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Chapter 36

TERRORISM AND CHEMICAL, 

BIOLOGICAL, RADIOLOGICAL, 

NUCLEAR, AND EXPLOSIVE WEAPONS

ROSS H. PASTEL, PhD,* and ELSPETH CAMERON RITCHIE, MD, MPH†

INTRODUCTION

TERMINOLOGY

RISK COMMUNICATION AND PERCEPTION

Communicating With the Public

Risk Perception

Mass Media

TRIAGE AND ISSUES OF DIFFERENTIAL DIAGNOSIS

Psychological Symptoms

Estimating Psychological Casualties

ACUTE EFFECTS

Mass Panic

Distress and Outbreaks of Multiple Unexplained Symptoms

Mental Disorders

LONG-TERM EFFECTS

Distress and Chronic Outbreaks of Multiple Unexplained Symptoms

Mental Disorders

SUMMARY

*Lieutenant Colonel, Medical Service Corps, US Army; Chief, Division of Traumatic Brain Injury, Research Directorate, Defense Centers of Excellence for 

Psychological Health and Traumatic Brain Injury, 1335 East-West Highway, Suite 900, Silver Spring, Maryland 20910; formerly, Assistant Professor, 

Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, Bethesda, Maryland

†

Colonel, US Army (Retired); formerly, Psychiatry Consultant to The Surgeon General, US Army, and Director, Behavioral Health Proponency, Office 

of The Surgeon General, Falls Church, Virginia; currently, Chief Clinical Officer, District of Columbia Department of Mental Health, 64 New York 

Avenue NE, 4th Floor, Washington, DC 20002
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Combat and Operational Behavioral Health

INTRODUCTION

Chemical, biological, radiological, nuclear, and 

explosive (CBRNE) agents have gained increased international attention in the last 20 years. In 1992 Boris 

Yeltsin, the Russian president, admitted for the first 

time that the Soviet Union had continued to develop 

an offensive biological warfare program following 

the Soviet Union’s ratification of the Biological and 

Toxin Weapon Convention in 1972.1 In 1995 the world 

was stunned by two major terrorist attacks. In March 

the Aum Shinrikyo cult carried out a large-scale sarin 

attack on the Tokyo subway system. In April two 

home-grown American terrorists, Timothy McVeigh 

and Terry Nichols, attacked the Murrah Federal Building in Oklahoma City, Oklahoma, with a large truck 

bomb. Early in the new millennium on September 

11, 2001, the terrorist group al Qaeda attacked the 

Pentagon and the twin towers of the World Trade 

Center. Although the anthrax mail attacks followed 

within the week, they were not recognized until 

October, when the first victim fell ill. In the midst of 

these terrorist attacks, an emerging infectious disease outbreak caused by a new contagious disease 

called severe acute respiratory syndrome (SARS) 

appeared and caused widespread death and illness 

around the globe, including in China, Taiwan, Hong 

Kong, Singapore, Vietnam, and Canada. Although 

not a terrorist attack, the SARS epidemic resembles 

what might happen following a terrorist attack with 

a contagious disease such as smallpox.

CBRNE weapons are no longer weapons only of 

states; they have become available to terrorists as well. 

Many experts believe that a large-scale attack with 

CBRNE weapons is not a matter of if, but of when. 

Therefore, it is critical that mental healthcare practitioners become aware of the possible psychological 

consequences following a CBRNE attack. 

The psychological effects differ from other medical effects in that personnel do not need to be physically exposed to these agents to exhibit symptoms. 

Psychological effects can cause symptoms that may 

mimic the prodromal (or early) symptoms of CBRNE 

agents. Fortunately, the acute and long-term effects 

after CBRNE attacks have no apparent unique psychological disorders, but rather seem to exist on a 

continuum with effects seen after natural disasters or 

high explosives.2 Psychophysiologic effects, typically 

syndromes of medically unexplained symptoms, will 

likely dominate the long-term picture,3 and treatment 

may be difficult because of patient resistance and difficulties with doctor–patient relationships.4

This chapter will not be a comprehensive review of 

the literature; rather, it will introduce the clinician to 

potential problems resulting from CBRNE attacks. The 

chapter will briefly cover some unique aspects of such 

attacks, which can amplify the psychological effects, 

before reviewing acute and long-term effects.

Terminology

Terminology has an important effect on perception. Having a name for something presupposes an 

understanding. Terminology can be positive, neutral, 

or negative, depending on the connotations and context. One important collective behavior phenomenon 

has variously been called mass hysteria, epidemic 

hysteria, and mass psychogenic illness.5–7 Unfortunately, these terms have a pejorative connotation. For 

example, hysteria comes from the Greek word hystera, 

meaning uterus. Thus, when “mass hysteria” is used 

to describe an event involving medically unexplained 

physical symptoms, the immediate presupposition is 

that mostly females are involved. The common connotation for hysteria presupposes an overemotional 

response to an event, that is, a pejorative connotation. 

Use of “mass hysteria” by media, medical personnel, 

or public officials can lead to a negative perception of 

medical personnel and public officials by people affected by an event and vice versa. Similarly, in “mass 

psychogenic illness,” psyche refers to the mind and 

genic refers to genesis or creation. The connotation is 

that symptoms are “all in the head” and thus not real. 

