Psychosocial Responses to Biological and Chemical Terrorist Threats and Events:
Implications for the Workplace
Journal of the American Association of Occupational Health Nurses, 50 (4),
182-189.
Randal Beaton, Ph.D., E.M.T.
Research Professor
Department of Psychosocial and Community Health
Box 357263
University of Washington, School of Nursing
Seattle, WA 98195-7263
Shirley Murphy, R.N., Ph.D., F.A.A.N.
Professor Emeritus
Department of Psychosocial and Community Health
Box 357263
University of Washington, School of Nursing
Seattle, WA 98195-7263
Contact is Randal Beaton, Ph.D., E.M.T.
Department of Psychosocial and Community Health
Box 357263
University of Washington, School of Nursing
Seattle, WA 98195-7263
Phone: 206.543.8551
e-mail: randyb@u.washington.edu
The authors thank the following sources of support for this research:
1) R18 grant 0H03559 from the National Institute for Occupational Safety and Health
at the Centers for Disease Control and Prevention.
2) University of Washington, School of Nursing RIFP Award.
1
ABSTRACT
This article represents a selective review of what is known about the psychosocial
concomitants of natural and technological disasters. Data are drawn from primary and secondary
traumatic experiences and from the few available prior investigations of terrorist attacks on
civilians or employees, which employed either conventional, biological or chemical weapons
(BCW).
Even threats of terrorist attacks employing BCW will likely cause anxiety, adverse health
effects and an exacerbation of pre-existing psychiatric symptoms in both workers and employees
in part because these agents are/or may: Cause a massive number of casualties, unpredictable in
nature, difficult to detect and are the result of intentional, man-made and malevolent actions.
Finally, a series of specific recommendations are made to assist OHN’s to prevent and/or
remediate maladaptive psychological responses and psychosocial reactions in their workplaces
by educating themselves and their workforces, assisting in a risk assessment of the workplace,
disaster planning and policy formulation and psychosocial triage.
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INTRODUCTION:
In the aftermath of the deadly attacks on the World Trade Center and the Pentagon on
September 11, 2001, as well as the recent highly publicized anthrax cases, the general public and
even US public health officials are concerned. Much is known about the acute and chronic
impact of natural disasters on psychological functioning from prior investigations (Murphy &
Cowan, 1985; McCammon, Durham, Allison and Williamson, 1988; McFarlane, 1988).
Likewise, much is known about the psychological sequalae of combat often experienced by
soldiers in wartime (Deahl, Gillman, Thomas, Searly and Srinivasan, 1997; Gallers, Foy,
Donahoe and Goldfarb, 1988; Ursano & Norwood, 1997). However, less is known about the
psychological impact of technological disasters. Even less is known about the psychological
reactions to the threat of terrorist attacks employing biological or chemical weapons (BCW) or
the psychological impact of actual BCW terrorist events with large numbers of victims and an
even greater number of co-victims1. Biological and chemical weapons, along with nuclear
devices, are all considered Weapons of Mass Destruction (WMD). (The Soldier and Biological
Chemical Command [SBCCOM], 1999a). Nuclear, biological and chemical weapons all have
the potential to inflict a massive number of casualties.
The first section of this paper focuses on what is generally known about the
psychological consequences of natural and technological disasters involving civilians, and will
also include some findings from studies that have investigated the impact of combat exposure on
military personnel as well as the effects of repeated secondary trauma exposures in emergency
workers. The authors will also consider the lessons from the few investigations of previous
terrorist attacks on civilians employing chemical and bioweapons as well as the aftermath of the
Co-victims may include witnesses, family, friends and associates of victims as well as “exposed” rescue workers
and emergency health providers.
1
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conventional terrorist attack on civilian employees at the Alfred Murrah Federal Building in
Oklahoma City in 1995. Based on this selected review of the literature, some tentative
generalizations about likely psychological and behavioral responses to biological and chemical
terrorist attacks2 on nonmilitary populations will be made along with recommendations for
occupational and environmental health nurses. This review article relies heavily on exemplars in
the literature to help us to learn the critical lessons from past disasters so that we might avoid or
at least partially mitigate such untoward psychological and behavioral consequences in survivors
of any potential future BCW terrorist event.
