Low-level radiation as defined for this conference is based on a North Atlantic Treaty Organization directive1 as doses of 0.7 Gy or less. This radiation dose level is not likely to result in performance decrement. The perception of radiation exposure, however, can result in psychological casualties that will ultimately diminish the operational capability of our armed forces. The Army Specific Military Requirements for Nuclear Weapons and Radiation Effects Information prepared by the U.S. Army Nuclear and Chemical Agency is cognizant of this issue and has given it its highest priority rating. The requirements state that the military should "Evaluate psychological effects of radiological environments on soldier performance."2
Military operations that threaten health and well being have produced psychological casualties throughout history. During World War I and II, we learned that the numbers of psychological casualties are directly related to the intensity and duration of combat. Over the intervening years, the nature of combat deployments has changed. Our understanding of the complexity of the psychological reactions as well as the most effective ways to treat these reactions have changed as well.
Fear of radiation, also known as radiophobia, is likely to produce acute anxiety effects. Human perceptions, interactions, and expectations can combine to produce distinct changes in emotional responses after radiation exposure. According to the National Research Council,3 "Usually the perception of risk from radiation exposure is much greater than the actual risks. . . ." For example, as Dr. Collins pointed out in his presentation, the nuclear reactor accident in 1979 at Three Mile Island in Pennsylvania produced virtually no radiation exposure above background levels. Yet, the perceived radiation hazard and the public's fear of radiation evoked long-term emotional, behavioral, and physiological signs of stress.4 The particular fear associated with potential radiation exposure from nuclear power plants appears to be heightened by the fact that ionizing radiation presents an invisible and unfamiliar threat. Other causes of radiation-induced stress include loss of control, the fear of sterility and impotence, the fear of malformed offspring, and the fear of developing cancer. Four years after the Three Mile Island accident, residents in the community exhibited more adverse psychological, behavioral, neuroendocrine, and cardiovascular symptoms than did a control group.5
Psychological symptoms that have been reported following radiation accidents have been dramatic. Fear, anxiety, stress, depression, neurasthenia, and hypochondria were observed as part of the clinical course of persons exposed to radiation during the 1986 Chernobyl, Ukraine, nuclear power plant accident.6 Deficits in memory, attention, and sensorimotor activities were also demonstrated in these individuals. Many people reported symptoms of fatigue, pallor, inattention, abdominal pain, and headache as a result of the Chernobyl accident. Ukrainian doctors have labeled this syndrome "vegetative dystonia."7 A large scale epidemiological study of Estonian liquidators found no increases in cancer, leukemia, or mortality overall, but reported an increase in suicide.8
The reaction of the public and even the medical establishment to radiation accident victims is often characterized as fearful. Following the radiation accident in Goiania, Brazil, in 1987, the radiation exposure victims were subjected to chronic stress and intense ostracism.9 Everyone fled from the victims, including doctors and nurses who were afraid they would become contaminated themselves. Analysis of the psychological aftermath of Hiroshima/Nagasaki, Three Mile Island, Chernobyl, and Goiania revealed long-term fear of radiation.10
Traumatic events such as witnessing a nuclear reactor explosion and military combat have been demonstrated to lead to posttraumatic stress disorder (PTSD) or acute stress disorder (ASD).11 PTSD is an anxiety disorder resulting from a traumatic event. According to the DSM-IV,12 the following criteria must be met for an individual to be diagnosed with PTSD. The person must have experienced a traumatic event that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. The individual's response should have involved intense fear, helplessness, or horror. The traumatic event is re-experienced in specific ways such as recurrent and intrusive distressing recollections or dreams of the experience. The individual attempts to avoid stimuli associated with the traumatic event. However, symptoms of increased arousal such as hypervigilance and irritability persist. The duration of the disturbance is more than a month and causes clinically significant distress or impairment in functioning.
ASD is the category given to the psychological distress to trauma and disaster events that occur within 4 weeks of the experience and last between 2 days and 4 weeks.12 ASD refers to debilitating recollections, numbing, avoidance, and anxiety up to a month after a traumatic episode, whereas PTSD refers to the continuation of those symptoms thereafter. PTSD may be chronic or with delayed onset.
The prevalence of PTSD in male Vietnam War veterans was reported to be up to 15% and was higher in those patients with war injury or imprisonment. Estimated prevalence in Gulf War veterans was up to 10%. Chronic PTSD has also been associated with a higher rate of long-term physical illness and disease.13 It is projected that nearly 50% of the U.S. population will be exposed to some traumatic event, and 10% to 20% are likely to develop PTSD as a consequence.14
On December 8, 1999, the Food and Drug Administration approved the addition of PTSD to the usage indications for the selective serotonin reuptake inhibitor antidepressant Zoloft (sertraline hydrochloride). Until this recommendation, there were no drugs specifically approved for this use in the United States. However, pharmacological treatment may be valuable as both a primary modality and in conjunction with family, group, and individual therapy.15
The discussions following the oral presentations at the lowlevel radiation conference revealed several actions that could serve as countermeasures to psychological casualties that are likely to occur as a result of a radiation event or simply the perception of a radiation exposure. Soldiers as well as civilians should be educated on the acute and long-term health consequences of radiation. The effects of dose on health issues should be emphasized. In addition, the absence of health risks from background radiation, medical X-rays, and food irradiation should be discussed. The latter is important because both military rations and civilian supermarkets are likely to provide more irradiated food in the future.