A preferred term is “outbreak of multiple unexplained 

symptoms” (OMUS).7 Although clumsy, this term 

is relatively neutral. OMUS is also descriptive—the 

symptoms are real but unexplained, rather than “all 

in the head.”

Another common term used in CBRNE events is 

“worried well.” This terminology presupposes that 

the “worried well” are not suffering a real medical 

effect from a CBRNE exposure, but are simply worried that they might be ill. However, after a CBRNE 

event, many people with unknown exposures may be 

symptomatic—distressed and in pain. How can they 

be “well?” Again, “worried well” is a pejorative term 

and should be discarded. In the 1950s a more useful 

term, “disaster fatigue,” was used. This term was based 

on the military experience with combat exhaustion 

or battle fatigue (now called combat stress reaction). 

In World War II, battle fatigue was originally called 

“war neurosis” or “psychoneurosis” (which also had 

a negative connotation for soldiers). 
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Terrorism and Chemical, Biological, Radiological, Nuclear, and Explosive Weapons

Panic is another commonly used term, often used in 

reference to the general public, that is, a “mass panic.” 

In the strict sense, mass panic means an acute fear 

reaction marked by loss of self-control and followed 

by nonsocial and unreasoning flight.8 Flight can be a 

normal reaction to the presence of an immediate danger. It becomes a mass panic only when large numbers 

of people stampede without regard to others in an 

attempt to escape danger. Thus, to describe a panic 

following the anthrax attacks in 2001 or the New York 

City outbreak of West Nile virus in 1999 is inaccurate 

because there was no mass exodus from any city, nor 

was there an explicit danger from which to escape. A 

more accurate term would be “mass anxiety.”

Terrorism and CBRNE incidents (whether in warfare or in terrorism) are most typically mass casualty 

events (MCEs). However, MCEs vary widely both in 

the number and severity of casualties and the ability of the local environment to respond to the event. 

One group has proposed a useful terminology that 

categorizes MCEs into emergencies, disasters, and 

catastrophes based on the demand characteristics 

(number of people in need of rescue, shelter, or medical treatment) of the event and the locally available 

response capacity.9 Disasters are events in which 

the demands are in excess of the locally available 

response capacity (eg, the 2001 World Trade Center 

attack). Although emergencies may have high demand characteristics, they are not disasters because 

the locally available response capacity can handle 

the demand (eg, the 2001 attack on the Pentagon). 

Catastrophes occur when the event not only overwhelms the local response capacity, but also causes 

substantial damage to the infrastructure supporting 

the response system (eg, the 1995 Kobe earthquake 

in Japan).

Persistent idiopathic (medically unexplained) 

symptoms that drive patients to seek medical care4

typically fall within syndromes, including chronic 

fatigue syndrome, fibromyalgia, and multiple chemical sensitivity. These syndromes have overlapping 

symptom clusters and may be identified more by the 

specialty of the physician providing treatment than by 

the patient’s symptoms.

Risk Communication AND Perception

Communicating With the Public

In a CBRNE event, it is likely that the extent of the 

danger will not be known immediately, especially for 

chemical, biological, radiological, and nuclear (CBRN) 

weapons. Public health authorities and public officials 

will attempt to calculate the extent of the threat, and 

inform the media and the public. New York City Mayor 

Rudolph Giuliani was extremely effective following 

the events of September 11, 2001, and demonstrated the 

value of daily or twice-daily scheduled briefings with 

the media and the public. Much has been published on 

principles of health communication, including having 

a consistent message delivered by a knowledgeable 

and credible official, listening and responding to the 

concerns of the public, and avoiding the appearance 

of defensiveness or concealment. 

After any toxic accident or terrorist attack, many 

people will feel anxious about the potential health 

effects of a CBRN release. Such anxieties may be 

multiplied if devastating descriptions of the potential 

aftermath appear in the media. Following the 2001 

events, fears were exacerbated by media suggestions 

that in an anthrax attack, “your next breath may kill 

you.” Public officials should provide accurate hazard 

communication and workable measures that can be 

taken to protect individuals and families. According to 

one risk communication approach, risk equals hazard 

plus outrage.10 Hazard is the scientifically based risk 

assessment, but outrage is made up of nonquantifiable 

factors related to the public’s concern and perception of 

the event. Outrage following an attack with weapons 

of mass destruction will significantly influence both 

acute and long-term psychological effects. 

The US Army Center for Health Promotion and Preventive Medicine has more detailed information and 

training courses available (see the Center’s Web site: 

http://usachppm.apgea.army.mil/risk/). The Centers 

for Disease Control and Prevention has developed a 

course on emergency risk communication training (see 

the CDC’s Web site: http://www.cdc.gov/cdcynergy/

emergency/). 

Risk Perception

Risk perception is an important driver of the outrage 

component in risk communication. CBRN weapons 

involve a number of factors that can increase the perception of risk. Many CBRN weapons are invisible 

and odorless (radiation, biological agents, and some 

chemical agents), which leads to uncertainty about 

both exposure and amount of exposure. In many 

cases, exposure is not known until the patients become 

symptomatic. However, these agents may initially 

induce nonspecific symptoms (eg, fatigue, headache, 

nausea, dyspnea, dizziness, and muscle and joint 

ache). Regardless of illness induced, chemical agent 

and radiation exposures will also increase the fear of 

the long-term effects of the exposure.