The first exemplar is from the Gulf War a decade ago and describes civilian
psychological and behavioral responses to the imminent threat of a BCW event. During the Gulf
War, SCUD missiles were launched on civilian targets in Israel. The SCUD missile was
considered an inaccurate weapon, but when aimed at populations centers was likely to hit with
enough precision to cause damage and, if armed with chemical or biological weapons, massive
numbers of casualties. Israelis prepared for a potential BCW attacks and had to master the use of
gas masks. When missile alerts sounded, often at night, residents had to listen to radio
instructions as to whether they should go to air-raid shelters or sealed rooms as a defense against
a possible chemical agent. Researchers reported on the identified disorders of 773 Israeli
civilians taken to emergency rooms at 12 Israeli hospitals during or immediately following
SCUD missile attacks. Though the threat of BCW clearly existed, there were no chemical or
biological agents on any of the SCUD missile warheads. Nonetheless, 43% of those Israeli
citizens admitted to hospitals during the SCUD missile attacks were diagnosed as “psychological
casualties” and 27% of the total seen had mistakenly injected themselves with the nerve gas
2
This review article will focus on BCW and will not include a review of what is known about psychological
responses to the threat of or an actual nuclear or radiological agent, except incidentally.
4
antidote they had been provided (Bleich, Daycian, Koslowsky, et al, 1992). Another study of the
Israeli populace before, during and after the SCUD missile attacks, associated with the Gulf War
found a 250% increase in the risk for clinical depression during the period of the SCUD missile
attacks. Those at greatest risk were the less educated, middle-aged women in the Israeli
population. (Lormranz, Hobfoll, Johnson, Eyal & Zemach 1994).
DEFINING TERRORISM, BIOTERRORISM AND CHEMICAL TERRORISM
Terrorism is defined by the Federal Bureau of Investigation as “The unlawful use of force
or violence committed . . . . against persons or property to intimidate or coerce a government (or)
the civilian populations . . . . in furtherance of political or social objectives.” (SBCCOM, 1999a
p. 1-6). Bioterrorism is defined as a terrorist action that employs the use of naturally occurring
(or potentially modified) pathogens as a bioweapon(s) to infect and cause illness in a targeted
population (Gwerder, Beaton & Daniell, 2001). Terrorism using chemical warfare agents
usually involves the use of some harmful or lethal industrial or non-industrial chemical (or
chemical agents) that are somehow released or disseminated with the goal of causing massive
numbers of casualties, symptoms and/or death in a targeted population (SBCCOM, 1999b, M33).
The September 11, 2001 attacks in New York and Washington DC and the subsequent
anthrax incidents on the Eastern seaboard all targeted workplaces in the United States and
certainly met the Federal Bureau of Investigation (FBI) definition of terrorism and bioterrorism.
Most profoundly affected were those employees who were at work that day (or in the case of
anthrax), days and weeks of the events. The vast majority of the victims were simply employees
doing their jobs when the attacks occurred. Obviously, those companies or organizations who
had offices at the WTC or nearby on September 11, 2001 or those who had direct business
5
dealings with those housed at the WTC were actual victims or co-victims of the attacks. A
special set of victims were First Responders and Rescue workers dispatched to the WTC3 or to
the Pentagon. These employee groups and related co-victims felt and perhaps still feel a greater
sense of connection and were probably more likely to experience a more profound psychological
reaction than those who were not so intimately connected with the events of September 11, 2001
(Hanchar, 2001). Yet, in the context of these unforgettable televised (or worse yet – real life,
real time) images of the September 11, 2001 carnage and the aftermath, all Americans; many for
the first time in their lives, were confronted with the notion that we, as Americans, are vulnerable
– at our workplaces and in our communities in the US – our “Homeland”.
