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Acts of Terrorism and How It Affects Family

ii Understanding the Psychological Consequences of Traumatic Events, Disasters, and Terrorism

Terrorism is intended to provoke collective fear and uncertainty. This fearfulness can spread rapidly and is not limited to those experiencing the issue directly—others that are affected include family members of victims and survivors, and people who are exposed through broadcast images. Psychological suffering is normally more prevalent than the concrete injuries from a terrorism event. Understanding these psychological consequences is disquisitional to the nation's efforts to develop intervention strategies at the pre-event, event, and mail service-event phases that will limit the agin psychological effects of terrorism.

This chapter serves as a brief overview of the literature on traumatic events, disasters, and terrorism. It first reviews a sample of the literature on the psychological consequences of traumatic events and disasters. The affiliate then describes the smaller torso 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 affiliate 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 straight responses to terrorism events. For a comprehensive review, the reader is referred to Holloway et al. (1997), Norris et al. (2002a, 2002b), and Rubonis and Bickman (1991).

TRAUMATIC EVENTS

The upshot of traumatic events on human functioning has been a subject of study for many years. An abundance of research has examined traumatic events ranging from individual events such equally motor vehicle crashes and sexual assaults to community-wide events such as natural disasters, commercial plane crashes, and customs violence, likewise as global events such as war.

As divers by the The Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition (DSM-IV), a traumatic event—or witnessing such an event—triggers fear, helplessness, or horror in response to the perceived or actual threat of injury or death to the individual or to another (APA, 1994). Traumatic events are normally perceived by the individual to be life-threatening, unexpected, and infrequent, and are characterized by high intensity (Ursano et al., 1994). Withal, traumatic events may be repeated inside a community, and in such environments the presence of a threat may become the norm. Show suggests that the type and severity of outcomes often vary according to the type of consequence (Freedy and Donkervoet, 1995).

The upshot of exposure to a traumatic event is variable and specific to the individual; both psychological and physiological responses tin vary widely. Social context, biological and genetic makeup, past experiences, and future expectations will collaborate with characteristics of the traumatic experience to produce the private's psychological response (Ursano et al., 1992). In general, those exposed to a traumatic outcome show increased rates of acute stress disorder, posttraumatic stress disorder (PTSD), major depression, panic disorder, generalized anxiety disorder, and substance use disorder (Kessler et al., 1995). Although psychiatric illnesses such every bit PTSD are the more than astringent outcomes of traumatic events, they are also the best studied. Much of the research literature has focused specifically on PTSD considering it is a recognized and well-defined consequence of traumatic events (meet Box 2-one). Notwithstanding, PTSD is just 1 effect in a myriad of consequences resulting from traumatic events.

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Box 2-1

Posttraumatic Stress Disorder. PTSD and acute stress disorder (ASD) are two of the principal DSM-IV illnesses that are diagnosed afterward a traumatic consequence. The diagnosis of both PTSD and ASD requires exposure to a traumatic event and a response to the event (more...)

Spectrum of Consequences of Traumatic Events

The experience of a traumatic result does not necessarily lead to serious psychological difficulties. As discussed in Chapter 1, at that place is a spectrum of consequences ranging from distress responses such as mild anxiety, to behavioral changes such equally balmy difficulty sleeping, to the onset of a diagnosable psychiatric illness (see Effigy i-2). These consequences more often than not can be placed into three categories of severity, which may likewise correspond to strategies for intervention:

  • The majority of people may experience mild distress responses and/or behavioral change, such as insomnia, feeling upset, worrying, and increased smoking or booze apply. These individuals volition probable recover with no required handling, merely may benefit from education and community-wide supportive interventions.

  • A smaller group may have more moderate symptoms such as persistent indisposition and anxiety and volition probable benefit from psychological and medical supportive interventions.

  • A small subgroup will develop psychiatric illnesses such as PTSD or major low and will require specialized treatment.

The number of people experiencing each of these outcomes varies directly with the severity of the event and with proximity of exposure to it. Most people will experience balmy or infrequent symptoms, while only a few may experience frequent and/or astringent symptoms. Because terrorist attacks may cause violent injury, death, and destruction, there often will be a targeted population that experiences extreme trauma, a widening grouping of family unit members and friends who are likewise therefore direct affected, and an even larger customs and societal population who are confronted with the danger of terrorism through the media and on a daily basis. Furthermore, the relative number of people in any 1 of these categories is based not only on the population but too characteristics of the event itself. Figure 2-1 provides a conceptual illustration of this human relationship betwixt proximity and severity, and outcomes; it should exist kept in mind that this bend is theoretical and proportions volition change in some situations.

