Center for the Study of Traumatic Stress

Understanding the Effects of Trauma and Traumatic Events to Help Prevent, Mitigate and Foster Recovery for Individuals, Organizations and Communities A Program of Uniformed Services University, Our Nation’s Federal Medical School, Bethesda, Maryland • www. usuhs.mil/csts/ Psychological and Behavioral Issues Healthcare Providers Need to Know when Treating Patients Following a Radiation Event

Introduction Traumatic Stress Disorder (PTSD) are the disorders An attack using radiation will create uncertainty, fear, and most people think of in connection with trauma, major terror. Following the detonation of a Radiation Dispersal depression, increased substance use, family conflict, and Device (RDD) the management of acute psychological and generalized anxiety disorder are also encountered. behavioral responses will be as important as the treatment It is important to remember that people with no prior of RDD-related injuries and illnesses. history of psychiatric illness are vulnerable to psychiatric Radiation is a dreaded threat, usually seen as illness after a terrorist exposure. In the aftermath of catastrophic and fatal. Radiation is invisible, odorless and the Oklahoma City bombing, nearly 40% of those unknown. These ingredients stimulate worst-case fantasies. who developed PTSD and depression had no previous People must rely on health care providers and scientists to psychiatric disorder. Those at high risk of developing determine whether or not a person has been contaminated. psychiatric disorders include: Radiation exposure may not be manifest immediately. The ■ those directly exposed (e.g., people near the blast and health effects of radiation can be delayed in time, not only those participating in rescue and recovery operations of affecting those exposed but also future generations. Those people and remains), who have been exposed or anticipate possible exposure feel ■ a sense of vulnerability, anxiety, and a lack of control. The those who were more vulnerable before the event due to common lack of consensus among experts can increase existing mental illness, public fear and anger. ■ those who suffered resource losses and disruption of After a terrorist event there are three groups of their social supports after the event. psychological responses: those who are distressed; those There have been a number of technological disasters, who manifest behavioral changes; and those who may terrorist attacks, and use of novel weapons in the context develop psychiatric illness. Distress following a radiation of war which suggest that healthcare providers’ offices, release will be common and manifest as sadness, anger, medical clinics, and hospitals will be deluged with fear, difficulty sleeping, impaired concentration, and symptomatic and asymptomatic patients seeking evaluation disbelief. Psychological distress after a radiologic icident and care for possible contamination following a radiation may also manifest as somatic complaints for which no event . Some of these patients will be diagnosed as having diagnosis can be found (often referred to as “MIPS” acute radiation sickness, others will have diagnosable — Multiple Idiopathic Physical Symptoms. These patients conditions unrelated to radiation, and a large number should be managed by general health care providers. Some will be found to have symptoms for which no etiology individuals will manifest changes in their behavior such as can be found. A very conservative estimate of unexposed: decreasing travel, staying at home, refusal to send children exposed patients seen in medical settings is 4:1. In the acute to school as well as increased smoking and alcohol use. aftermath, many unexposed patients will fear that they For the vast majority of people, distress and psychological have been exposed because they will misattribute signs and and behavioral symptoms related to the traumatic event symptoms of autonomic arousal to radiation. In the longer exposure will diminish over time. term, patients will present to primary care providers with For others, however, symptoms will persist and affect multiple somatic complaints for which no etiology can be function at home and work, and may result in psychiatric determined. Attachment A suggests strategies for managing illness. While Acute Stress Disorder (ASD) and Post- these patients.

