behavior such as
psychological effects. Following widespread exposure to adecreasing travel, staying at home, refusal to send children
CBRN agent, the management of acute psychological andto school as well as increased smoking and alcohol use.
behavioral responses will be as important as the treatment
For the vast majority of people, distress andof any CBRN-related injuries and illnesses.
psychological and behavioral symptoms related to the
CBRN exposure is often a dreaded threat seen as
traumatic event exposure will diminish over time.
catastrophic with the potential for severe illness, injury,
For others, however, symptoms will persist and affector death. Radiation is invisible, odorless, and unknown.
function at home and work, and may result in psychiatric
These ingredients stimulate worst-case fantasies. People
illness. While Acute Stress Disorder (ASD) and Post
must often rely on health care providers and scientists toTraumatic Stress Disorder (PTSD) are the disorders mostdetermine whether or not a person has been exposed and/people think of in connection with with trauma, majoror the extent to which the exposure occurred. Exposure
depression, increased substance use, family conflict, andto a CBRN agent may not manifest immediately. The
generalized anxiety disorder are also encountered.
health effects of CBRN exposure can also lead to delayed
It is important to remember that people with no prioreffects on future generations, both physiologically andpsychologically. Those who have been exposed or anticipate history of psychiatric illness are vulnerable to psychiatricillness after a CBRN exposure.
possible exposure feel a sense of vulnerability, anxiety, andThose at high risk of developing psychiatric disorders
a lack of control. The common lack of consensus among
include:experts can increase public fear and anger.
After a CBRN event there are three groups of■ Those directly exposed.
psychological responses: distress, behavioral changes,■ Those with existing mental illness.
and psychiatric illness. Distress following a CBRN event■ Those who suffered resource losses and disruption ofis common and manifest as sadness, anger, fear, difﬁculty
their social supports after the event.
sleeping, impaired concentration, and disbelief. These
Continued

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There have been a number of technological disasters,
terrorist attacks, and use of novel weapons in the context
of war which suggest that healthcare providers’ ofﬁces,
medical clinics, and hospitals will be deluged withsymptomatic and asymptomatic patients seeking evaluationand care for possible contamination following a CBRN
event. Some of these patients will be diagnosed as having
illness related to exposure, others will have diagnosableconditions unrelated to exposure, and a large number will
be found to have symptoms for which no etiology can befound. A very conservative estimate of unexposed: exposed
patients seen in medical settings is 4:1. In the acuteaftermath, many unexposed patients will fear that they
have been exposed because they will misattribute signs andsymptoms of autonomic arousal to exposure of the fear
CBRN agent. In the longer term, patients will present toprimary care providers with multiple somatic complaints
for which no etiology can be determined. Appendix A
suggests strategies for managing these patients.

care providers’ families will be reassuring to health careproviders and help them focus on their mission.
II. Triage and Initial Disposition
Triage and disposition is challenging. For example,
in the 1987 Cs-137 accident in Goiânia, Brazil, 8.3% of
the ﬁrst 60,000 people screened presented with signs andsymptoms consistent with acute radiation sickness: skinreddening, vomiting, diarrhea, etc. although they had notbeen exposed.
The term “worried well” and similar disparaging terms
should never be used. When labels suggesting “it’s all inyour head” are used, patients feel stigmatized and that
their health concerns have not been taken seriously. The
use of such labels contributes to mistrust of the medical
community and a loss of its credibility. In situations that
require triage, non-stigmatizing terminology, such as “highrisk”, “moderate risk”, and “minimal risk”, conveys continued
concern and monitoring which is reassuring to patients.
Mental health professionals, ideally psychiatrists dueto their background as physicians, should be an integral
part of the teams that perform initial screening and triage.
Referral to a mental health specialist is usually experienced
as stigmatizing. The patient may feel that the physician
has missed some important clue of contamination and isdismissing them prematurely.
The establishment of an “Emergency Services Extended
Care Center” (ESECC) offers an important means ofmonitoring patients who remain fearful and are notreassured by negative ﬁndings. In the event that a patientis misdiagnosed, the patient can be accompanied back to
the Emergency Department. Patients with minor physicalproblems who cannot return home can be referred here.
Ideally, there would be simple tasks that the patients canperform while in the ESECC will help them transition outof the patient role and restore their sense of control.