In the risk literature, a number of factors have been 
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Combat and Operational Behavioral Health

shown to increase the perception of risk, including 

potentially fatal illness, involuntary exposure (lack of 

control), a catastrophic event, presence of an unknown 

perpetrator, delayed detection and reaction by authorities, and potential effect on future generations.11,12

Fear of radiation, in particular, is prevalent, largely 

because of ignorance and misinformation. Thoughts 

and images typically associated with radiation are 

death, cancer, sterility, and fear for future generations. A number of factors may further amplify risk 

perception: scapegoating, distrust of governmental 

and industrial experts, and news media hype and 

misinformation.

Mass Media

The acute and long-term consequences of terrorism 

and CBRNE events are certainly shaped by risk perception. Risk perception, at least in part, is shaped by the 

mass media. Mass media has played an important role 

in various OMUS situations.13 Media are an important 

risk amplifier because they select and frame risk messages to inform the public, and intensive reporting (or 

media hype) can create continuing waves of news.13

The power of the media can be seen in studies that 

followed both the 1995 Oklahoma City bombing and 

the events of September 11, 2001. In a study of over 

2,000 middle-school children surveyed 7 weeks after 

the Oklahoma City bombing, both emotional exposure 

and television exposure were significantly related to 

posttraumatic stress symptomatology.14 When children 

with no direct (felt or heard the explosion) or emotional 

(knew someone killed or injured) exposure to the 

bombing were divided into high and low television 

exposure, children with high television exposure had 

significantly higher posttraumatic stress scores.14 A 

telephone survey study done 3 to 5 days after September 11 found that 44% of the people surveyed had one 

or more substantial stress symptoms, including sleep 

difficulties, irritability and anger, difficulty concentrating, and disturbing thoughts, memories, and dreams.15

The people responding to this survey were not present 

at the event; therefore, much of what they knew was 

presumably based on media reporting. 

In a contagious disease outbreak, information 

becomes extremely important. The public is eager 

for information and needs to know what precautionary measures should be taken. In Hong Kong, most 

respondents to a survey reported actively seeking 

SARS information on a daily basis, and relied more on 

mass media (television, newspapers and radio) than 

on medical professionals, friends, or the Internet.16

Substantial misinformation and false beliefs persisted 

among Hong Kong adults even at an advanced stage 

of the SARS epidemic, despite constant media and 

public service announcements.17 Recommended measures were not practiced uniformly. Many people did 

not understand transmission routes; only one third 

of respondents avoided direct contact by touch with 

contaminated objects (fomites), and less than one 

half practiced at least five of the seven recommended 

precautions. 

Triage and Issues of Differential Diagnosis

An important lesson learned from the Israeli Scud 

missile experience is the importance of a separate 

stress center at hospitals, so that psychological casualties can be removed from the emergency room and 

taken to a less stressful environment. Only recently 

have neuropsychiatric casualties been included as a 

triage category.18 When Israel was attacked with Scud 

missiles during the Persian Gulf War in 1991, large 

numbers of people reported to the emergency room 

for treatment.19,20 Studies reported that approximately 

70% to 80% of the patients in the early attacks had 

stress-related symptoms. 

Psychological Symptoms

Many symptoms commonly seen following a 

CBRNE incident (fatigue, nausea, vomiting, headaches, 

and anorexia) are common in combat21 and can be induced by acute radiation sickness (ARS) and chemical 

agent exposure, or during the prodromal syndrome of 

exposure to various biological agents and toxins.22 Because many CBRN agents are invisible, many soldiers 

may experience symptoms that they blame on CBRN 

exposure, regardless of actual exposure or dose of 

exposure. These patients are not “worried well.” They 

are worried—possibly with good reason—but they are 

not well if they are in distress and pain. 

Some CBRN agents may directly induce psychological effects in addition to medical effects (eg, nerve 

agents can induce anxiety).23 In other cases, symptoms 

may precede signs; that is, patients exposed to pulmonary agents may initially present with respiratory 

distress without measurable physical signs.24 Symptomatic ambulatory cases with mild or perceived exposures will present difficulties for CBRN event triage.

Unfortunately, most disaster exercises for CBRNE 

or other incidents include few psychological casualties. Without proper training based on actual CBRNE 

accidents, incidents, and attacks, healthcare providers will be unprepared for the sudden onslaught 
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Terrorism and Chemical, Biological, Radiological, Nuclear, and Explosive Weapons

of patients presenting with mild or psychological 

symptoms who will arrive at the hospital before the 

severely wounded.

Estimating Psychological Casualties

Based on historical experience in World War II, 

military medical planners can get a rough estimate of 

battle fatigue or combat stress casualties, based on the 

number of wounded in action (WIA) expected from 

different types of battles.25,26 In World War II, the ratio 

of combat stress casualties to WIA was in the range of 

1:10 to 1:2.25,26 The civilian psychological casualty (PC) 

to WIA ratio for the first Israeli Scud missile attack was 

16:1 (if PCs are combined with unjustified atropine 

injections) or 8:1 (if only the PCs are included). In the 

1987 radiological contamination accident in Goiânia, 

Brazil, where no explosion occurred, the PC to WIA 

ratio was 500:1 (with WIA defined as anyone contaminated either externally or internally), or 2,500:1 

(with WIA defined as those individuals requiring close 

medical surveillance). 

