Hippocrates, the “Father of Medicine”, had written that disease was not only “pathos” (suffering), but also “ponos” (toil), as the body fought to restore normalcy. This may have also served as the first description of “stress”. Centuries later, Hans Seyle, M.D., Ph.D., a Hungarian-born endocrinologist and experimental pathologist (“The Father of Stress” and stress physiology), discovered the General Adaptation Syndrome (GAS), a physiological response to stressors (demands) upon the human body. The syndrome details how stress induces hormonal autonomic responses which can lead to disease.

Stress is the subjective experience that occurs when we perceive that the demands of a situation exceed our resources to successfully cope with those demands. Stress is a normal response to a perceived change in the environment, which may be either an actual event or the perception of a threat, even when the threat is not manifested or realized. Stress is a normal phenomenon which elicits evolutionary survival mechanisms. The dimensions of the stress response extend across multiple domains of human function: physical, emotional, cognitive, behavioral, social, and spiritual.

A stressor is any stimulus which evokes a stress response. Stressors may be real or imagined, internal or external. The overall impact of a stressor will depend upon its characteristics and the characteristics of those who have been affected. The perceived more than the absolute qualities of a stressor determine its potential impact. The stress response is greatly influenced by thoughts and perceptions of the situation. Stress can be a constructive stimulus and a positive force for taking adaptive and productive action, however, when stress is intense, prolonged or chronic, it can also be destructive leading to serious psychological, emotional and/or physical harm.

Coping mechanisms play an essential role in the response to stress. Acute coping involves both threat appraisal and execution of a response to the threat. An individual’s own sense of self-efficacy. The ability to cope with an event may be affected by fatigue, frustration, helplessness and personal risk; and are all components experienced in any critical incident or disaster.

Within the context of traumatic stress (psychotrauma), the complexities and interrelationships between mind and body become evident, as it has been shown, both experimentally and clinically, that psychological stressors can induce physiological changes, and physical illness and injury may inflict profound psychosocial implications.

In essence, the effects of traumatic stress becomes a complex interplay of psychological and various physiological factors. The “fight or flight” reaction described by the eminent physiologist W.B. Cannon, is an example of the physiological responses provoked by an external stressor, such as fear of imminent injury or death. When faced with a stressor, personality  characteristics such as anxiety, anger, and depersonalization contribute  to effective flight, fight or ”freeze” responses, respectively.

The National Institute of Mental Health reports that more than 3.2 million Americans suffer from posttraumatic stress disorder (PTSD) in any given year. Thousands of cases are reported globally, especially in areas which are geopolitically unstable and involved in conflict, war and subjected to terrorist and insurgent attacks.

Typically, traumatic stress disorders are most often associated with veterans who have lived through harsh combat conditions. Terms such as “irritable heart” during the American Civil War, ”shell –shock” in World War I and II, “combat exhaustion” during the Korean War, and then “combat stress” during the Vietnam War, later re-classified to posttraumatic stress disorder (PTSD). PTSD has become an epidemic among returning veterans of the Global War on Terror, Operations Iraqi Freedom and Enduring Freedom.

However, anyone affected by a traumatic event, such as a natural disaster or an act of violence, may develop PTSD or stress-related symptomatology.

In the arena of disaster behavioral health, traumatic stress is capable of affecting victims and responders.  Individuals may develop direct or vicarious trauma. The psychotraumatic implications of a critical incident or event involving an intentional act which generates fear, panic, anxiety infrastructure destruction, mass casualties, and mass fatalities within populations may be even more profound.

Indeed, terrorists seek to shape future events through intimidation or coercion of civilians and governments. By fostering insecurity both within and across geopolitical boundaries, current and evolving terrorist threats pose a significant global challenge to the health and safety of populations. This includes psychological and emotional health and wellness.

Generally, all disasters and catastrophic events leave a “psychological footprint” which is usually larger than the physical impact, and may affect individuals and whole populations not even “directly” affected by the event. This was apparent in the aftermath of the September 11 terrorist attacks in the U.S.

Even today, years after the coordinated attacks on the U.S., a shroud of uncertainty remains, stifling many aspects of Western life via cognitive and emotional (rather than physical ) mechanisms. Similarly, bioterrorism utilizing weaponized B, anthracis (anthrax) in the immediate aftermath of September 11,2001 attacks resulted in few deaths, but significant psychological effects, including fear of additional releases involving bio threat agents.

