Preparing for the Psychological Consequences of Terrorism A Public Health Strategy (2003) / Chapter Skim
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2. Understanding the Psychological Consequences of Traumatic Events, Disasters, and Terrorism
2. Understanding the Psychological Consequences of Traumatic Events, Disasters, and Terrorism
Pages 34-63
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From page 34... ...
The chapter then describes the smaller body of research that specifically examines the consequences of terrorist attacks and discusses how the consequences of terrorism may differ from other types of traumatic events. This chapter is not meant to represent a thorough review of the trauma and disaster literature; rather it is intended to highlight some of the salient and relevant findings that may direct responses to terrorism events.
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From page 35... ...
Although psychiatric illnesses such as PTSD are the more severe outcomes of traumatic events, they are also the best studied. Much of the research literature has focused specifically on PTSD because it is a recognized and well-defined result of traumatic events (see Box 2-1~.
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From page 37... ...
People with mild symptoms may expect fairly rapid resolution of their symptoms and may require fairly simple interventions and/or support, such as appropriate risk communication messages from the media and public health community explaining that these symptoms are normal, expected reactions to the experience of a traumatic event. The minority of people with severe symptoms and/or psychiatric illness may require conventional treatment from the mental health system.
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From page 38... ...
Widespread negative psychological effects have also been reported following acts of violence on high school campuses, such as the school shootings at Columbine High School in Littleton, Colorado, and Santana High School in Santee, California. Biological research has demonstrated that, like adults, children exposed to traumatic events show alterations in stress hormone systems.
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From page 39... ...
It is difficult to draw definitive conclusions from this research, however, since findings are frequently confounded with preexisting risk factors for experiencing a traumatic event that are also associated with differences in brain physiology.
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reviewed 177 articles that examined 80 different disasters.~ The authors organized the most frequently documented negative sequelae of disasters into five categories: · Specific psychiatric illnesses (for example, PTSD, depression) · Nonspecific distress (symptoms without a specific diagnosis, such as demoralization, perceived stress, and negative affect)
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From page 41... ...
The studies included in Norris and colleagues' review suggested that symptoms measured shortly after the disaster were predictive of symptoms at subsequent points in time, and the greatest severity of symptoms was usually experienced within one year following the disaster; only a minority of disaster survivors had any significant and persistent impairment after the first year. Moderators of Adverse Outcomes After Disasters As discussed, many of the initial reactions to disasters can be considered ordinary distress responses to traumatic events and the symptoms will dissipate over time.
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From page 43... ...
suggested, based on a review of the disaster literature, that human-caused disasters may result in higher rates of diagnosable psychiatric illnesses, and others have reported that human-caused disasters result in more persistent psychopathology (Baum, 1990; Green et al., 1990; Solomon and Green, 1992~. Conversely, Rub onis and Bickman (1991)
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From page 44... ...
Therefore, although research shows that all types of disasters, including intentional and inadvertent human-caused disasters, may cause psychological distress, behavior change, or psychiatric illness to different degrees, additional studies should identify the mechanisms and specific characteristics leading to adverse outcomes. Norris and colleagues (2001)
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From page 45... ...
Terrorism carries with it a potentially greater impact than other disasters on distress responses, behavioral change, and psychiatric illness by virtue of the unique characteristics of terrorism events (see Table 2-1~. Terrorist attacks, and the threat of a terrorism event, may also result in more severe psychological consequences than other types of traumatic events due to a perceived lack of control.
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From page 46... ...
46 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM TABLE 2-1 Characteristics of Disasters of Different Etiologies Etiology Human-Caused Characteristics Natural Error or Neglect Terrorism Intent Not present Not present Present intended to threaten and/ or incite fear Predictability Possibly, where disasters are cyclic in nature Possibly, where there Largely is a hazard site unpredictable; possible where there is a target of symbolic value Preventability May not be possible, May be possible with May be possible but warning may training and vigilance with security and limit impact monitoring of terrorist activity Societal disruption of normalcy and safety Local Present Present Present General May be present May be present Present Resultant sense of Present Present Present vulnerability Impact on emergency providers Directly involved Present Indirectly involved May be present Impact on special May be present groups Emergency, medical public health, and psychological management Pre-event Present May be present May be present Present Present Present preparedness Necessary Necessary Necessary Event response Necessary Necessary Necessary Post event recovery Necessary Necessary Necessary
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From page 47... ...
Terrorism has the capacity to erode the sense of community or national security; damage morale and cohesion; and open the racial or ethnic, economic, and religious cracks that exist in our society, as evidenced by an increase in hate crimes following ~ , ~ ~ ~ ~ the September 11, 2001, attacks (Human Rights Watch, 2002; FBI, 2002~. Spectrum of Consequences of Terrorism Following a terrorism event, most people will experience stressrelated symptoms across the spectrum of psychological responses as illustrated earlier in Figure 2-1.
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From page 48... ...