Individuals must be made aware that there are minimal risks, if any, to exposure to low-level radiation. Informing radiation victims that medical treatments are available for the elimination of internally deposited radionuclides, reduces fear and provides a sense of control. The knowledge that a radiation area can be decontaminated is important for the community to know. The establishment of support groups for irradiated individuals and their families is of considerable importance. Informing the community of the absence of threat from individuals receiving radiation exposure is also significant. The unnecessary social stigmatization of exposed individuals from radiation accidents has been a major issue at Hiroshima, Nagasaki, Goiania, and Chernobyl. Communication and social interaction are essential to maintain a strong functioning community.
As a result of interactions between members of this session and audience participation, the following recommendations became apparent: (1) A survey should be conducted to assess a soldier's knowledge of radiation, including health effects and risks from radiation weapons (depleted uranium) and fallout. This work has already been initiated by Dr. Ross Pastel and is presented elsewhere in this publication. (2) Medical personnel should be trained in the treatment of both radiation sickness and psychological trauma that may occur with the mere perception of a nuclear exposure. (3) In the event of a radiation incident, the psychological stressors that are likely to affect performance as well as neuropsychiatric casualty rates should be identified. (4) Models should be developed to predict psychological casualties with greater accuracy. The model presented by Dr. Gene McClellan in this volume is a good starting point. Information for the model could be obtained from the psychological data generated from previous radiation events including those at Nagasaki, Hiroshima, and Tokaimura in Japan, Chernobyl in the Ukraine, Goiania in Brazil, and Three Mile Island in the United States.
1. NATO (North Atlantic Treaty Organization) ACE Directive: Policy for defensive measures against low level radiological hazards during military operations. ACE directive No. 80-63. Brussels, Belgium, Supreme Headquarters Allied Powers Europe, August 2, 1996. 2. Army Specific Military Requirements for Nuclear Weapons and Radiation Effects Information FY 99/00, United States Army Nuclear and Chemical Agency, 1999. 3. National Research Council: Potential Radiation Exposure in Military Operations. Washington, DC, National Academy Press, 1996.
4. Baum A, Cohen L, Hall M: Control and intrusive memories as possible determinants of chronic stress. Psychosom Med 1993; 55: 274-86.
5. McKinnon W, Weisse CS, Reynolds CP, Bowles CA, Baum A: Chronic stress, leukocyte subpopulations, and humoral response to latent viruses. Health Psychol 1989; 8: 389-402.
6. Viel JF, Curbakova E, Dzerve B, Eglite M, Zvagule T, Vincent C: Risk factors for long-term mental and psychosomatic distress in Latvian Chernobyl liquidators. Environ Health Perspect 1997; 105(Suppl 6): 1539-44.
7. Stiehm ER: The psychologic fallout from Chernobyl. Am J Dis Child 1992; 146: 761-2.
8. Rahu M, Tekkel M, Veidebaum T, et al: The Estonian study of Chernobyl cleanup workers: II. Incidence of cancer and mortality. Radial Res 1997: 147: 653-7.
9. Collins DL, de Carvalho AB: Chronic stress from the Goiania 137Cs radiation accident. Behav Med 1993; 18: 149-57.
10. Bromet EJ: Psychological effects of radiation catastrophes. In Effects of Ionizing Radiation: Atomic Bomb Survivors and Their Children (1945-1995). Edited by Peterson LE, Abrahamson S. Washington, DC, Joseph Henry Press, 1998.
11. Fullerton CS, Ursano RJ: Posttraumatic Stress Disorder: Acute and Long-Term Responses to Trauma and Disaster. Washington, DC, American Psychiatric Press, 1997.
12. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. Washington DC, American Psychiatric Association, 1994.
13. Friedman MJ, Schnurr PP, McDonagh-Coyle A: Post-traumatic stress disorder in the military veteran. Psychiatr Clin N Am 1994; 17: 265-77.
14. Tomb DA: The phenomenology of post-traumatic stress disorder. Psychiatr Clin N Am 1994; 17: 237-50.
15. Sutherland SM, Davidson JR: Pharmacotherapy for post-traumatic stress disorder. Psychiatr Clin N Am 1994; 17: 409-23.
Guarantor: Michael R. Landauer, PhD
Contributors: Michael R. Landauer, PhD*; Robert W. Young, PhD^; Lt Col Aimee L. Hawley, USAF MC*
*Armed Forces Radiobiology Research Institute, 8901 Wisconsin Avenue, Bethesda, MD 20889-5603.
^Scientific Solutions & Analysis, 946 Torrey Pine Drive, Winter Springs, FL 32708. This manuscript was received for review in February 2001. The revised manuscript was accepted for publication in November 2001.
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