Disaster Response Education and Training Project, Center for the Study of Traumatic Stress For more information see www.usuhs.mil/csts/ I. Healthcare Providers and Mental Health Care after a Referral to a mental health specialist is usually experienced Radiation Event as stigmatizing. The patient may feel that the physician Following a radiologic event, people will likely turn has missed some important clue of contamination and is to healthcare providers for information and guidance. dismissing him prematurely. For example, following the 2001 anthrax attacks, 77% of The establishment of an “Emergency Services Extended a representative sample of Americans reported that they Care Center” (ESECC) offers an important means of would trust their own doctor most as a reliable source of monitoring patients, who remain fearful and are not information. reassured by negative findings. In the event that a patient Healthcare providers play a key role in determining how is misdiagnosed, the patient can be accompanied back to patients and the general public respond to a radiological the Emergency Department. Patients with minor physical terrorist event. A well-organized, effective medical response problems who cannot return home can be referred here. will instill hope and confidence, reduce fear and anxiety, Ideally, there would be simple tasks that the patients can and support the continuity of basic community functions. perform while in the ESECC will help them transition out Healthcare providers are also subject to fear and terror. of the patient role and restore their sense of control. Absenteeism, flight, refusal to see patients, and other fear-organized behaviors have been reported following III. Early Psychological Interventions infectious disease outbreaks (such as the outbreak of Early psychological interventions (psychological first pneumonic plague in Surat, India) and other instances of aid) are provided in the first hours, days, and weeks after new or unfamiliar, life-threatening agents. exposure to a terrorist event. The most important element Some healthcare providers are prompted by concerns of psychological first aid is good medical care. In addition, for their personal safety. At times health care providers, like psychological first aid includes: others, have fled their health care responsibilities. Many of those who abandon their responsibilities do so because they Psychological First Aid feel they need to protect their families, often by evacuation. ■ Reduce physiological arousal – encourage rest, sleep, Ensuring that health care providers understand normalization of eat/sleep/work cycles radiation and countermeasures for protection can minimize ■ role abandonment. Perhaps most importantly, health Provide food and shelter in a safe environment care providers are more likely to provide patient care if ■ Orient survivors to the availability of services/support. they believe that their families will be taken care of in ■ Facilitate communication with family, friends, and their absence – e.g. are given potassium iodide, etc. The community. availability of ongoing telephone contact with families ■ Assist in locating loved ones and dedication of personnel to assist health care provider’s families will be reassuring to health care providers and help ■ Keep families together and facilitate reunions with loved them focus on their mission. ones ■ Provide information and foster communication and II. Triage and Initial Disposition education. Triage and disposition is challenging. For example, in ■ Observe and listen supportively to those most affected the 1987 Cs-137 accident in Goiânia, Brazil, 8.3% of the first 60,000 people screened, presented with signs and ■ Decrease exposure to reminders of the traumatic event symptoms consistent with acute radiation sickness: skin ■ Advise decreasing watching/listening to medial coverage reddening, vomiting, diarrhea, etc. although they had not of overly traumatic images and sounds (e.g., people been exposed. jumping out of buildings, victim stories) The term “worried well” and similar disparaging terms ■ Educate patients to check rumors with available should never be used. When labels suggesting “it’s all in information resources your head” are used, patients feel stigmatized and that ■ their health concerns have not been taken seriously. The Use established community structures to encourage use of such labels contributes to mistrust of the medical social conduct and education (e.g., faith-based community and a loss of its credibility. A non-stigmatizing institutions and businesses triage labeling system such as “high risk”, “moderate risk”, ■ Distribute flyers and host websites “minimal risk” conveys continued concern and monitoring ■ Encourage talking to and involvement with the which is reassuring to patients. patients natural social supports such as families, Mental Health professionals, ideally psychiatrists due friends, neighbors, and coworkers. This will encourage to their background as physicians, should be an integral discussion of fears, interpersonal support, and early part of the teams that perform initial screening and triage. detection of persistent symptoms. ■ Offer reevaluation if symptoms persist. iodide and other protective mechanisms can be ■ Educate about the expected natural recovery that occurs substantial. for most people over time. ■ Patients presenting with multiple somatic complaints ■ “Debriefing” is a controversial acute intervention. to primary care provider may have physical illness, or Appendix B discusses it in more detail. this may be an expression of distress, depression or demoralization. Accurate differential diagnosis and IV. Health Care: Evaluation and Diagnosis management of these individuals will require education of primary