1-2 months after attacks 17% of a nationally representative sample reported symptoms of posttraumatic stress 2 months after the attacks; 5.8%, at 6-month follow-up 9.7% of Manhattan residents reported an increase in smoking, 24.6% reported an increase in alcohol consumption, and 3.2% reported an increase in marijuana use 5-8 weeks after the attacks Schuster et al., 2001 Schlenger et al., 2002 Silver et al., 2002 Vlahov et al., 2002 27% diagnosed with PTSD Amir et al., 1998 after treatment intervention consisting of group debriefing with brief group psychotherapy
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UNDERSTANDING THE PSYCHOLOGICAL CONSEQUENCES TABLE 2-2 Continued 49 Event Year Morbidity or Outcome Reference Oklahoma City: 1995 Fear during event and feeling Tucker et al., 2000 bombing that treatment was helpful were associated with higher risk of PTSD among adults seeking help Children, especially girls, who Peak, 2000 knew someone who died or who was injured in the bombing had more severe PTSD symptoms than those that did not know victims 45% of sample of survivors of direct blast had one or more psychiatric illnesses; 34% had PTSD Degree of television and emotional exposure was associated with posttraumatic stress symptoms among middle school students Tokyo, Japan: sarin 1995 gas released in subway NYC: shooting at van 1994 of Hasidic Jews North et al., 1999 Pfefferbaum et al., 2001b Somatic and psychological symptoms present at 2-, 3-, and 5-year follow-up 8 of 34 victims developed PTSD after the attack Symptoms of distress present in exposed individuals at 1-, 3-, and 6-month follow-up Kawana et al., 2001 Tochigi et al., 2002 Ohbu et al., 1997 4 of 11 survivors diagnosed Trappler & with PTSD and comorbid Friedman, 1996 major depression Ireland: various 1993-1994 5% of police officers exposed to Wilson et al., 1997 terrorism events terrorist-related critical incidents had PTSD at 7-10 month follow-up continued on next payee
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Although limited in number, these international research efforts add useful information to the knowledge-base on psychological consequences of different types of terrorism events. In general, findings regarding the psychological sequelae of terrorist attacks are simi
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Seven weeks after the bombing, 14.6 percent of the youth reported not feeling safe and 34.1 percent reported worrying about themselves or their families (Pfefferbaum et al., 1999~. This survey of middle school students also found that television and emotional exposure to the terrorism event was associated with posttraumatic stress symptoms (Pfefferbaum et al., 2001b)
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From page 52... ...
Results indicate widespread distress responses and symptoms of psychiatric illness that were not limited to students in proximity to the World Trade Center. Prevalence rates of symptoms such as those related to PTSD, generalized anxiety disorder, and separation anxiety were significantly higher than would be expected in children not exposed to a traumatic event.
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Other behaviors and outcomes reflecting functional impairment after terrorism events are in need of further study. School dropout rates, divorce, and domestic or interpersonal violence and conflict are potential future research topics in this area.
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reviewed a previously conducted meta-analysis examining predictors of adverse outcomes for traumatic events in general and concluded that preexisting factors have less influence on an individual than the disaster itself and subsequent factors such as community support. Some models of response propose that the impact of pre-existing factors is confounded with the dose of exposure; when the dose is less, the impact of pre-existing factors is more evident, and as the magnitude of the event increases, pre-event characteristics become less important.
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From page 55... ...
As in studies of disasters, the pre-event experience of traumatic events may be related to psychological consequences following terrorism events. For example, the investigation of New York City public school students after September 11,2001, found that nearly two-thirds of the students surveyed reported one or more prior traumatic events such as seeing someone killed or seriously injured and experiencing the violent or accidental death of a family member.
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From page 56... ...
Evidence suggests that terrorism events are similar to other traumatic events in this regard. As described earlier, psychological consequences will vary across the population in relation to the quality and extent of exposure: some people will experience direct physical trauma or threat of trauma; others, such as family members and friends, will experience grief and loss; and a wider population will be affected by secondary adversities and a general climate of fear.
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From page 57... ...
Results revealed that victims frequently reported a number of posttraumatic stress symptoms even after the hoax was announced. A similar relationship with adverse psychological consequences may exist with false alarms for terrorism events, although research in this area is also limited.
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From page 58... ...
Similarly, post-event factors predicting depression included panic attack during or shortly after the attacks, death of a friend or relative during the attacks, and job loss due to attacks. Although many people will exhibit some manifestation of distress in the aftermath of a terrorism event, several specific symptoms have been identified as being more predictive of later psychiatric illness.
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From page 59... ...
In contrast, terrorism events, like other disaster events, can also produce unique positive outcomes for the community. Because terrorism is generally directed at a population or subpopulation, there is often a sig7 Active coping strategies are behavioral or psychological responses intended to change the nature of the stressor itself or the way in which one thinks about it.
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From page 60... ...
In the case of a bombing or other physical terrorist attack, the individual will know immediately whether or not he or she has been physically harmed. A particularly difficult challenge that may present in cases of CBRN terrorism is the differentiation of apparent anxiety in people due to the possibility of exposure to a chemical or biological agent from direct neuropsychological or behavioral changes due to exposure to the agent.
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From page 61... ...
The model depicted in Tables 1-3, 1-5, and 1-6 is a potentially comprehensive structure for directing future research, and providing a framework for research to recognize and address the gaps. Much has yet to be learned even on the basic epidemiologic level, such as the incidence of psychiatric illnesses in various disaster populations when comparing terrorism with other kinds of events.
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From page 62... ...
In addition, research that refines possible population-based predictors of adverse outcomes after terrorism events, including ethnicity, age, and other pre-existing characteristics, is needed to guide future outreach and intervention efforts. Evidence is lacking on substance abuse outcomes after a terrorism event, and on interventions for these behaviors.
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From page 63... ...
The broader trauma literature may begin to help direct prevention and intervention efforts in response to terrorism events. However, it is no longer sufficient to rely on information obtained from research on other kinds of traumatic events because disasters, and particularly terrorism, differ in fundamental ways.
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