For many, along with this heightened sense of vulnerability came a sense of dread,
increased vigilance and the unfamiliar, (yet not really entirely novel) threats of domestic
biological and/or chemical weapon (BCW) attacks perpetrated by terrorists. Adding to this
apprehension was the acknowledgement by US government officials and public health scientists
alike that BCW events are sometimes difficult to detect and diagnose in a timely fashion. Many
of the likely chemical agents and bioweapon pathogens that terrorists are likely to employ are
colorless, odorless, silent and potentially lethal. While there really is no recent precedent in this
country, biological agents have actually been used as weapons in warfare for centuries (Gwerder,
Beaton and Daniell, 2001) and chemical agents such as mustard gas and phosgene were widely
used as weapons during World War I (Gilchrist and Matz, 1933). The potential for BCW agents
to instill fear in the general populace is magnified by their ability to inflict harm without being
readily detectable. There is the potential for panic, social unrest and economic dislocation in the
aftermath of an actual BCW attack. Some, but not all, of the biological agents pose the potential
3
Or, later to who were dispatched or served at “Ground Zero: (the remains of the collapsed WTC towers)”.
6
for person – to – person transmission (SBCCOM, 1999b). Not only are BCW agents sometimes
difficult to detect in a timely fashion, they are also difficult to defend against. Most civilians are
vulnerable to most, if not all, of these BCW agents (Tucker, 1997). Table 1 summarizes some
key potentially anxiety – provoking components of BCW agents likely to be used in terrorist
attacks. Yet, on the other hand, we now know that the symptoms, syndromes or diseases caused
by many of these BCW agents are not necessarily fatal. In fact, most of them result in
symptoms; syndromes or illnesses that are treatable and even, in some cases at least, may be
completely preventable (CDC, 2001). Finally, all of the known potential biological agents that
might be weaponized by terrorists have historically been effectively treated by the US public
health system and even, in the case of small pox for instance, effectively eradicated.
PSYCHOLOGICAL IMPACT OF BIOLOGICAL/CHEMICAL TERRORISM
The impact of biological and chemical terrorism can best be understood in the context of
the previous research, which has documented outcomes of exposure to a variety of traumatic
events. Traumatic events are typically unexpected and uncontrollable and can result in abnormal
reactions in “normal” individuals. By definition, exposure to traumatic events includes either
experiencing or being confronted with actual or threatened death or injury to self or others
(American Psychological Association [APA], 1994). Traumatic events that are abrupt and of
brief duration, i.e. lasting a few minutes or hours, are referred to as short-term (Type I) traumatic
events and are contrasted to Type II traumatic events that are prolonged, repeated, or ongoing
traumatic events (Terr, 1991).
Type I events include natural disasters (earthquakes, floods, and hurricanes), accidental
disasters (vehicular accidents and airplane crashes) and deliberately caused human-made
disasters (bombings, school massacres, arson fires, and terrorist activities). Certainly terrorist
7
campaigns, or a series of events, especially, if they are long-term, might also qualify as Type II
traumatic event(s). Previous studies have shown that deliberate intentional malevolent acts, such
as terrorist attacks, specifically designed to cause harm to others result in more severe
psychological consequences (Murphy, Braun, Tillery, Cain, Johnson & Beaton 1994). Before
we describe the psychological outcomes of trauma we will consider some relevant theoretical
models. To better understand likely and known psychological responses to threats of as well as
actual extreme stressors, such as a BCW incident, we will describe three theoretical models of
stress, trauma and coping in the next section.
HUMAN RESPONSES TO THREAT AND EXTREME STRESSORS: THEORETICAL
FRAMEWORKS.