Both examples involve civilians of two foreign nations, so extrapolation to US citizens or military personnel is difficult. The available data suggest that it is 

unlikely that the PC to WIA ratio following a CBRNE 

attack or incident will resemble the 1:10 to 1:2 range 

seen in World War II battles. The low end of the range 

may resemble World War II statistics, but the high end 

could go much higher, depending on the characteristics 

of the CBRNE attack. Most importantly, it is time to 

ensure that training for disaster and CBRNE incident 

should involve large numbers of psychological casualties, not the typical token few. 

Acute Effects

Mass Panic

The common image of behavior during or after a 

disaster is that of mass panic, described as “highly 

disorganized flight by hysterical individuals who 

have stampeded at the sight of actual or potential 

danger.”27(p68) During the Cold War, civil defense planners feared that a mass panic would follow a nuclear 

attack. However, studies of disasters and wars over 

the last 50 years show that disorganized flight (mass 

panic) is very rare.28–30 The few occasions when it did 

occur were very circumscribed and were characterized 

by limited escape routes with the possibility of entrapment, a perception of collective powerlessness, and a 

feeling of individual isolation.27,29,31 The most frequent 

historical examples of mass panic are in cases of fires, 

mine collapses, and sinking ships. Mass anxiety is not

mass panic.

In the initial use of chlorine gas on the Western front 

by Germany in 1915, “a full-blown, blind, contagious 

panic swept portions of the line.”32(p91) However, no 

panic occurred farther out on the line where there was 

little or no gas. In the next six gas attacks over the following 2 months, no mass panics occurred, although 

protective equipment was rudimentary and not widely 

available. Only four other gas panics were documented 

in World War I. 

Most victims of the Tokyo sarin subway attack were 

office workers going to their jobs in central Tokyo. Despite the crowded conditions of the morning rush hour 

and the limited escape routes, there were no reports of 

mass panic. One fireman reported a “perplexing silence” 

at the accident scene—no talking, just the coughing of 

the victims as they awaited medical assistance.33

Distress and Outbreaks of Multiple Unexplained 

Symptoms 

Perceived exposure to a CBRNE agent can result in 

the appearance of symptoms that may be hard to differentiate from mild symptoms expected from actual 

exposure. Thus, an OMUS can occur independently 

or in conjunction with a CBRNE event. However, in 

a CBRNE event, not all symptomatic casualties have 

been exposed to a toxic agent.34 Symptoms of psychological origin can also occur in casualties actually 

exposed to a CBRNE agent and may make treatment 

more difficult (victims finding out they have been exposed to a lethal disease such as anthrax or smallpox 

are unlikely to remain calm). Regardless of the actual 

exposure, it is important to pay attention to the patient’s symptoms of pain and distress while attempting 

to discern actual exposure.

The US military has experienced several OMUS incidents. In World War I, outbreaks of gas neurosis (gas 

hysteria) occurred, in which some soldiers experienced 

symptoms of gas poisoning (eg, dyspnea, coughing, 

and burning of skin) without clinical exposure to gas.35

In one incident, 500 battle-tested troops drifted into 

medical aid stations over a 1-week period following 

desultory gas shelling. They exhibited chest pain, fatigue, dyspnea, coughing, husky voice, and indefinite 

eye symptoms, all consistent with chemical exposure.36

However, the divisional gas officer found no evidence 

of gas inhalation or burning. 

More recently, in 1988, 1,800 male military recruits 

were evacuated from barracks due to an epidemic of 

coughing, dyspnea, and chest pain that broke out at a 

training center.37 The symptoms were consistent with 
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Combat and Operational Behavioral Health

exposure to a chemical agent or toxin. Recruits and 

medical personnel suspected an airborne toxin, but 

none was detected. These examples of OMUS demonstrate that a perceived exposure can induce symptoms 

resembling an actual exposure.

The Goiânia radiation incident was a dramatic 

example of a co-occurrence of OMUS and a CBRNE 

event. Over 125,000 people demanded to be screened 

for radiological exposure following the news of radiological contamination.38 Screening identified only 

249 persons with any radiological contamination, but 

5,000 of the first 60,000 people screened had symptoms 

consistent with radiation sickness (vomiting, diarrhea, 

and/or rashes around the face and neck). None of the 

symptomatic persons were contaminated.

Chemical Warfare Agents

The Israeli experience with 18 Scud missile attacks 

during the Persian Gulf War involved both the effects of missile explosions and, at least initially, the 

perception of a possible nerve agent attack. One study 

of patients arriving in the emergency departments of 

11 local hospitals in Israel19 found that approximately 

332 of the 773 casualties (43%) were psychological 

casualties and an additional 209 (27%) had injected 

themselves with atropine because they feared the 

missiles contained nerve agent. After the first Scud 

attack, there were 365 casualties: 172 psychological 

casualties (47%), 171 cases of unjustified atropine 

injections (47%), and only 22 cases of physical injury 

(6%). Another study20 looked at patients reporting 

to the emergency department of a Tel Aviv hospital 

within 8 hours of a Scud attack. Of the 103 patients 

admitted, 70 had psychological distress (68%) and 19 

had unjustified atropine injections (18%); only 9 had 

direct injuries (9%). All these findings were among 

civilians, not soldiers. 