I. Healthcare Providers and Mental Health Care after a
CBRN Event
Following a CBRN event, people will likely turn tohealthcare providers for information and guidance. For
example, following the 2001 anthrax attacks, 77% of arepresentative sample of Americans reported that theywould trust their own doctor most as a reliable source of
information.
Healthcare providers play a key role in determining
how patients and the general public respond to a CBRN
event. A well-organized, effective medical response will
instill hope and conﬁdence, reduce fear and anxiety, andsupport the continuity of basic community functions.
Healthcare providers are also subject to fear and terror.
Absenteeism, ﬂight, refusal to see patients, and otherfear-organized behaviors have been reported following
infectious disease outbreaks (such as the outbreak ofpneumonic plague in Surat, India) and other instances of
new or unfamiliar, life-threatening agents.
Some healthcare providers are prompted by concerns
for their personal safety. At times, health care providers,like others, have ﬂed their health care responsibilities
during CBRN events involving feared to be contagious or
have person-to-person transmission. Many of those whoabandon their responsibilities do so because they feel theyneed to protect their families from exposure or feel theneed to evacuate the area for personal safety.
Ensuring that health care providers understand the
CBRN agent and countermeasures for protection canminimize role abandonment. Perhaps most importantly,
health care providers are more likely to provide patient care
if they believe that their families will be taken care of in
their absence. The availability of ongoing telephone contact
with families and dedication of personnel to assist healthIII. Early Psychological Interventions
Early psychological interventions, such as PsychologicalFirst Aid (PFA) are provided in the ﬁrst hours, days, andweeks after exposure to a CBRN event. PFA is based upona set of do-no-harm principles that include: calming
arousal and reducing fear, enhancing feelings of safety,
increasing connectedness, restoring hope, and empowering
individuals and community. In a CBRN event, a criticalelement of PFA involves good medical care. In addition, theprinciples of PFA can be furthered by the following:
Psychological First Aid■ Reduce physiological arousal — encourage rest, sleep,and normalization of eat/sleep/work cycles.
■ Provide food and shelter in a safe environment.
■ Orient survivors to the availability of services/support.
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■ Facilitate communication with family, friends, and
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1. Carefully assess and record the speciﬁcs of thepatients’ concerns.
2. Establish follow-up appointments rather than “return
if there’s a problem”.
3. Consult medical management as appropriate.
4. Listen for patient fears and concerns.
■ Patients do not process or remember information
well when they are very frightened. Handouts on the
CBRN agent of concern that summarize key points andinstruct on how to get follow-up should be used.
■ Many people will be unsure if they have illness from the
CBRN agent(s) (in the case of radiation exposures, up
to 50% of those in contaminated areas).
■ Everyone will be worried about damage to their genetic
material and potential harm to future generations.
When children are exposed, parental fears will be
amplified and children will require developmentally
appropriate care and interventions.
■ Negative life events that occur after a CBRN event
increase risk for psychiatric illness, other medical
illness, and injury.
■ Distress is decreased by reinforcing self-efﬁcacy andproviding information that can be used to protect
oneself and one’s family.
■ The psychological value of distributing protective
mechanisms (medication, antidotes, devices, etc.) canbe substantial.
■ Patients presenting with multiple somatic complaints
to primary care providers may have physical illness,or this may be an expression of distress, depression,or demoralization. Accurate differential diagnosis andmanagement of these individuals will require educationof primary care providers.
■ Lack of baseline health data in exposed populations
will lead to the misattribution of illness to CBRN agent
exposure by individuals and communities.

community.
Assist in locating loved ones.
Keep families together and facilitate reunions withloved ones.
Provide information and foster communication andeducation.
Observe and listen supportively to those most affected.
Decrease exposure to reminders of the traumatic event.
Advise decreasing watching/listening to media coveragecoverage of overly traumatic images and sounds (e.g.,
people jumping out of buildings, victim stories)
Educate patients to check rumors with available
information resources.
Use established community structures to encouragesocial conduct and education (e.g., faith-based
institutions and businesses.
Distribute ﬂyers and host websites.
Encourage talking to and involvement with patient
natural social supports such as families, friends,
neighbors, and coworkers. This will encourage
discussion of fears, interpersonal support, and early
detection of persistent symptoms.
Offer reevaluation if symptoms persist.
Educate about the expected natural recovery that
occurs for most people over time.
“Debrieﬁng” is a controversial acute intervention.
Appendix B discusses it in more detail.