Roy’s (1989) adaptation model hypothesizes that human responses to stressors include
both adaptive and maladaptive reactions. Importantly, not all behavioral and psychological
responses to potential and/or actual traumatic events are maladaptive. For instance, the primitive
biobehavioral “fight or flight” response might well be adaptive in the event of an actual chemical
attack. Furthermore, some apprehension and concern may well be appropriate responses to the
threat of BCW events, especially if they serve to motivate problem solving, planning and
thoughtful policymaking. It is important to note that there are large individual differences in the
way people respond to trauma presumably including threats of and actual BCW events. Some
individuals appear to be hardier than others and may be able to cope and function in the face of
extreme trauma, such as a BCW attack. Likewise, especially, in the aftermath, social support
seeking and communication are seen as healthy adaptive responses to trauma. In the immediate
aftermath of most disasters, including September 11, 2001, “the best” in humanity actually
8
becomes more evident. Strangers help strangers and society actually becomes more cohesive.
People adapt and divert their energies to respond to the disaster needs (Mileti, 2001).
On the other hand, disaster research has taught us that mass violence is the most
psychologically disturbing type of disaster and of those directly exposed to such a disaster,
perhaps two-thirds (67%) are psychologically impaired to some degree. Some examples of
maladaptive outcomes to extreme stressors includes adverse health conditions (both stressrelated and physical illness), increased absenteeism, immuno-suppression, disturbed sleep,
neuro-endocrine and cardiovascular dysregulation, increased substance use, substance abuse
and/or lapse and relapse. Also observed in the aftermath of large scale traumatic events in those
directly impacted are chronic problems in living, family strains and conflicts and job stress
(Green, 1994).
Lazarus and Folkman’s, (1994) theoretical model of coping and threat appraisal proposed
that, in response to a potential threat, humans in essence pose two questions to themselves: (1) Is
there a real threat? And, (2) if there is a real threat, can I cope with it? In the aftermath of the
terrorist attacks on the US on September 11, 2001 and the subsequent anthrax bioterror incidents,
the answer to the first question to this threat appraisal is now “possibly”, with varying degrees of
uncertainty and ambiguity. One might conceive of the subjective threat appraisal process as a
continuum extending from a minimal, or only theoretical threat, to a very real imminent threat
(such as an Israeli resident might have felt during a SCUD missile attack). An individual’s
response to the second threat appraisal question depends not only on one’s answer to the first
question, (is there a threat?), but also on the nature of the BCW threat and the appraised
possibility/probability of an actual event in their community. Their appraisal of whether they can
cope with a specific threat clearly depends on a variety of factors including accurate, up-to-date
9
information about the prevention and remedial treatment efforts in response to a BCW attack.
The answer to the threat appraisal question also depends on the risk profile and vulnerability of a
particular workplace.
In the aftermath of a major BCW attack, potentially with massive casualties, survivors
will likely evidence meta-cognitive changes characterized by Janoff-Bulman (1992) as “shattered
assumptions”. These “shattered assumptions” are that: (1) the world is safe, (2) that the world is
predictable and (3) that “bad things do not happen to good people”. Operating without these
fundamental cognitive assumptions, people are more likely to feel constant threat as well as
alienated and psychologically distressed. If these BCW threats are numerous, inescapable and/or
uncontrollable punishing attacks, civilian survivors might show signs of learned helplessness,
demoralization and depression (Seligman 1975).
PSYCHOLOGICAL RESPONSES TO PRIOR BCW TRAUMATIC EVENTS:
Three Mile Island (TMI)
TMI is an example of a much-studied technological disaster event that resulted in
enduring psychological effects on those who lived nearby. TMI was really the first technological
disaster, which lead researchers to conclude that there was something clearly “different” about
man-made, technological disasters. On March 28, 1979, Pennsylvania as well as residents in
nearby states were threatened by a series of operational problems at the TMI nuclear reactor.
Community responses were assessed to the potential meltdown of the nuclear reactor and
radioactive releases from TMI. TMI exposed community residents to both actual traumatic
events (radioactive releases) and to the on-going threats of more releases, and even to the threat
of a catastrophic plant “meltdown”. The resultant adverse health effects on those in the
surrounding community could best be characterized as chronic stress syndromes – those who
10
lived near TMI reported more anxiety, more somatic symptoms and feeling more alienated.