After the 1995 sarin attack in the Tokyo subway,33,39

over 5,500 people visited 280 medical facilities the day 

of the attack and the following week. Of these, 1,046 

were admitted as patients. Saint Luke’s International 

Hospital saw the most patients: 641 patients on the 

first day and 349 in the following week.39 Of the 641 

patients admitted to the emergency department on the 

first day, 111 were admitted to the hospital (4 severe 

cases, 107 moderate cases), and 530 mild cases were 

observed for 6 hours and then released. The patients 

with mild cases suffered mainly from eye problems. It 

is difficult to determine from the literature how many 

of the mild cases were psychological casualties.

Biological Agents

In 1994 two outbreaks of plague occurred in India: 

a bubonic plague outbreak in Maharashtra state, followed by a pneumonic plague outbreak 1 month later 

and 500 km away in Surat.40 Of the 5,000 suspected 

cases of plague, there were 167 confirmed cases and 55 

deaths.41 Unfortunately, no data are readily available 

on psychological reactions or rates of such reactions. 

However, there were observable effects on behavior. 

The local media fueled the anxiety with exaggerated 

reports.41,42 An estimated 400,000 to 600,000 people fled 

Surat, including hospital staff, private medical practitioners, and municipal workers.43,44 In Delhi, 1,200 km 

from Surat, people fashioned masks from available 

materials, and many bought and hoarded tetracycline, 

an antibiotic used to treat plague.45

In 2001, after the September 11th attacks and before 

the first of 23 anthrax cases,46 the media had already 

reported increased purchases of gas masks and ciprofloxacin (“cipro,” used to treat anthrax). After the 

anthrax mail attacks, there were increased patient 

requests for ciprofloxacin and anecdotal reports of 

increased prescriptions.47 Hospitals reported their already busy emergency rooms were filled with people 

anxious about anthrax, many demanding treatment.

The outbreak of SARS, a new and emerging infection, created much fear and anxiety. In Beijing, schools 

and universities were closed, hundreds of companies 

closed their doors, and some surrounding villages shut 

themselves off from contact with others.48 Rumors of 

neighborhoods being quarantined led to stockpiling of 

food.49 Although officials asked people to avoid travel, 

thousands of businesspersons, migrant workers, and 

college students left Beijing. In Taiwan, 160 doctors and 

nurses quit work at various hospitals, fearing both the 

disease itself and the inadequacy of infection control 

measures.50 SARS patients often spent hours in isolation between contacts with staff and were deprived 

of family visits, leading to complaints of sadness, 

anxiety, boredom, loneliness, and nonspecific anger 

and frustration.51,52 Fear and anxiety often waxed and 

waned with fever.51

One study measured the psychosocial effects of 

SARS on hospital staff in a Toronto hospital using 

questionnaires.53 Almost two thirds of the respondents 

reported concerns for their own or their family’s health. 

Factors associated with increased concerns were perception of a greater risk of death from SARS, living with 

children, personal or family lifestyle affected by SARS 

outbreak, and being treated differently by other people 

because of working in a hospital. Emotional distress 

was found in almost 30% of all responders and in 45% 

of nurses, who were most at risk for infection. Factors 

identified for significant association with emotional 

distress were being a nurse, part-time employment 

status, lifestyle affected by SARS outbreak, and ability 

to do one’s job affected by precautionary measures.
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Terrorism and Chemical, Biological, Radiological, Nuclear, and Explosive Weapons

Radiological Agents

The Three Mile Island (TMI) accident in Pennsylvania in 1979 demonstrated the importance of 

psychological effects following a CBRNE incident. 

According to the president’s commission that studied 

the accident, the only medical effect documented was 

mental distress.54 There were no cases of ARS, and the 

estimated exposure doses for people living within 10 

miles of TMI were approximately the dose of an average chest radiograph, much lower than the annual 

background radiation dose.55 Populations exhibiting 

the most distress were TMI workers, families with 

preschool-age children, and those living within 5 miles 

of TMI. Studies of TMI workers reported no long-term 

effects, only short-term acute effects. TMI personnel reported nausea, stomach troubles, headaches, 

diarrhea, sleep disturbances, and loss of appetite in 

greater frequency than did the control group. These 

symptoms are also common to the ARS prodrome, but 

TMI personnel were not exposed to radiation doses 

that would cause ARS.

Unlike the TMI accident, the 1986 Chernobyl accident in Ukraine did release significant amounts of 

radiation. Approximately 135,000 people were evacuated from a 30-km zone in the first 2 weeks after the 

accident. Most of these people had to be permanently 

relocated. In addition, an estimated 600,000 to 800,000 

“liquidators” were brought in to handle the emergency situation and subsequent cleanup operations.56

Although over 200 cases of ARS were recorded, the 

primary health effect was widespread psychological 

distress.57,58

In the 1987 Goiânia incident, two scavengers removed a cesium-137 teletherapy unit from an abandoned radiotherapy institute.59 While dismantling the 

unit, they accidentally ruptured the source capsule 

that contained radioactive cesium-137 powder. When 

the accident became public, the perceived threat of 

radiation exposure caused over 120,000 people (approximately 10% of the city’s population of 1.2 million) to be screened over a 6-month span for possible 

contamination.60 Residents and others in the city at 

that time felt sufficiently at risk that they took time 

off from work or came on weekends to wait in line to 

be scanned.38,61 Approximately 5,000 (8%) of the first 

60,000 people screened presented with symptoms that 

mimicked ARS (eg, rash around neck and upper body, 

vomiting, diarrhea), but none of these individuals 

were contaminated.38 Only 249 people had measurable 

radiological contamination.

