Molly J. Hall, Ann E. Norwood, Robert J. Ursano, Carol S. Fullerton


Biosecur Bioterror. 2003;1(2) 

In This Article

Psychiatric Illness and Primary Care

Although most people do not develop psychiatric disorders following a disaster or a terrorist attack, some people will become ill. The risk of developing post-traumatic stress disorder is highest in those individuals who are directly exposed to high magnitude, severely disturbing events. These individuals may or may not have other risk factors such as a preexisting psychiatric condition or recent negative life events. Of exposed individuals in the Oklahoma City bombing who developed PTSD and depression, 40% had no predisposing psychiatric illness.[23] More commonly, disorders such as depression, generalized anxiety, panic, and somatization develop and are most likely to be seen in primary care settings. Increased alcohol, nicotine, or other substance use as well as family conflict and family violence may occur. People at increased risk to develop these disorders are those directly exposed to an event, including medical personnel caring for victims of bioterrorism, those who were more vulnerable before the event due to existing mental illness, and those who suffered acute losses and other negative life events after the event. In a follow-up study[24] by the New York Academy of Medicine, people suffering from continuing PTSD symptoms 15 months after the attack had experienced subsequent stressful events such as divorce or loss of a family member. Studies of the impacts of September 11 have shown that distress and ongoing stress symptoms are not predicted simply by the dose of traumatic exposure, degree of injury, or other loss. Individuals not directly exposed may suffer more than some who were directly affected. An important recent finding points to the fact that early abandonment of active coping, or an early "giving up" and denial of an ongoing threat, appears to increase the likelihood of ongoing distress and PTSD.[11]

In addition to anticipating that there may be more patients presenting with psychiatric symptoms, primary care clinics should routinely assess the degree of concern about exposure-related illness regardless of whether a known exposure occurred. A helpful screening question might ask whether or not the patient's visit is related to terrorism or bioterrorism concerns. If the answer is positive, extra time could be devoted to exploring the nature of these concerns in order to develop recommendations for additional testing, clinic visits, and patient education. Medically unexplained physical symptoms pose a clinical and management challenge. Scheduled follow-up visits in conjunction with the development of a clinical contact registry communicates compassion and concern. Early triage into this level of follow-on care may mitigate the later development of persistent medically unexplained syndromes such as Gulf War syndrome.[25]


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