IV. Health Care: Evaluation and Diagnosis■ Psychological and behavioral issues of a CBRN
event will generally far outweigh the physical illness
management problems.
■ Depression, bereavement, family conﬂict, andsomatization will be the more common psychiatricpresentations than posttraumatic stress disorder(PTSD).
■ Increased smoking and increased alcohol use can be
expected, at least in the short run.
■ Sleep disturbance, hypervigilance, decreased
concentration, and uncertainty will be common early
psychological distress symptoms. These should bemanaged by education, counseling, and, perhaps, brief
use of hypnotic medication for sleep.
■ Uncertainty about health effects should be recognized
and not minimized in communicating to patients andthe public.
■ The principles of medical care and management of thepatient present with medically unexplained symptoms(MUPS) include:

V. Patient Education■ Repeated education about risks and protective
countermeasures will help diminish fear, concern, anddistress.
■ Health care providers should anticipate questions about
the safety of their food and water supplies and whether
homes are contaminated.
■ Educate patients that distress is universal and thatthey may experience common responses such as
sleep disturbance, loss of appetite, and diminishedconcentration that should resolve over the next several
weeks. If these symptoms persist or begin to affect theirfunction at work or home, they should return to theirhealth care provider.
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■ Fears and preoccupation with contamination and long-

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VII. Public Health and Mental Health■ Establishment of a clinical registry and appropriate
health surveillance are important psychologicalinterventions. Patients who have their contact
information recorded in a database will feel moreassured that follow-up will be available.
■ Smoking cessation programs can be an important
public health intervention.
■ Handouts on stress and fear management techniques
and activities should be available for distribution.
■ Public health outreach to senior citizens will be
important since their distress may heighten theirwithdrawal and staying at home. Door-to-door contact
programs for this group and those with chronic medical
needs who stay at home will be needed.
■ Family concerns about genetic effects on future
generations will be high.
■ People will want to move away from contaminatedareas both acutely and over time.
■ Many will believe the federal government should pay
for their relocation and the cost of lost property.
■ Who delivers risk information is as important as, ormore so, than the content for whether the information
is believed and trusted.
■ Contamination of food supplies, in particular milk
and ethnically important foods (e.g., reindeer in
Norway following the Chernobyl disaster) create acuteand long-term education needs and potential healthsurveillance needs.
■ Contaminated communities may manifest cohesion oranger, low morale, and decreased social service due to
distress and economic losses.
■ Relocation of families is complicated and requires
particular attention to familial needs and social justice.
Maximizing the choice of families is important. Some(perhaps 10%) will not want to move following events
after which this is recommended.
■ Expect concern over whether there is equitable
distribution of health care resources to those affectedor believed to be affected (food, healthcare, etc.). A
perception of inequity will stress social fault lines andmay divide communities.
■ The rationale underlying prioritization of services must
be explained to the public and must be reasonable tothose designated as lower priority.
■ Expect and plan for ongoing health surveillance formonths to years.
■ Fears of CBRN exposure can mobilize both heroism
and avoidance in ﬁrst responders. Both can haveimportant positive or negative effects on performance.
■ Distribution of protective mechanisms must be closely

term health consequences may remain high for months
or years. Responding accurately and empathetically andrecognizing what is not known is important.
The images and history attached to various exposures
as well as proximity to recent events (radiation andnuclear power, infectious outbreaks, etc.) are likely toenhance fears.
Patients should be counseled to expect to hearconﬂicting views by experts and, ideally, how to sort
through it.
Health care providers should understand the basic
areas of disagreement about the health consequencesof the CBRN agent of concern and be ready to explainthem to patients in a very straightforward and simple
manner. Uncertainly about health effects should be
acknowledged and not minimized in communicating topatients and the public.
Simple metaphors or other messages to explain
complex scientiﬁc ideas must be developed for
healthcare providers to use with their patients (as well
as appearing in mass media campaigns).
Stigmatization of those exposed or traveling fromcontaminated areas can be expected. This will affectthe relocation and entry of new students into school
systems.
Outreach health education to school systems, parentteacher education programs, and school nurse training
can allay community anxiety.
Social media will be a source of information formany patients. Fear-based communication andmisinformation will proliferate rapidly following a
CBRN event. Patients should be encouraged to use
trusted sources of information. Those managing
a CBRN event should utilize social media as amechanism for providing accurate, ongoing, andregularly updated information to the public.