Investigators also documented psychophysiological dysregulation in nearby community residents
for up to five years following the containment and clean-up of TMI (Baum, Fleming, and Singer,
1983). It is worth noting that TMI was an unintentional man-made technological disaster.
The Sarin Gas Attack On The Tokyo Subway
On March 20, 1995 eleven 20 ounce vinyl bags of sarin, a deadly neurotoxin, were placed
on five different trains of Tokyo’s heavily traveled subway system. Only nine of the bags were
punctured and released their contents. The sarin nerve agent attack was an intentionally caused
chemical terrorist event that highlighted the many challenges that will confront both First
Responders and community residents in the aftermath of a BCW/WMD attack. Although the
chemical agent was of poor quality, the dissemination inefficient and only a small amount of the
toxic nerve agent was released, 13 people died, over 1000 experienced some degree of acute or
chronic nerve gas exposure and another 4500 were considered “psychological casualties”. The
latter group of “worried well” individuals only thought they were experiencing symptoms of a
sarin gas exposure. According to one Associated Press report, over 50% of those involved in the
1995 sarin nerve gas attack still reportedly suffered some form of physical or mental disability
over three years later (Yamaguchi, 1998). Since the incident was not recognized as a nerve agent
exposure for several hours a mass decontamination was not performed. As a result, 135
firefighters and EMS personnel (10% of the responders) suffered secondary contamination and
20% of receiving hospital’s staff suffered effects from secondary exposure (Okamura, Suzuki,
Fukuda, et al., 1998).
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PSYCHOLOGICAL RESPONSES TO INTENTIONAL TERRORIST INCIDENTS:
The Oklahoma City Bombing
The bombing of the Alfred P. Murrah Federal Building in Oklahoma City on April 19,
1995 was the most severe incident of terrorism ever experienced in the United States prior to the
September 11, 2001 attacks on the World Trade Center in New York City and the Pentagon. A
large conventional incendiary device (a bomb) exploded outside the Murrah Federal Building.
The device, detonated by a terrorist (or terrorists) killed 168 people, including 19 children. The
Oklahoma City event, although it did not involve BCW, has been studied extensively and
provides valuable information pertaining to both human responses to terrorist events as well as
providing guidelines for health providers’ responses needed to assist affected individuals and
communities. For example, Maningas, Robison, and Mallonee, (1997) documented the
emergency medical response (EMS) efforts used to treat the non-fatally injured (93% of those in
the building at the time of the bombing). The post-event survivor’s emotional distress was
profound; 45% of all adult survivors experienced a post-event psychiatric disorder (pre-event
rates were controlled in the study design), and, in addition, 34% met diagnostic criteria for posttraumatic stress disorder (PTSD). The onset of PTSD symptoms was sudden and very unusual,
with 76% of those exposed, reporting same day onset (North, Nixon, Shariat, Mallonee,
McMillen, Spitznagel and Smith, 1999). In a follow-up study conducted 1 and ½ to 3 years after
the blast, 30% of the injured in the Oklahoma City bombing (n=494) reported being diagnosed
with audiologic deficits, anxiety, and depression. These findings suggested the occurrence of
both delayed and chronic PTSD as well as serious psychological consequences of impaired
hearing. The most frequently used health services post-event was counseling (63%) (Shariat,
Mallonee, Kruger, Farmer and North, 1999).
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Primary And Secondary Trauma Responses In Emergency And Health Care Personnel.
According to Figley (1995), secondary traumatic stress (STS) is the natural consequent behaviors
and emotions resulting from knowing about a traumatizing event experienced by a significant
other – the stress resulting from helping or wanting to help a traumatized or suffering person.
STS differs from a primary stress response because of the indirectness of the experience with the
event. Limited data comparing these two phenomena suggest that individuals in either group
may meet one or more DSM IV criteria (APA, 1994) for PTSD. In addition, or in place of
PTSD, emergency/rescue personnel may experience burnout, physical illnesses, interpersonal
problems with colleagues, and erosion of job performance. Additionally, rescue workers may
need to contend with large numbers of “worried well” who may make it difficult to reach and
treat victims (Okumura, Suzuki, Fukuda, et al., 1998).
