1. Psychological Aspects of Bioterrorism Robert J. Ursano, M. D
Psychological Aspects of Bioterrorism Robert J. Ursano, M.D. Professor/Chair Department of Psychiatry Uniformed Services University Director Center for the Study of Traumatic Stress

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6. Good morning and welcome to the Center for Public Health Preparedness Grand Rounds Series at the University at Albany’s School of Public Health. I’m Peter Slocum and I will be your moderator today.
Before we begin, I’d like to remind you that we’ll be taking your calls later in the hour. The toll free number is You may also send your written questions via fax to
Our topic today is Pschological Aspects of Bioterrorism, with Dr. Robert Ursano.
This program will address the fact that communities and individuals react to the stress of terror, as they do to natural events. We will discuss what public and private health professionals need to consider when dealing with the public’s emotional and psychological health in times of stress and emergency.
And now I’d like to welcome our guest, Dr. Ursano, Professor and Chair of the Department of Psychiatry and Director of the Center for the Study of Traumatic Stress, Uniformed Services University School of Medicine. Thank you for joining us today, Dr. Ursano.

7. Uniformed Services University
Center for the Study of Traumatic Stress
Uniformed Services University
DIRECTORS Robert J. Ursano, M.D Carol S. Fullerton, Ph.D Brian W. Flynn, Ed.D Nancy Vineburgh, M.A SCIENTISTS Harry C. Holloway, M.D. James E. McCarroll, Ph.D. Thomas Grieger, M.D John Newby, Ph.D. Charles Engel, M.D Robert Gifford, Ph.D. Molly Hall, M.D John Stuart, Ph.D. Elizabeth Osuch, M.D Mark Willis, M.S.
Welcome, Dr. Ursano, and thank you for joining us today. If you would, please start off by telling us a little bit about the Center for the Study of Traumatic Stress, your colleagues, and what you do.

8. Psychological Goals of Terrorism
Erode sense of national security
Disrupt the continuity of society
Destroy social capital
Morale
Cohesion
Shared Values
The primary goal of terrorists, it seems, is to induce fear, but what does that really mean to a community, a country, a society?

9. Terrorism Opens the fault lines, the potential cracks in our society
Racial/ethnic
Economic
Religious

10. The Nation’s Security Military Power Economic Power
Information Systems
Health
You’ve written about health and economic power as critical to our nation’s security as military power - can you elaborate a bit on that for us?

11. Characteristics of Traumatic Events
Individuals
Exposed
Intentional
assault
robbery
rape
Unintentional
accident
MVA
injury
Is it true that communities, just like individuals, react to stress in somewhat predictable ways?
[what is MVA?]

12. Characteristics of Traumatic Events
Communities/
Populations Exposed
Human Made
industrial acc.
plane crash
toxic exposure
Natural
hurricane earthquake
tornado

13. Disasters Human Made Natural Terrorism
Do people generally seem less fearful about natural threats as opposed to man-made ones?

14. Types of Terrorism
Single Attack (Oklahoma City bombing or Columbine High School shooting)
Multisite Attack (WTC-Pentagon attacks)
Multisite Continuous/Repeated (Anthrax attack)
Continuous/Repeated
(DC Metro Sniper attacks)

15. Terrorism and the Public’s Health
Public and Private
Outpatient/ Hospital
Medical Care System
Emergency Response System
Public Health System
How does the community, as opposed to an individual, respond to terrorism?
EMS
Police/Fire
Water/Electric/ Communication Emerg. Response
Protection
Prevention
Promotion

16. Mental Health in Disaster and Terrorism
Change in Safety
Change in Travel
Distress Responses
Human
Behavior in
High Stress
Environments
Mental
Health/
Illness
What behavioral and mental health relationships come into play in response to disasters, or terrorism, and who is affected?
Before you move on, can you explain what is meant by ‘over dedication’?
And when you refer to ‘Change in Safety and Travel’ what exactly do you mean?
PTSD
Depression
Smoking
Alcohol
Over dedication

17. Haddon Matrix Agent: Vector: Population: Malaria Mosquito Person Pre
During
Post
Are a community’s vulnerabilities before an event like an individual’s?

18. Psychological and Behavioral Intervention Matrix (Bio)
Agent: Vector: Population:
Anthrx/Terror Terrst/Mail Person
Response/ Recovery
Behaviors
Help seeking
Specific Rx’s
Justice system
Rehabilitation
Disaster Behaviors:
Quarantine
Evacuation
Grief Leadership
Preparedness
Participation in
Vaccination
Information/plan.
Security
Detectors
Airport Screening
Specific medicaion rx
Suppotive rx
Masks/Cover
Premedication
Air detection system
Pre
During
Post

19. Ionizing Radiation Psychological and Behavioral Intervention Matrix
Response/ Recovery Behaviors
Help seeking
Specific Rx’s
Primary Care
Justice system
Decontamination
Disaster Behaviors:
Evacuation
Shelter in Place
Grief Leadership
Preparedness
Behaviors
Alert training
Information/plan.
Security
Detectors
Airport
Screening
Protected Buildings
Protective Clothing
Prepositioning Iodide
Pre
During
Post
Agent: Vector: Population:
Rad. /Terror Terrorist Person