By its very nature, terrorism depends more on its use of human psychology than on its access to weapons of mass effect for either its success or its failure. Essentially, terrorism targets behavioral health and wellness.

Terrorism is expressed in forms of tactical ultra-violence, usually utilizing high order /improvised explosive devices and/or armed assaults. However, terrorism and asymmetric warfare have taken the shape of chemo-terrorism, bioterrorism and even radiological terrorism utilizing weapons of mass effect (WMEs). WMEs/CBRN(E) agents are not well understood by the majority of the general public, and create a tremendous aura of fear ,anxiety and uncertainty due to lack of knowledge, misconceptions, and poor emergency preparedness, including  psychological  preparedness.

For example, a radiological event, e.g. detonation of a radiological dispersal device (RDD) in an urban area would create concerns and utter panic regarding radiological contamination and the biomedical effects of any radiological exposures. In the aftermath of such an event the fear and uncertainty generated by such an event would drive even totally “unaffected” individuals to seek medical attention, i.e. the “worried well”.

Are the “worried well” actually well? They are victims of traumatic victimization, which can range from transient anxiety to the development of full blown PTSD. It is this writer’s opinion that these individuals must be assessed, and referred to appropriate mental health services. Even early anxiety reactions may serve as predictors and precursors of subsequent maladjustment or more extensive traumatic psychopathology.

Many individuals equate radiation with nuclear warfare, nuclear power accidents, genetic mutations, and the remnants of Cold War mentality, including the images of science fiction movies during the Cold War era. Furthermore, ionizing radiation cannot be detected by the human senses, making it even a more insidious, nebulous and mysterious threat. T.S. Elliot said it best, “Give me a handful of dust and I’ll show you true fear”.

The use of CBRN agents, such as chemical or biological warfare/terrorism agents, will generate illness, injury, disability and even death. Many psychological signs and symptoms will manifest themselves during, and in the aftermath, of a chem-bio attack, including the fear of illness or contagion, depression, bereavement, survivor guilt, feelings of loss, insomnia, uncertainty, alcohol/substance abuse and denial among others. These are common components of traumatic victimization in all critical incident and disaster scenarios, and would be present in varying degrees in all CBRNe events.

In addition, certain psychological manifestations may have an organic basis due to exposures to CBRN agents. For example, neurobehavioral abnormalities may present among victims of nerve agent exposures. Several reports have been generated describing the chronic neurological and neurobehavioral manifestations of sarin exposure in victims of the Syrian attacks. There may also be synergistic interplay between acute psychological trauma and the neurotoxic effects of nerve agents, especially low-level exposures.

Overall, the importance of a rapid, progressive and purposeful return to normalcy is essential for individual and community resiliency and recovery. Consequences such as communications disruptions and population displacement add to the psychosocial consequences of CBRNe and other critical incidents and events. Therefore, re-establishment of communications capabilities, family and societal connections and networks are vital to assist in mitigating the stressors induced by these consequences and enhancing survivor behavioral health.

The ready and prompt availability of Critical Incident Stress Management (CISM) assets to minimize and mitigate the impact of and chronic effects of traumatic stress and enhance recovery from traumatic and critical incident stress. When acute stressors or risk are great, CISM may involve early defusing, a special form of debriefing for those most at risk who cannot wait for a formal group debriefing.

While CISM activities are intended for all levels of responders interfacing with cross-trained peers and mental health professionals, similar behavioral health strategies are available to civilian victims and behavioral health systems must be deployed and readily available for all traumatic stress-psychotrauma victims.

In conclusion, the broadest casualty of CBRNe terrorism is the collective psyche of the affected population and the human mind is without question a prime target for these diabolical acts.

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Frank G. Rando possesses over 30 years of real world experience as a public safety professional,clinician, educator ,emergency and crisis manager ,author and consultant in the areas of tactical ,disaster and operational medicine, weapons and tactics, law enforcement /criminal investigations ,counterterrorism, hazardous materials management and emergency response ,toxicology, environmental safety and health,and health care and public health emergency management .