LIKELY MALADAPTIVE RESPONSES TO BCW EVENTS
Domains Of Functioning Affected By Traumatic Events.
Although responses to traumatic events vary widely, human adaptation to loss is lasting,
rather than brief duration, and can be accompanied by adverse health consequences (Green,
1994; Murphy, DasGupta, Cain, Johnson, Lohan, Wu and Mekwa, 1999; North et al., 1999). A
body of research findings resulting from Type I traumatic events that might also be relevant for a
BCW event identifies four major domains of human responses following BCW exposure: (1.)
Emotional responses include shock, terror, guilt, horror, irritability, anxiety, hostility, and
depression. (2.) Cognitive responses include inability to concentrate, confusion, self-blame,
intrusive thoughts (flashbacks) about the experience, decreased sense of self-efficacy, fear of
losing additional control over life events, and fear of reoccurrence of the event. (3.) Biological
responses include sleep disturbance (insomnia, nightmares), exaggerated startle response, and
13
psychosomatic symptoms, and (4.) Behavioral responses include avoidance, social withdrawal,
interpersonal stress (decreased intimacy and lowered trust in others) and substance abuse. All of
these maladaptive responses profoundly affect individuals’ coping abilities and Type I Posttraumatic reaction frequently include all four domains (Green, 1994, Meichenbaum, 1994;
Murphy, Braun, Tillery, Cain, Johnson and Beaton, 1999; Shariat, Mallonee, Kruger, Farmer and
North, 1999)
Maladaptive Mental Stress Disorders.
In response to an extreme stressor such as a BCW attack an individual may experience an
Acute and/or Post-traumatic Stress Disorder(s) (APA, 1994). The trauma exposure criteria for
Acute Stress Disorder and Post-traumatic Stress Disorder (PTSD) are identical: People are
exposed to a traumatic event which (1) involves actual or threatened death or serious injury, or a
threat to the physical integrity of self or others and (2) the person’s response (to this traumatic
event) involves intense fear, helplessness or horror . . . . (APA, p. 431). To meet APA diagnostic
criteria for an Acute Stress Disorder (ASD), an individual must evidence several dissociative
symptoms for at least two days following traumatic exposure, which might include a subjective
sense of detachment or “emotional numbing”, a reduced awareness of their surroundings (e.g.
“being in a daze”), experiencing the world as “unreal” or “dreamlike” and an individual with
ASD may also have difficulty recalling specific details of the event (APA, 1994, p. 492)
There is some evidence that a prior history of psychiatric disorders or certain personality
characteristics might predispose certain individuals to PTSD or other stress-related symptoms
(McFarlane, 1998). However, one tenant from the research on etiology of PTSD is that the
nature, magnitude and scope of the traumatic event or disaster – especially when it is massive –
is usually more important than a history of mental disorders, personality variables or
14
demographic variables (Green, 1994). One important point for OHN’s, is that they may not be
able to predict who, how and to what extent specific individuals will evidence maladaptive
emotional reactions in the face of an actual BCW attack.
Though they are generally considered to be less severe, adjustment disorders to stressors
such traumatic events can also occur (APA, 1994). These adjustment disorders may be either
acute or chronic and are associated with depressed mood, anxiety and/or disturbances of conduct.
The distress associated with adjustment disorders is, by definition, in excess of what would be
expected from exposure to a particular stressor. It is also possible that a BCW event could
precipitate another anxiety syndrome such as a panic disorder, a major depressive episode or
even, more rarely, a psychotic disturbance. Table 2 summarizes some of the likely maladaptive
psychological reactions and/or mental disorders that might arise due to threats and/or actual
BCW events.
