Background

Intentional mass casualty events such as bombings are designed to cause death, destruction, fear and confusion. In comparison to natural disasters, intentional mass casualty events are associated with higher rates of long term psychological symptoms. The level of fear and distress after a bombing depends on several factors, including injury of self and/or injury or death of family members and friends; separation from or lack of knowledge about loved ones; and the witnessing of horrific and frightening scenes.

Emergency responders and other health care providers may also experience psychological symptoms resulting from continued exposure to death and devastation.
Most fear and distress reactions are normal, expected, and can be managed using principles of good psychological patient care. Clinicians should take all reports of physical, emotional, cognitive and behavioral reactions seriously.

Clinical Presentation

• Physical reactions: fatigue/exhaustion, gastrointestinal distress, tightening in throat/chest/stomach, headache, worsening chronic conditions, somatic complaints, or racing heartbeat. 
• Emotional reactions: depression/sadness, irritability/anger/resentment, anxiety/fear, despair/hopelessness, guilt/self-doubt, unpredictable mood swings, emotional numbness, or inappropriately flat affect. 
• Cognitive reactions: confusion/disorganization, recurring dreams or nightmares, preoccupation with the disaster, trouble concentrating/remembering things, difficulty making decisions, questioning spiritual beliefs, disorientation, indecisiveness, worry, shortened attention span, memory loss, unwanted memories, or self-blame. 
• Behavioral reactions: sleep problems, crying easily, excessive activity level, increased conflicts with others, hypervigilance/startle reactions, isolation/social withdrawal, distrust, irritability, feeling rejected or abandoned, being distant, judgmental, or over-controlling. Abuse of substances and/or alcohol is also a common symptom.

Initial Management

Provide psychological first aid (PFA) to patients, family members, and emergency response personnel as needed:

• Establish contact and engagement 
• Provide/ensure safety and security 
• Stabilize, as necessary 
• Gather information regarding current needs and concerns 
• Avoid encouraging patient to talk about the event as this may intensify symptoms 
• Provide practical assistance 
• Provide information and education regarding signs of distress and how to cope 
• Link with appropriate/needed follow-up services 
• Provide family members with accurate, timely, and credible information about patient status and what will be happening next 
• Provide family members a quiet location away from distressing signs and sounds 
• Minimize separation of pediatric and other patients where separation increases distress 
• Optimize services of hospital social services and chaplains

Refer to a behavioral health specialist when the following signs occur:

• Disorientation: inability to know date, location, or recent events 
• High anxiety and hyper-arousal: highly agitated, unable to sleep, frequent nightmares, flashbacks, or intrusive thoughts 
• Dissociation: emotional disconnection, sense of seeing self from another perspective, seeing the environment as unreal, or time distortion 
• Severe depression: hopelessness and despair, unrelenting feelings of worthlessness or guilt, frequent crying for no apparent reason, or withdrawal 
• Psychosis: hearing voices, seeing things that are not there, appearing out of touch with reality, or excessive preoccupation with ideas or thoughts 
• Inability to care for one self: does not eat or bathe, isolated from others, or unable to manage tasks of daily living 
• Suicidal or homicidal thoughts or plans 
• Problematic use of alcohol or drugs 
• Domestic violence: child, spouse, elder, or animal abuse

Address emergency response personnel concerns as needed:

• Be aware of personal stress vulnerabilities in emergency responders 
• Identify physical, emotional, cognitive and behavioral signs in self and coworkers, and practice self-care 
• Enforce breaks 
• Use a buddy system to identify stress 
• Provide PFA as needed 
• Seek help from a mental health specialist if necessary 
• Be aware of stress and fears in your family resulting from your work/role

Disposition

• Most fear and distress reactions are normal and will resolve without the intervention of a mental health specialist; however, referral services should be made available to all patients, families and emergency response personnel 
• Individuals who belong to strong social networks, such as families and faith communities, tend to do better than those who do not 
• Individuals and families that exhibit continuing signs of distress, and those exhibiting signs of mental illness, including psychosis, severe anxiety and depression, should be referred to a mental health specialist for ongoing care

This fact sheet is part of a series of materials developed by the Centers for Disease Control and Prevention (CDC) on blast injuries. For more information, visit CDC on the Web at: www.emergency.cdc.gov/BlastInjuries.

U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
June 2009