VI. Special Issues (Children and Pregnant Women)■ Parental concern for children will be high. This will betrue for children exposed and not exposed.
■ Reports by parents of child distress, fears, and worries
contain both accurate observations and the fears of theparent.
■ Direct assessment of children and adolescents isimportant to determine the child’s mental healthbecause of the high levels of distress in the parents.
■ Pregnant women and women with small children
will have high concern following a CBRN incident.
Pregnant women may seek abortion to avoid expectedor feared possible child malformations. Special
education and counseling will be needed.
4watched for abuse and exploitation.
■ Stress in and around contaminated areas is increased by
the often present need to stay in the location due to jobs
or inability to sell one’s home. This will have long-term
psychological and possibly physiologic health costs.

Stress Disorder (PTSD), depressive or anxiety disorders,and altered alcohol or smoking are important.
■ Based on this initial primary care assessment of
exposure, concern, presence or absence of symptoms,
and the presence or absence of disease (physical andpsychiatric), patients may be assigned to categories fortreatment, follow-up, education, and counseling on
risk, symptoms, concern, and/or disease ﬁndings.
■ Often the primary care provider has the most difﬁcultyin communicating with those who are:1. possibly exposed but unconcerned and with nosymptoms or disease
2. either exposed or unexposed with a high level ofconcern but asymptomatic (no symptoms or disease)
3. either exposed or unexposed with a high level ofconcern and unexplained symptoms (e.g., no disease).
These patients are often categorized as having MIPS
(Multiple Idiopathic Physical Symptoms).

APPENDIX A
Communication Between Primary Care Providers andPatients: Education Strategies after a CBRN Event
Background■ Fear of CBRN exposures may cause many todevelop persistent health concerns or to arbitrarily
link idiopathic symptoms to benign or improbable
exposures.
■ Large percentages of the general population will visit
their primary care provider each year, making primarycare a crucial setting for dissemination of accurate
health risk information following community CBRN
exposures.
■ Even under usual circumstances, a substantial
proportion of primary care patients present forassistance with medically unexplained physicalsymptoms (e.g., idiopathic fatigue and pain).
■ Therefore, communication and education plans forprimary care health care providers working withhealth care seeking populations are needed to ensure
appropriate medical care and assistance.

Communication Interventions for Critical Primary
Care Groups■ Possibly exposed but unconcerned with no symptoms
or disease — Many patients will deny or neglect
personal medical needs. Assuming medical needs
are sub-acute, careful contact information should beobtained and entered into a local registry to facilitate
follow-up to ensure patient has attended appropriately
to injuries and exposures.
■ Either exposed or unexposed with high levels ofconcern but asymptomatic – Some patients amplify
concerns and repeatedly resist clinician reassurances.
In a mass casualty situation, these patients candisrupt delivery of critical medical care; plan forthese patients by dedicating staff and an area to theircare. Development of a careful contact registry withdedicated efforts to provide follow-up contact andcare is one way of communicating compassion andconcern without succumbing to risky or unnecessary
testing. Research suggests that a negative test offers
only transient (i.e., days to a week or two) reassurance
and can sometimes increase illness concerns, especiallywhen false positive results occur. Discussing the basis
for patient concerns and exploring what tests thepatient thinks he or she might need prevents many
patients from feeling that the clinician has “blown
them off ”. Time contingent follow- up (planned rather
than “PRN” visits) reduces illness worry, increases
satisfaction with care, and may mitigate downstream
litigation conﬂicts and concerns.
■ Either exposed or unexposed with high levels ofconcern and unexplained symptoms (no disease, MIPS)— As with the asymptomatic concerned patient, thepatient with idiopathic symptoms can disrupt delivery

Primary Care Communications Triage■ After suspected exposure, it is useful for primary careclinics to routinely assess the degree of concern about
exposure-related illness, separate from actual exposures,“Is your visit today related to concerns about exposure
to (insert name of CBRN agent)?” at the beginning of
every visit.
■ It is important for all patients visiting primary care,regardless of the reason, that their exposure to the
CBRN agents be determined. In some settings thiswill be by using technology, and may also involve thepatient’s history of time and place/location over a
critical period of time, as well as symptoms.
■ Patients who respond ‘yes’ or ‘maybe’ to thequestionnaire on their concern about exposure-related
illness should receive extra primary care assessment
to elucidate the nature of the patient’s concerns andexpectations of and goals for the medical visit. These
concerns and expectations guide medical triage and theintensity of risk communication efforts.
■ Assessment of symptoms and possible disease after a
CBRN event will include physical and psychologicalsymptoms and disease. Assessment for Posttraumatic5