There are a number of diagnostic interviews as well as valid and reliable paper and pencil
tests that have been used to assess Acute and Post-traumatic Stress Disorder in various
populations. For example, the Stanford Acute Stress Reaction Questionnaire has been used to
measure and document symptoms of an acute stress disorder (Cardena, Koopman, Classen,
Waelde, and Spiegel, 2000) and the Clinician Administered Dissociate Stress Scale (CADSS)
has been used to assess the “depersonalization” and “de-realization” often noted in persons with
acute stress disorder (Bremmer, Krystal, Putnam, Southwick, Marman, Charney, and Magure,
1998). In the diagnosis of PTSD a structured interview, the Clinician Administered PTSD Scale
(CAPS) has been developed and widely used (Blake, Weathers, Nagy, Kaloupek, Klauminzer,
Charney, and Keane 1990a). A number of paper and pencil tests are also available to assess
post-traumatic stress symptomatology including the Keane (PK) PTSD scale of the MMPI
15
(Keane, Malloy, and Fairbank, 1984), the Trauma Symptom Inventory (Briere, Elliott, Harris,
and Cotman, 1995) and the brief 15 item Impact of Event Scale (Joseph, 2000). It is important to
note, however, that these interview schedules and psychometric tests have been used little, or not
at all, with victims of BCW.
If there has been an actual exposure to a biological or chemical agent, it will be necessary
to conduct a differential diagnosis to rule an organic symptom of the particular biological or
chemical agent. While biological and psychological symptoms of a BCW attack are not
mutually exclusive, during the acute phase such a failure to accurately diagnose could prove
fatal; e.g. motor agitation as a symptom of anxiety disorder versus neurotoxin exposure. On the
other hand, confusing anxiety symptoms with BCW in civilians who may have been present,
witnessed or informed or near a BCW attack, may result in large number of “worried well”
individuals who will either overwhelm the emergency medical system (e.g. the four thousand
plus hospital “walk-ins” following the sarin gas attacks in the Tokyo Subway) and/or who
receive unnecessary treatment (inappropriate use of antibiotics).
THE ROLE OF OCCUPATIONAL HEALTH NURSES
Given that the threat of terrorist BC events on US workplace(s) is real and since any
BCW event will likely have profound psychological and behavioral consequences, what can and
should occupational and environmental health nurses do?
Educate
Nurses must educate themselves, the public (who are potential consumers of care) and
current clients. Knowledge is generally more reassuring than rumor and misinformation.
Perhaps the most reliable and up to date information on the Web is provided by the Centers for
Disease Control at www.cdc.gov with a direct link to bioterrorism updates at www.bt.cdc.gov (e.g.
16
Anthrax is not contagious). Regarding chemical weapons, for instance, the effects of most nerve
gasses released out of doors are attenuated rapidly since they are volatile and, depending on
atmospheric temperature, may evaporate (SBCCOM 1999b).
Risk Assessments
Occupational health nurses are uniquely qualified by virtue of their health care training,
and by their preparatory coursework in toxicology. Furthermore, they are positioned in the
community to assess the risk of BC terrorist events at their workplaces. While no US workplace
is immune from such BCW threats, certain industries, corporations and sites might be targeted
for terrorist BCW attacks based on their symbolic value, the products they produce or the service
they provide. Because of their training and increasing knowledge of BC weapons, occupational
and environmental health nurses might well assist in early diagnoses of clandestine bioweapon or
chemical attacks on their work sites on the basis of worker signs/symptoms and/or symptom
clusters in groups of workers.
Policy Formulation
Occupational and environmental health nurses also have the knowledge and training to
assist management in the formulation and implementation of effective policies to respond to the
threat of biological and chemical terrorism; e.g. such policies at a minimum should include plans
to contact and coordinate their diagnostic efforts with local health and/or law enforcement
agencies. Your employer should have a proactive emergency plan to respond to an actual BC
attack or even to the credible threat of such an attack. A corporate entity needs to speak with one
– informed – voice about the level of threat or the post-disaster response plan. Occupational
health nurses have the knowledge and expertise to assist management in these efforts.