care providers. ■ Psychological and behavioral issues of a radiation release from an RDD will generally far outweigh the ■ Lack of baseline health data in exposed populations physical illness management problems. will lead to the misattribution of illness to radiation exposure by individuals and communities. ■ Depression, bereavement, family conflict, and somatization will be the more common psychiatric ■ Those with the additional negative life events, presentations than posttraumatic stress disorder either before or after an RDD event, will have more (PTSD). psychological distress and psychiatric illness. ■ Increased smoking and increased alcohol use can be V. Patient Education expected, at least in the short run. ■ Repeated education about risks and protective ■ Sleep disturbance, hypervigilance, decreased countermeasures will help diminish fear, concern, and concentration, and uncertainty will be common early distress. psychological distress symptoms. These should be managed by education, counseling and perhaps brief ■ Health care providers should anticipate questions about use of hypnotic medication for sleep. the safety of their food and water supplies and whether homes are contaminated. ■ Uncertainly about health effects should be recognized and not minimized in communicating to patients and ■ Educate patients that distress is universal and that the public. they may experience common responses such as sleep disturbance, loss of appetite, and diminished ■ The principles of medical care and management of the concentration that should resolve over the next several patient present with medically unexplained symptoms weeks. If these symptoms persist or begin to affect their (MUPS ) include: function at work or home, they should return to their 1. Carefully assess and record the specifics of the health care provider. patients’ concerns. ■ Fears and preoccupation with cancer will remain high 2. Establish follow-up/appointments rather than for years. Responding accurately, empathetically and “return if there’s a problem”. recognizing what is not known is important. 3. Consult medical management as appropriate. ■ Many people fear radiation. The images and history 4. Listen for patient fears and concerns. attached to the issues of radiation and nuclear power enhance these fears. ■ Patients do not process or remember information well when they are very frightened. Handouts on radiation ■ Patients should be counseled to expect to hear that summarize key points and instruct on how to get conflicting views by experts and, ideally, how to sort follow-up should be used. through it. ■ Many people will be unsure if they have radiation- ■ Health care providers should understand the basic areas related illness (up to 50% of those in contaminated of disagreement about radiation’s health consequences areas). and be ready to explain them to patients in a very straightforward and simple manner. Uncertainly ■ Both men and women will be worried about damage about health effects should be acknowledged and not to their genetic material and potential harm to future minimized in communicating to patients and the public. generations. ■ The concept of a “threshold dose” of radiation below ■ Negative life events occurring after an attack increases which risk is not changed is difficult for many to risk for psychiatric illness, illness, and injury. understand. Similarly the concept of “half life” is not ■ Distress is decreased by reinforcing self-efficacy and easily transmitted to communities. Simple metaphors providing information that can be used to protect or other messages to explain these complex scientific oneself and ones family. ideas (such as liquids evaporating at different rates) ■ The psychological value of distributing potassium must be developed for healthcare providers to use with their patients (as well as appearing in mass media ■ Contamination of food supplies, in particular milk and campaigns.) ethnically important foods (e.g., reindeer in Norway ■ Stigmatization of those exposed or traveling from following the Chernobyl disaster) create acute and long- contaminated areas can be expected. This will affect term education needs and potential health surveillance the relocation and entry of new students into school needs. systems. ■ Contaminated communities may manifest cohesion or ■ Outreach health education to school systems, parent- anger, low morale, and decreased social service due to teacher education programs and through school nurse distress and economic losses. training can allay community anxiety. ■ Relocation of families is complicated and requires particular attention to familial needs and social justice. VI. Special Issues (Children and Pregnant Women) Maximizing the choice of families is important. Some (perhaps 10%) will not want to move. ■ Parental concern for children will be high. This will be true for children exposed and not exposed. ■ Expect concern over whether there is equitable distribution of health care resources to those affected ■ Reports by parents of child distress, fears, and worries or believed to be affected (food, healthcare, etc). A contain both accurate observations and the fears of the perception of inequity will stress social fault lines and parent. may divide communities. ■ Direct assessment of children and adolescents is ■ The rationale underlying prioritization of services must important to determine the child’s mental health be explained to the public and must be reasonable to because of the high levels of distress in the parents. those designated as lower priority. ■ Pregnant women and women with small children ■ Expect and plan for ongoing health surveillance for will have high concern following a radiation incident. months to years. Pregnant women may seek abortion