of critical medical care. These patients may invoke
more clinician anxiety because unlike the patientwith isolated concerns, these patients are often visibly
suffering and their symptoms may sound potentiallycatastrophic (e.g., chest pain and sweating).
In addition to a dedicated area, stafﬁng, contact
registry, and redoubled primary care follow-up efforts,
intervention for patients concerned with unexplained
symptoms should involve brochures, fact sheets,and literature about self-management approaches to
medically unexplained symptoms. In the acute crisis,
it is helpful to triage these patients to an area distinct
from the area used to care for acutely ill individuals,
but the area should not be labeled or perceived asa “psychiatric care” area for “worried well” patients
so it remains maximally acceptable. Many of thesepatients fear their symptoms represent a harbinger ofimpending medical catastrophe. Patient resentment canlead to resentment and result in a “contest” in which
patients may “up the illness ante” until afforded medical
legitimacy. Therefore, patients with unexplained
symptoms should receive early and frequent validationfrom the clinician that symptoms are important andwill be followed up quickly and carefully. The care ofpatients with unexplained symptoms is frustrating forprimary care physicians, especially if the physician feelsthat “minor problems” are distracting them from moreacute care.
The use of an onsite “ombudsman” or “advocate”
who can help patients with unexplained symptoms
overcome perceived barriers to care helps to defuse
patient notions that “no one cares” and affords
clinicians’ a “program” to reduce the pressure to meetthese patients’ needs. The ombudsman can makespecial efforts ensure that symptoms are acknowledged,“embraced”, and carefully discussed. As with concerned
but asymptomatic patients, time-contingent followup is key. If symptoms persist and explanations for
symptoms remain unclear, some of these patients may
mistrust clinician motives and develop improbable“conspiracy theories”. Advocacy for these individuals
may reduce the likelihood of eventual litigation
including class action lawsuits.

meet in a single lengthy session to share individual
feelings and experiences. The effectiveness of debrieﬁng inpreventing later mental health problems is much in debate.
As a minimum the following should be considered if you
include debrieﬁng as part of an intervention plan.
■ Rest, respite, sleep, food, and water are the primary
tools of early intervention.
■ It is important to encourage natural recovery processes
such as talking to fellow workers, spouses, and friends.
This can decrease isolation and therefore facilitate
identiﬁcation of persistent symptoms and increase thechances of early referral.
■ Debrieﬁng has not been shown to prevent PTSD.
For some, it may relieve pain, restore some function,and limit disability. In some, debriefing may worsen
symptoms.
■ There are a number of early approaches other thandebrieﬁng (e.g., continue to follow and reevaluate, casemanagement and problem solving, couples emotional
support training, sleep medication, intermittent
psychotherapy, and advice giving/education). Theseshould be considered in an intervention plan.
■ Debrieﬁng during an ongoing traumatic event may beparticularly problematic.
■ Debrieﬁng is an opportunity for education about
responses to trauma such as emotional reactions to
disaster, somatic reactions, violence, substance abuse,
and family stress.
■ During a debrieﬁng there is an important opportunity
to identify and triage people who are in need ofadditional assistance/intervention.
■ Ongoing groups are more helpful than a one-time
meeting.
■ Talking in homogeneous groups (e.g., ﬁreﬁghters)
may be more helpful than in heterogeneous (stranger)
groups.
■ Individuals dealing with the death of a loved one
may have difﬁculty if placed in a group with others
who have survived a potentially deadly experience.
Therefore, it is generally important not to mix those
who have experienced a loss and those who haveexperienced life-threatening exposures.
■ Debrieﬁng groups with individuals having different
levels and types of exposures may “spread” exposure
from those with high trauma exposure to those with
low trauma exposure resulting in more symptoms in
low exposure individuals.
■ Different people have different stories and concerns.
Groups often tend to want to all agree on a single
perspective. In a heterogeneous group this may lead toisolation and stigmatization of some participants.

APPENDIX B
The Debrieﬁng Debate
The magnitude of death and destruction in disasters
and the extent of the response demand special attention.
Physical safety and security of victims and relief workers
must take ﬁrst priority.
After safety is assured, other interventions suchas debrieﬁng may begin. Debrieﬁng is a popular earlyintervention following disasters in which small groups ofpeople involved in the disaster, such as rescue workers,
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Center for the Study of Traumatic Stress
Department of Psychiatry
Uniformed Services University
4301 Jones Bridge Road, Bethesda, MD 20814-4799
www.CSTSonline.org
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