Explosives

Acute psychological effects were reported in 50% of 

bomb-injured patients in one study.62 Another study 

reported that approximately 12% of the casualties 

presented with emotional distress, with another 6% 

presenting with medical problems (eg, angina, diabetes, headache, or asthma).63

Mental Disorders

Chemical Warfare Agents 

Most patients from the Tokyo sarin attack who were 

admitted to a hospital remained hospitalized for a few 

days. Some reported sleep disturbances, nightmares, 

and anxiety. Whether these symptoms were due to 

acute stress disorder or to exposure to nerve agent is 

unknown. In studies done 1 month after the event, 

nearly 60% of casualties reported suffering from 

postincident symptoms, including fear of using the 

subway, sleep disturbances, flashbacks, depression, 

nightmares, irritability, headaches, malaise, physical 

tension, and emotional lability and irritability.33,39

Follow-up questionnaires at 3- and 6-month intervals 

showed little decrease in the percentage reporting 

symptoms. Unfortunately, it is difficult to determine to 

what extent these symptoms were psychological effects 

and to what extent they may have been sequelae to the 

cholinergic effects of sarin exposure. Because most of 

the casualties from Saint Luke’s International Hospital 

were mild cases (suffering mainly eye symptoms), it 

is possible that many of the postincident symptoms 

were psychological.

Radiological Agents

Most of the 20 hospitalized Goiânia patients suffered from depression and anxiety.64 The 11 victims 

most seriously affected were moved to one hospital, 

where they were kept confined and isolated because 

of immunosuppression, and the medical personnel 

treating them wore protective masks. Both measures 

increased stress in patients. Uncertainty about future 

health effects also increased stress, as did the lack of 

information concerning the duration of their treatment 

and the long-term prognosis.

Nuclear Weapons

Of all CBRNE agents, nuclear weapons have the 

greatest destructive impact—they are the quintessential weapons of mass destruction. The atomic weapons 

dropped on Hiroshima and Nagasaki caused incredible devastation, outbreaks of local fires, and large 

numbers of dead, dying, and injured people.65 In interviews done after the war, approximately two thirds 

of survivors described psychological disturbances of 
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Combat and Operational Behavioral Health

intense fear, emotional upset, or depression. However, 

only a single incident of an apparent mass panic was 

reported at Hiroshima: a large group of frightened 

people in a park pressed some victims into a river, 

and several died.66

During the following weeks, survivors continued to 

witness the sight of severely injured people suffering 

from burns and blast injuries. In addition, there were 

outbreaks of ARS. The continued exposures to the 

devastation and human suffering served as a constant 

reminder to survivors and reinforced the psychological 

impact of the original event.65

LONG-TERM EFFECTS

Distress and Chronic Outbreaks of Multiple Unexplained Symptoms

Although acute OMUS has been widely studied, 

the possibility of long-duration and large-scale OMUS 

syndromes has only lately been suggested.67 In recent 

years, a number of different chronic syndromes (eg, 

chronic fatigue syndrome, environmental somatization syndrome, multiple chemical sensitivity syndrome, and sick building syndrome) have appeared, 

all characterized by multiple nonspecific symptoms 

(eg, fatigue, headaches, sleep disturbances, nausea, 

dizziness, muscle and joint pains, and difficulties with 

memory and concentration) that are not connected 

with specific infectious or toxic agents.68–70 In each of 

these syndromes, the patient attributes an invisible 

contaminant or infectious agent as the cause for the 

symptoms.

Military Experience

The military has seen several chronic OMUS syndromes, including Agent Orange syndrome, atomic 

veterans syndrome, and Gulf War syndrome.3 Agent 

Orange syndrome began when the media publicized 

an association between exposure of Vietnam veterans 

to Agent Orange and a reported epidemic of cancer 

and children born with birth defects. Epidemiological 

studies done by the Centers for Disease Control and 

Prevention found no evidence of increased incidence 

of cancer or birth defects in this population.71–73 However, an increased prevalence of depression, anxiety, 

alcohol abuse or dependence, and posttraumatic 

stress disorder (PTSD) was demonstrated in Vietnam 

veterans compared with subjects who had not fought 

in Vietnam.71 Another study found that symptoms of 

psychological distress were strongly associated with 

self-reported herbicide exposure. This group presented 

with more symptoms than were found in Air Force 

personnel actively involved in aerial spraying of herbicides.74 This suggests that Agent Orange syndrome 

might be more related to a perception of exposure than 

to actual exposure.

An estimated 200,000 Department of Defense personnel (both military and civilian) observed the early 

US above-ground nuclear tests.75 The external doses 

received by these “atomic veterans” averaged about 

0.5 rem, with many receiving no dose and only 1% 

receiving a dose greater than 5 rem (the maximum annual occupational dose). Several case studies of atomic 

veterans reported long-term psychological distress.76,77

Initially, troops at the Desert Rock V test seemed to go 

through the experience with equanimity,78 but many 

years later, an anecdotal study found that veterans 

reported vivid recollections of an atmosphere of tension and fear at the test sites and thought they had 

been ill-prepared.76

A cluster of functional somatic symptoms was reported in atomic veterans and dubbed the “radiation 

response syndrome.”77 The syndrome has two components: (1) a core belief that radiation had caused 

physical harm, and (2) functional somatic symptoms 

that appeared to be an expression of this belief. The 

radiation response syndrome belief system included 

the views “that men were dying, that doctors are of 

little help, that one doctor may exist who could help, 

that the government is to blame for their illness, and 

that people think they are crazy for blaming exposure 

to ionizing radiation for their illnesses.”77(p128) Radiation 

response syndrome resembles delayed-onset PTSD, 

but rather than reexperiencing the trauma as in PTSD, 

the veterans are preoccupied with radiation and its 

effect on their lives. 