to avoid expected or feared possible child malformations. Special ■ Fears of radiation will mobilize both heroism and education and counseling will be needed. avoidance in first responders. Both can have important positive or negative effects on performance. VII. Public Health and Mental Health ■ Distribution of protective mechanisms including potassium iodide must be closely watched for abuse and ■ Establishment of a clinical registry and appropriate exploitation. health surveillance are important psychological interventions. Patients who have their contact ■ Stress in and around contaminated areas is increased by information recorded in a database will feel more the often present need to stay in the location due to jobs assured that follow-up will be available. or inability to sell one’s home. This will have long-term psychological and possibly physiologic health costs. ■ Smoking cessation programs can be an important public health intervention. APPENDIX A ■ Handouts on stress and fear management techniques Communication Between Primary Care Providers and and activities should be available for distribution. Patients: Education Strategies after an RDD Event ■ Public health outreach to senior citizens will be important since their distress may heighten their Background withdrawal and staying at home. Door-to-door contact ■ The virtual imperceptibility of low-level radiation programs for this group and those with chronic medical exposures may cause many to develop persistent health needs who stay at home will be needed. concerns or to arbitrarily link idiopathic symptoms to ■ Family concerns about genetic effects on future benign or improbable exposures. generations will be high. ■ Over 90% of the general population will visit their ■ People will want to move away from contaminated areas primary care provider each year, making primary care both acutely and over time. a crucial setting for dissemination of accurate health ■ Many will believe the federal government should pay for risk information following suspected community their relocation and the cost of lost property. radiological exposures. ■ Who delivers risk information is as important as, or ■ Even under usual circumstances, a third of primary more so, than the content for whether the information is care patients present for assistance with medically believed and trusted. unexplained physical symptoms (e.g., idiopathic fatigue and pain). ■ Therefore, communication and education plans for Communication Interventions for Critical Primary primary care health care providers working with Care Groups health care seeking populations are needed to ensure ■ Possibly exposed but unconcerned with no symptoms appropriate medical care and assistance. or disease – Many patients will deny or neglect personal ■ This is one part of the public health response after medical needs. Assuming medical needs are subacute, an RDD. careful contact information should be obtained and entered into a local registry to facilitate follow-up to Primary Care Communications Triage ensure patient has attended appropriately to injuries and ■ After suspected exposure, it is useful for primary care exposures. clinics to routinely assess the degree of concern about ■ Either exposed or unexposed with high levels of concern exposure-related illness, separate from actual exposures, but asymptomatic – Some patients amplify concerns “Is your visit today related to terrorism or radiation and repeatedly resist clinician reassurances. In a mass concerns?” at the beginning of every visit. casualty situation, these patients can disrupt delivery ■ It is important for all patients visiting primary care, of critical medical care; plan for these patients by regardless of the reason, that their exposure to the dedicating staff and an area to their care. Development radiation or other toxic agents be determined. In some of a careful contact registry with dedicated efforts settings this will be by using technology, and more to provide follow-up contact and care is one way of commonly it will be by the patient’s history of time and communicating compassion and concern without place/location over a critical period of time. succumbing to risky or unnecessary testing. Research suggests that a negative test offers only transient (i.e., ■ Patients who respond ‘yes’ or ‘maybe’ to the days to a week or two) reassurance and can sometimes questionnaire on their concern about exposure-related increase illness concerns, especially when false positive illness should receive extra primary care assessment to results occur. Discussing the basis for patient concerns elucidate the nature of the patient’s concerns and his/ and exploring what tests the patient thinks he or she her expectations of and goals for the medical visit. These might need prevents many patients from feeling that the concerns and expectations guide medical triage and the clinician has “blown them off”. Time contingent follow- intensity of risk communication efforts. up (planned rather than “PRN” visits) reduces illness ■ Assessment of symptoms and possible disease after worry, increases satisfaction with care, and may mitigate an RDD event will include physical and psychological downstream litigation conflicts and concerns. symptoms and disease. Assessment for Posttraumatic ■ Either exposed or unexposed with high levels of concern Stress Disorder (PTSD), depressive or anxiety disorders, and unexplained symptoms (no disease, MIPS) – As and altered alcohol or smoking are important. with the asymptomatic concerned patient, the patient ■ Based on this initial primary care assessment of with idiopathic symptoms can disrupt delivery of exposure, concern, presence or absence of symptoms, critical medical care. These patients may invoke more and the