17
Psychosocial Triage
Finally, many occupational and environmental health nurses also have the mental health
training and all possess the requisite psychosocial skills needed to reassure most apprehensive
workers (the “worried well”), and to recognize the signs and symptoms of more serious
psychiatric disorders such as PTSD or severe depression, in survivors who may be actual victims
or co-victims of a BCW event. The latter may need and benefit from short-term counseling
and/or debriefing. Debriefing, a popular, though controversial intervention can be offered on-site
(or off-site) shortly after a BCW disaster. Psychological responses to any traumatic event, like
grief, are highly idiosyncratic; nonetheless, Table 3 shows some of the likely time frames and
related interventions for BCW threats and events. However, there are a number of commonalties
in human reactions to trauma that have been addressed in this article that might help you, your
employer, and your employees, to better cope with BCW terrorist threats and to anticipate the
acute and long-term reactions of your employees (or managers) to a BCW terrorist event.
18
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Table 1.
Potentially Anxiety Provoking Components of Biological Chemical Weapon Threats.
Biological or chemical weapon agents are/or may be:






Life threatening, dangerous agents.
Uncertainty and unpredictability – when, where, what?
Ambiguous – Is small pox (Variola virus) available as a bioterrorist agent? If I was
vaccinated as a child (before 1972) am I vulnerable?
Imperceptible, Undetectable – as least some chemical and all biologic agents are
invisible, odorless, colorless and silent; human (or animal) signs and symptoms may be
first (or only) clues.
Man-made Technological Disasters vs. Natural
Intentional Malevolent Disasters vs. Unintentional.
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Table 2.
Potential Maladaptive Psychological Responses and Symptoms of Victims, Worried
Well and Other Witnesses and Co-victims to Threats of and Actual BCW Attacks.
Actual BCW attacks – Mental Disorders
Maladaptive Responses to
BCW Threats
Anxiety
Depression
Panic
Immuno-suppression
Insomnia
“Hysteria”
Stress – related disorders
Major depressive episode
Mental Disorders Arising from Actual BCW Attacks
Chronic PTSD Symptoms –
acute or chronic or delayed
De-realization
Re-experiencing trauma
Decreased concentration
Avoidance of trauma
reminders
Dissociative symptoms
Hyper-vigilance
Irritability
Nightmares
Last more than 2 days, less than 4 Lasts at least a month
weeks
Acute Adjustment disorders
Heightened arousal to
reminders of event
Other anxiety disorder
Chronic Adjustment
disorders
Major depressive episode
Major depressive episode
Substance Abuse
Substance Abuse
Acute Stress Disorder Symptoms
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Table 3.
Timing of Psychosocial Interventions for Biological/Chemical Terrorist Threats and
Events.
Timeframe
Pre-event: no specific threat
Pre-event; credible threat
Intervention
Education; reassurance; perspective on risk
Focused education on agent; highlight disaster
policy and planning
First priority is physical health of survivors;
implement disaster plan – will depend on
nature of agent.
Consider debriefing or one-to-one crisis
counseling for survivors; normalizing
Counseling available to treat ASD or other, 
syndromes emerging
Long-term psychotherapy and/or psychotropic
medications.
Peri-traumatic (minutes – 24 hours)
Peri-traumatic (48 – 72 hours)
Acute: Days – one month
Chronic: months – years
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In Summary:
“What does this mean for Workplace application?”
1. Both biological agents and chemical weapons (BCW) could potentially be used in future
terrorist attacks on US workplaces and communities.
2. Threats of BCW terrorism may lead to anxiety, adverse health effects, and the exacerbation
of psychiatric symptoms and syndromes in both workers and managers.
3. Actual BCW attacks will likely cause both acute and chronic mental disorders in a significant
number of surviving victims who may also be employees or employers.
4. OHN’s can help prevent and/or remediate maladaptive psychological responses by educating
themselves and their workforce(s) assisting in a risk assessment of the workplace, disaster
planning, assisting management in policy formulation and psychosocial triage.
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