Chemical Warfare Agents

Three years after World War I, approximately one 

half of gassed veterans claimed subjective complaints 

in medical examinations.79 When there were no objective findings, no compensation or pensions were 

paid, nor were these complaints included in statistics 

of permanent disabilities. There were reports of large 

numbers of men who had recovered from acute gas 

poisoning and had good physical examinations, but 

suffered from serious sequelae, most particularly 

of easy fatigability and difficulty breathing on exertion.80 This condition was variously known as effort 

syndrome, disordered action of the heart, and neurocirculatory asthenia. Chronic gas cases often involved 

acute attacks of breathlessness at night accompanied 

by nightmares, and patients usually reported insomnia 

and unrefreshing sleep.80
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Terrorism and Chemical, Biological, Radiological, Nuclear, and Explosive Weapons

A long-term study of sarin patients who had been 

hospitalized at Saint Luke’s Hospital found that 

somatic and psychological symptoms continued for 

5 years after the incident.81 A high rate of medically 

unexplained physical symptoms was reported. Eye 

symptoms, fatigue, muscle stiffness, and headache 

were all reported by more than 10% of the study 

population.

Biological Agents

Puzzling long-term effects were seen in the survivors of the 2001 anthrax attacks. Newspapers reported that survivors continued to exhibit symptoms 

of fatigue, shortness of breath, chest pains, memory 

problems, nightmares, and rage 6 to 12 months after 

their illnesses.82 Only one of the inhalational anthrax 

survivors was well enough to return to work at the 

time of the study. In the one published study of anthrax 

survivors 1 year after the attack, many of the survivors 

reported reduced health-related quality of life and 

psychological distress.83

Radiological Agents

No long-term psychological stress in TMI workers 

has been reported.84 However, TMI residents, compared to controls, displayed a significant amount of 

stress on several measures (performance; self-reported 

measures of anxiety, depression, and somatic complaints; physiological measures of urinary norepinephrine, epinephrine, and cortisol; disturbed sleep; 

and changes in immune system parameters) for up to 

6 years after the accident.85–87 The TMI symptoms were 

not the result of exposure to radiation but to perceived 

radiation threat, demonstrating that fear of exposure 

to radiation can cause significant distress and stress 

symptoms that can mimic symptoms of actual radiation exposure. 

The large number of people (~10,000) who lived or 

worked within 300 meters of the contaminated area 

in Goiânia exhibited fear, psychosomatic reactions, 

fear about the future, insecurity, and doubt about the 

effectiveness of government remedial measures.88 A 

public opinion poll conducted 6 months after the incident88 found that two thirds of both affected Goiânia 

residents and a control group living away from the 

contamination believed that Goiânia was still contaminated. Research conducted 3 years later showed that 

stress parameters were still increased and performance 

decreased both in nonirradiated individuals with perceived exposure (those living within 1 km of the area 

where contaminated waste from the incident had been 

stored) and in irradiated individuals from Goiânia.89

A variety of psychoneurological syndromes have 

been reported as sequelae of Chernobyl in the Russian 

literature.90–92 These syndromes are characterized by 

multiple unexplained physical symptoms including 

fatigue, sleep and mood disturbances, headaches, 

impaired memory and concentration, and muscle or 

joint pain. These syndromes were reported in liquidators who both had and had not experienced ARS.90,92

No significant correlations were found among physical 

symptoms, radiation dose, and physical examination 

data.92

Nuclear Weapons

Survivors of Hiroshima and Nagasaki were severely 

stigmatized, especially those with severe burns that resulted in scarring and keloids. Lifton described a “neurasthenic survivor syndrome” characterized by “persistence of symptoms of withdrawal from social life, 

insomnia, nightmares, chronic depressive and anxiety 

reactions and far-reaching somatization . . . in addition, 

fatigue, emotional lability, loss of initiative, and generalized personal, sexual and social maladaptation.”93(p504) 

A study of over 7,000 Nagasaki atomic bomb patients 

done 15 years later showed long-term psychological 

effects in approximately 7%, with the majority complaining of fatigue, lack of spirit, poor memory, and 

introversion.94 These symptoms were twice as common 

in survivors who had shown ARS symptoms and were 

related to severity of ARS symptoms.

Mental Disorders

Chemical Warfare Agents

PTSD has been reported in American World War II 

veterans exposed to mustard agent while participating in field trials and chamber tests.95 According to 

follow-up studies of the Tokyo sarin attack, conducted 

3 and 5 years after the accident by the National Police 

Agency and the National Research Institute for Police 

Science, reporting of somatic complaints—eye strain, 

weakened eye sight, and easy fatigability—remained 

relatively stable from the acute stage through both 

follow-up periods.33 PTSD symptoms still reported by 

14% to 18% of studied survivors included flashbacks, 

fear of the subway, intense distress at exposure to 

reminders of the attack, and avoidance of thinking 

about the attack. 

