Numerous issues emerged as relevant to appropriate medical care in CBW environments. For example, it was found that, at least for nerve agents, stress and fear increased with prolonged and low-dose exposures. The need for health workers trained to deal with stress reactions was emphasized, as well as the need for commanders and supervisors to be sensitive to the manifestations of stress among their troops. To reduce the incidence of severe adverse reactions, certain strategies were recommended, including making certain troops had privacy and time during rest periods to interact with others about their concerns and experiences. Attention was also specifically directed at those who may witness grotesque injuries and handle the dead. Such activities were judged to be among the most stressful experiences possible in these environments. In cases of actual CBW exposures, it was also recommended that spouses of the affected troops be briefed about what had occurred so that the spouse could be an active participant in the post-trauma support efforts.
The recommendations outline the possibility of major decreases in performance and concentration arising from the psychological reactions to CBW environments, decrements that could in some cases cause life-threatening mistakes. Such decrements could also result from the physiological effects of nerve agents, or from heat stress alone, so the importance of distinguishing the causes and treating them appropriately was emphasized.
Under issues of training, the recommendations underscored the importance of prior training to reduce stress and to strengthen group cohesiveness, which further reduces stress. These training issues were quite varied, from training to deal with injuries and death to training in handling the protective gear effectively. An interesting recommendation addressed the costs versus benefits of the use of live agents in training and concluded that further investigation was needed to resolve this question. Finally, CBW trainers were warned to expect a certain number of individuals to develop claustrophobia during training exercises and were advised to attempt "talk down" procedures or remove the individual from the area.
In summary, then, numerous aspects of CBW environments can cause stress reactions of varying magnitudes in those involved. Although no direct statements are made regarding the long-term effects of such stress reactions, some of the characteristics of CBW environments fall into the description of experiences "outside the usual human experience ... [and] ... stressful to almost anyone" (DSM-III-R). Thus, it may be assumed that experiences in these environments may result in adverse psychological effects, including depression, anxiety, and PTSD-like symptoms in certain individuals.