20. Psychological and Behavioral Intervention Matrix (WTC)
Pre
During
Post
Agent: Vector: Population:
Blast/Terror Terrst /Truck Person
Modify Building
design
Airport
Screening
Preparedness
Behaviors
Risk Assessment
Information/plan.
Sprinkler system
Firefighter Response
Harden CP Door
Passenger
active coping
Disaster Behaviors:
Escape/Rescue
Evacuation
Response/Recovery
Behaviors
Specific Rx’s
Screening
Parent-Teacher Ed
Emergency
Response
System
Justice system

21. World Trade Center Explosion February 26, 1993 (March 1993 Survey)
76% thought something serious had happened
32% had not begun to evacuate by one hour
30% decided not to evacuate
36% participated in a previous emergency evacuation
How did people react to the 1993 World Trade Center explosion?
Do you think people would react differently since 9/11?
Aguirre, Wenger, and Vigo, 1998

22. World Trade Center Explosion February 26, 1993 (March 1993 Survey)
Crowds inhibit individual solutions in favor of shared norm, esp. if members known
Large groups take longer
Social relationships effect response
Smoke, injury speed evacuation
Higher in building, slower the response
How do social relationships effect response?
You refer to ‘injury’ as something which speeds evacuation – how so?
Aguirre, Wenger, and Vigo, 1998

23. Acute Event Scene Responses
Most search and rescue is done by bystanders (50%)
Majority of casualties are not transported by ambulance (cars, taxi, walk, police)
Least serious casualties arrive first at the closest hospital
80-95% of casualties are not admitted to the hospital and most need treatment for non-traumatic injury
I understand that there are a few misconceptions as to what usually happens at the scene, in terms of dealing with victims and the need for acute care – can you share with us some facts?
Aud der Heide, 2002 / Quarenteli 1983

24. Loss of Access to Routine Medical Care and Home Care
Hurricane Andrew: 1000 Physician Offices, 4 Mental Health Facilities, 11 pharmacies, 7 Convalescent Homes, 2 Dialysis Units, 38 Assisted-living Facilities
Home health care: Nursing, Oxygen, suction, IV antibiotics, medication, ventilation, chemotherapy
Therefore, chronic medical conditions worsen and care is sought at already overburdened hospitals
What happens if medical infrastructure is damaged or destroyed during an event?
How might one utilize other agencies when medical facilities are down?
Aud der Heide, 2002 / Sabatino JAHA 1992

25. Post-Traumatic Stress Disorder (PTSD)
PTSD not uncommon after many types of traumatic events
Examples: Motor vehicle accidents and industrial explosions
Nearly all have the acute form at some point
Can develop in people without psychiatric history
Rapid recovery is the norm
Does everyone involved in such an event exhibit stress effects?

26. Other Trauma-Related Disorders
Traumatic grief
Unexplained somatic symptoms
Depression
Sleep disturbances
Increased use of alcohol and cigarettes
Increased family violence and conflict
Can you share other types of problems we might expect to see as a result of a disaster or terrorist event?

27. Oklahoma City Terrorist Attack (at 6 months)
34% PTSD
25% Depression
40% Never experienced psychiatric problems in the past
Let’s talk about the attack in Oklahoma City… Do the figures on the next slide represent actual victims, families, first responders, people who live in the town?
North et. al., JAMA 1999

28. Stress Reactions After 9/11 Terrorist Attacks Nationally representative sample N= days after attack
44% Report one or more substantial
stress symptoms
90% Report at least low levels of stress
Can one be affected by television coverage?
Schuster et. al., 2001

29. Stress Reactions After 9/11 Terrorist Attacks (2) Nationally representative sample N= days after attack
Substantial Stress Reaction
Female (50% relative risk)
Less than 100 mi. (61% > 1000 mi.)
TV viewing 9/11 greater than 12 hrs.
(58% > 0 to 3 hrs.)
Can you explain the statistics revealed on this slide?
Schuster et. al., 2001

30. Those With No Previous Psychiatric Illness Are At Risk
Oklahoma City near Murah Building
(DIS study)
USAF POWs returning from Vietnam
Twin studies of Vietnam Combat Veterans
North et al Jama 1999 / Ursano et al AJP 1981 / Goldberg et al Arch Gen Psych 1984

31. Somatic Symptoms Frequently increased following disasters
Can be an expression of anxiety or depression and leads to the seeking of health care
MUPS or MIPS
(Multiple Unexplained or Idiopathic Physical Symptoms)
Ursano, Fullerton et al 1995/ McCarroll, Ursano, Fullerton et al Psychosomatics 2000

32. Estimated Mental Health Needs in NY State after Sept 11
Expos Group (pop) %PTSD #Case %Seek Treatment
WTC area (162,715) % , % ,615
Manhattan (919,000) % , % ,586
All 5 NYC Burs. (6.92 mil) 5% , % ,577
Nearby counties(4.8mil) 1% , % ,752
________________________________
TOTAL % 527, % 129,530
What do we know about the 9/11/01 World Trade Center Event with regard to PTSD?
Herman et al JUH 2002