The casualties seen at Saint Luke’s were surveyed 

at 2, 3, and 5 years, using a questionnaire that asked 

about 14 physical symptoms, 8 eye symptoms, and 11 

psychological symptoms (symptoms of avoidance, hyperarousal, and reexperiencing).81 The most common 

symptoms across all time periods were eye symptoms: 

eye strain (33%–39%), dim vision (23%–26%), and 
602

Combat and Operational Behavioral Health

difficulties focusing (17%–21%). Physical symptoms 

(tiredness, fatigue, muscle ache, headache) were also 

common. Most of the psychological symptoms remained stable over the three time periods, with rates 

of 10% to 16% still being reported at the 5-year point 

for memory difficulties, depressed mood, avoidance of 

accident reminders, flashbacks, and fear in the subway 

or at the attack site. PTSD frequency, as determined 

by criteria in the Diagnostic and Statistical Manual of 

Mental Disorders, 4th Edition,

96 remained stable, with 

2% to 3% of patients meeting the criteria during the 

three time points. The incidence of partial PTSD (one 

symptom from each category) ranged from 7% to 9%. 

Because of the persistence of physical symptoms, a 

modified set of PTSD criteria (adding at least one 

medically unexplained physical symptom to the diagnosis) were developed, and 10% to 14% of patients met 

these criteria. The physical symptoms were reported 

to deteriorate following flashbacks and to improve 

during psychiatric therapy. The victims continued to 

be stressed by lack of government support, limited 

resources available for medical follow-ups, and a feeling of stigmatization.

Biological Agents

Several infectious disease outbreaks have been 

reported to cause both PTSD and a decreased healthrelated quality of life. For example, the majority of survivors of an outbreak of Legionnaires disease reported 

fatigue, neurologic symptoms, and neuromuscular 

symptoms 17 months after diagnosis.97 Health-related 

quality of life was impaired in seven of eight dimensions, and 15% of patients experienced PTSD. Similarly, 

survivors of acute respiratory distress syndrome have 

also reported PTSD and decreased health-related quality of life.98,99 Because most category A biological warfare agents cause acute respiratory distress syndrome, 

similar long-term effects should be expected.

Radiological Agents

A study conducted 8 years after the Chernobyl accident found that 44% of 1,412 Latvian liquidators had 

mental-psychosomatic disorders: depression (neurotic 

depression and brief depressive reaction), physiologic 

malfunction arising from mental factors, or unspecified disorders of the autonomic nervous system.100The 

actual numbers of mental-psychosomatic disorders 

might have been higher, but anxiety, PTSD, and sleep 

disturbances were not studied because of the coding 

scheme used.101 Two other studies of Chernobyl exposure found PTSD and PTSD symptoms.102,103

An epidemiologic study of over 4,700 Estonian liquidators found an increase in suicide, but no increases 

in cancer, leukemia, or overall mortality.104 Suicide 

accounted for almost 20% of mortality in the liquidator cohort. Reasons for the increased suicide rate are 

not currently known. However, data from Vietnam 

veterans with PTSD have demonstrated an increased 

risk for traumatic deaths, including suicide.105 Other 

studies demonstrating a variety of mental health disorders in Chernobyl liquidators support the speculation 

that fear of radiation might cause depression, PTSD, 

and other disorders associated with increased rates 

of suicide. The primary toxic agent appears to be fear, 

rather than radiation.

Explosives

Long-term psychological consequences after terrorist attacks with explosives have been reported. After 

the Oklahoma City bombing, 45% of the survivors 

suffered a postdisaster psychiatric disorder, including 34% with PTSD.106 Another study reported PTSD 

in 50% of the patients 6 months after a bombing.107

PTSD patients had a lower mean injury severity score 

(1.2) than did patients without PTSD (6.6). Nearly one 

in five civilian survivors of terrorist attacks (18%) in 

another study suffered from PTSD, while another 13% 

suffered from major depression.108 When broken down 

by severity of injury, PTSD was present in 31% of the 

severely injured, but in only 11% of the uninjured and 

8% of the moderately injured. The adjusted prevalence 

ratio for PTSD (severely injured/others) was 4.2. Similarly, major depression occurred in 22% of the severely 

injured, but in only 9% of the moderately injured or 

uninjured.108

Summary

Mass panic is not likely to occur in CBRNE incidents. Although mass panic can occur in situations 

involving limited escape routes, it will still probably 

be a rare event. Psychological effects are likely to cause 

large numbers of casualties following attacks using 

CBRNE weapons. Initial presentation may resemble 

combat stress casualties or may include a variety of 

nonspecific symptoms, such as difficulty breathing, 

dizziness, fatigue, headache, and sleep disturbances. 

Triage and differential diagnosis may be challenging 

in the initial stages. The number of psychological casualties could increase based on possible amplification 

of risk perception by mass media reporting. Unlike 

most physical injuries or illnesses caused by CBRNE 
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Terrorism and Chemical, Biological, Radiological, Nuclear, and Explosive Weapons

agents, psychological effects can be contagious. Given 

the history of postcombat syndromes, long-term effects 

are also very likely, and will be difficult to diagnose 

and treat. These chronic OMUS syndromes will also 

be greatly influenced by risk perception and mass 

media reporting. 

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