presence or absence of disease (medical and clinician anxiety because unlike the patient with isolated psychiatric), patients may be assigned to categories for concerns, these patients are often visibly suffering and treatment, follow-up, education, and counseling on risk, their symptoms may sound potentially catastrophic symptoms, concern, and/or disease findings. (e.g., chest pain and sweating). ■ Often the primary care provider has the most difficulty In addition to a dedicated area, staffing, contact in communicating with those who are: registry, and redoubled primary care follow-up efforts, intervention for patients concerned with unexplained 1) possibly exposed but unconcerned and with no symptoms should involve brochures, fact sheets, symptoms or disease and literature about self-management approaches to 2) either exposed or unexposed with a high level medically unexplained symptoms. In the acute crisis, it of concern but asymptomatic (no symptoms or is helpful to triage these patients to an area distinct from disease) the area used to care for acutely ill individuals, but the 3) either exposed or unexposed with a high level area should not be labeled or perceived as a “psychiatric of concern and unexplained symptoms (e.g., no care” area for “worried well” patients so it remains disease). These patients are often categorized maximally acceptable. Many of these patients fear their as having MIPS (Multiple Idiopathic Physical symptoms represent a harbinger of impending medical Symptoms). catastrophe. Patient resentment can lead 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 validation from the clinician ■ Debriefing during an ongoing traumatic event may be that symptoms are important and will be followed particularly problematic. up quickly and carefully. The care of patients with ■ Debriefing is an opportunity for education about unexplained symptoms is frustrating for primary care responses to trauma such as emotional reactions to physicians, especially if the physician feels that “minor disaster, somatic reactions, violence, substance abuse, problems” are distracting them from more acute care. and family stress. The use of an onsite “ombudsman” or “advocate” ■ who can help patients with unexplained symptoms During a debriefing there is an important opportunity overcome perceived barriers to care helps to defuse to identify and triage people who are in need of patient notions that “no one cares” and affords additional assistance/intervention. clinicians’ a “program” to reduce the pressure to meet ■ Ongoing groups are more helpful than a one-time these patients’ needs. The ombudsman can make meeting. special efforts ensure that symptoms are acknowledged, ■ Talking in homogeneous groups (e.g., firefighters) “embraced”, and carefully discussed. As with concerned may be more helpful than in heterogeneous (stranger) but asymptomatic patients, time-contingent follow-up is groups. key. If symptoms persist and explanations for symptoms ■ Individuals dealing with the death of a loved one may remain unclear, some of these patients may mistrust have difficulty if placed in a group with others who clinician motives and develop improbable “conspiracy have survived a death threat. Therefore it is generally theories”. Advocacy for these individuals may reduce the important not to mix those who have experienced a likelihood of eventual litigation including class action loss and those who have experienced life-threatening lawsuits. exposures. ■ Debriefing groups with individuals having different APPENDIX B levels and types of exposures may “spread” exposure The Debriefing Debate from those with high trauma exposure to those with low The magnitude of death and destruction in disasters trauma exposure resulting in more symptoms in low and the extent of the response demand special attention. exposure individuals. Physical safety and security of victims and relief workers must take first priority. ■ Different people have different stories and concerns. After safety is assured, other interventions such as Groups often tend to want to all agree on a single debriefing may begin. Debriefing is a popular, early perspective. In a heterogeneous group this may lead to intervention following disasters in which small groups of isolation and stigmatization of some participants. people involved in the disaster, such as rescue workers, meet in a single lengthy session to share individual feelings and Reference: B. Raphael & J.P. Wilson (Eds.), Psychological experiences. The effectiveness of debriefing in preventing Debriefing. Theory, practice and evidence UK: Cambridge later mental health problems is much in debate. As a University Press, 2000. minimum the following should be considered if you include debriefing as part of an intervention plan. References Bromet, E. J., Goldgaber, D., Carlson, G., Panina, N., ■ Rest, respite, sleep, food and water are the primary tools Golovakha, E.,Gluzman, S. F., Gilbert, T., Gluzman, D., of early intervention. Lyubsky, S., Schwartz, J. E:. Children’s well-being 11 ■ It is important to encourage natural recovery processes years after theChornobyl catastrophe. Archives of General such as participants talking to fellow workers, spouses Psychiatry, Vol 57: 563–571, 2000. and friends. This can decrease isolation and therefore Collins, D. L.: Behavioral differences of irradiated persons facilitate identification of persistent symptoms and associated with the Kyshtym, Chelyabinsk, and Chernobyl increase the chances of early referral. nuclear accidents. Military Medicine, 157(10): 548552, 1992. ■ Debriefing has not been shown to prevent PTSD. For some, it may relieve pain, restore some function and Green, B. L., Korol, M., Gleser, G. 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