33. National Study of Reactions to Terrorist Attack 1-2 months post 9/11 (N=2273)
Probable PTSD
New York City %
Washington DC %
Other Metro Areas %
Rest of USA %
Again, do the figures reflected on this slide represent actual victims, families, first responders, people who live in the town?
Schlinger et. al., JAMA 2002

34. PTSD & Increased Alcohol Use in Pentagon Attack Survivors 7 Months (N=77)
Exposure
70.1% Saw, heard, felt, or smelled the aircraft, explosion, or fire
32.5% Feared death
13% Experience difficulty with evacuation
10% Saw someone die
You mentioned earlier that increased substance abuse is one result of exposure to a disaster or terrorist event – can you expand on this?
Grieger, Fullerton, & Ursano 2003

35. Longitudinal National Study of Reactions to Terrorist Attack 2 weeks (N=2,729), 2 months (N=933) 6 months (N=787)
Outside of NYC mos mos.
Fears of Future Terrorism % %
Fear of Harm to Family % %
What happens over time to people affected in these ways?
Silver et. al., JAMA 2002

36. Longitudinal National Study of Reactions to Terrorist Attack 2 weeks (N=2,729), 2 months (N=933) 6 months (N=787)
Outside of NYC mos mos.
9/11 Posttraumatic Stress % %
Silver et. al., JAMA 2002

37. Perceived safety Confidence in government Stigmatization
Terrorism Effects
Terrorism potentially has profound psychological effects. How is a community affected vs. an individual?

38. Depression
May be a primary factor in traumatized patients who are reclusive or difficult to treat
Requires evaluation and treatment
If individuals trauma of any sort, does it effect others around them?
Anything we should know about prognosis?

39. Traumatic Grief / Bereavement
Not uncommon following traumatic events
Often overlooked in some groups
(e.g., parents of adult children who die unexpectedly)
May adversely affect social interaction
Can you give us an example of how traumatic grief can adversely affect social interaction?

40. Family Conflict Common following a traumatic event
Triggered by fear of new threats
(e.g., loss of safety, economic impacts, potential loss of job)
How does post traumatic stress affect the family? Do different families react differently?

41. Intervention After Disasters
Assure Basic Needs
Psychological First Aid
Needs Assessment
Monitor the Recovery Environment
Outreach/Information Dissemination
Fostering Resiliency/Recovery
Consultation/Technical Assistance
Triage
Treatment
How can we help with recovery after a disaster? Do you have any messages for our local health audience as to specific role or roles they can play in emergency response?

42. Workplace Needs Distress management Shelter in place
Support for continuity of operations centers/leaders (“Site R”)
Grief leadership
Evacuation leadership
Centralized locator offsite
Travel policies
Can you expand on each of the ‘Workplace Needs’? For instance, what is ‘Distress Management’?

43. Media Can serve to supply disturbing information & propagate distress
Can be a tool for:
Education
Recovery
Providing empathy with victims
Do you have any suggestions for us as to how we can properly use the media?

44. Leaders Working with the Media
Decrease exposure
Less disturbing pictures and stories
Information may carry different meanings
Perhaps you could comment on the challenges that Public Health leaders should consider when dealing with the media?

45. Preventive Mental Health
Drink lots of OJ
Eat your bread crusts
Be kind to your neighbors
Think cool thoughts
Jangle gently as you go
Avoid vexatious and disputatious folk
Finally, what can we do BEFORE a disaster to improve the public’s mental well-being and perhaps prevent some of the damage a terrorist event might evoke?
[I suggest that one of you quote “If you are able to keep your wits about you while others are in panic…” rather than putting on slide]

46. Uniformed Services University
Center for the Study of Traumatic Stress
Uniformed Services University
Resources: Center for the Study of Traumatic Stress web-site:

47. Resources continued:
Terrorism and Disaster Ursano, RJ, Fullerton CS, Norwood, AE Cambridge University Press, 2003
Preparing for the Psychological
Consequences of Terrorism:
A Public Health Strategy The National Academies Press, 2003

48. Evaluations Please submit your evaluations on-line:
or send hardcopy version provided by your site coordinator to the
University at Albany School of Public Health
Center for Public Health Preparedness.
Thank you!
CLOSE: (at 9:57 precisely)
Dr. Ursano, thank you very much for joining us and sharing your expertise on Pscyhological Effects of Terrorism. We really appreciate your presentation.
(Show slide)
Before we close, I’d like to remind all of you to please take a moment to fill out your evaluations either on line, or send a printed copy back to us at the Center for Public Health Preparedness. Your feedback is invaluable to the development of our future programs.
This program will be available on videotape or web-streaming within the next few weeks. Please check our website for more details. We hope you’ll tune in on April 15th for our joint program with T2B2 on Emergency and Risk Communication with special guest from the CDC, Barbara Reynolds.
I’m Peter Slocum. Thank you for joining us for the University at Albany’s Center for Public Health Preparedness Grand Rounds Series.

49. Center for Public Health Preparedness University at Albany School of Public Health