FIGURE 2-1. Severity of psychological reactions experienced by the population following a traumatic event.

Effigy 2-1

Severity of psychological reactions experienced past the population following a traumatic event. NOTE: Indicative only.

The association betwixt severity and/or number of symptoms and the number of people affected is important to consider when planning interventions in the backwash of a community-wide disaster or terrorism effect. The severity and diagnostic constellations of symptoms will dictate what treatment or intervention, if any, is needed. People with mild symptoms may wait fairly rapid resolution of their symptoms and may require fairly elementary interventions and/or support, such equally appropriate take chances communication messages from the media and public health customs explaining that these symptoms are normal, expected reactions to the experience of a traumatic upshot. The minority of people with severe symptoms and/or psychiatric disease may require conventional treatment from the mental health system. This highlights the demand for coordination and collaboration between the public health and mental health communities in guild to accost the needs of diverse populations across the spectrum of symptoms and manifestations.

Traumatic Events in Children and Adolescents

The childhood feel of traumatic events induces immediate biological and psychological reactions, some of which may persist for an extended period. The psychological symptoms of traumatic events in children and adolescents are similar to those recognized in adults, just often appear as age-appropriate expressions of the stressful event. See Box 2-2 for examples of possible reactions of children to traumatic events.

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Box 2-two

Possible Reactions to Traumatic Events of Children. Children 5 years and younger may take a persistent fearfulness of being separated from parents or caregivers or exist excessively clingy

Youth who have been exposed to violence have been more likely to develop psychological bug and take poor functioning at home and school (Cohen, 1998; Pynoos et al., 1995; Richters and Martinez, 1993). Recent studies indicate that about one-third of children exposed to customs violence develop PTSD (Berman et al., 1996; Fitzpatrick and Boldizar, 1993). Youth exposed to traumatic events also tin develop low, other anxiety disorders, substance use disorders, and issues with schoolhouse performance (Brent et al., 1995; Clarke et al., 1995; Saigh et al., 1997; Singer et al., 1995; Weine et al., 1995). Widespread negative psychological furnishings 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 prove alterations in stress hormone systems. Notwithstanding, a unique difference among children is the association of exposure to traumatic events with measurable discrepancies in neurophysiological evolution. It is believed that prolonged levels of significant stress may adversely affect the neurophysiological development of immature children in ways that may take long-term consequences for behavioral responses to stress and afterwards psychiatric affliction (for reviews, see De Bellis, 2001; Glaser, 2000). It is difficult to draw definitive conclusions from this enquiry, notwithstanding, since findings are oft confounded with preexisting hazard factors for experiencing a traumatic event that are also associated with differences in brain physiology.

DISASTERS

A subset of the broader trauma literature has focused on the psychological consequences of disasters. Disasters differ from other forms of traumatic events in that, by definition, they are likely to affect larger segments of the population or entire communities of individuals, causing widespread destruction and distress.

Spectrum of Consequences of Disasters

Comprehensive reviews of the literature have consistently revealed a wide range of agin outcomes following disasters (come across, for example, Katz et al., 2002; Norris et al., 2002b; Rubonis and Bickman, 1991; Solomon and Green, 1992). Results of a review of 49 research articles and books conducted by Solomon and Greenish (1992) revealed that most authors reported negative psychological consequences of disasters. Norris and colleagues (2002b) reviewed 177 articles that examined 80 unlike disasters.1 The authors organized the most often documented negative sequelae of disasters into five categories:

  • Specific psychiatric illnesses (for instance, PTSD, depression)

  • Nonspecific distress (symptoms without a specific diagnosis, such as demoralization, perceived stress, and negative affect)

  • Health issues and concerns (for example, somatic complaints, sleep disruption, increased apply of sick leave)

  • Chronic problems in living (for example, social disruption, family conflict, fiscal and occupational stress)

  • Psychosocial resources loss (for example, decreases in social participation and perceived support)

The authors suggest that children were the segment of the population at greatest take chances for psychological trauma, behavioral changes, and impairment. Research suggests that disasters experienced at a younger age may have long-term psychological consequences. One study followed a grouping of adolescents who experienced the sinking of a ship, and institute that more than a third of those adolescents who developed PTSD subsequent to the disaster nonetheless had PTSD at either v or eight years follow-up (Yule et al., 2000).

It is important to annotation that many psychological reactions to disasters are considered ordinary responses to stress. For example, near half of the survivors of an earthquake in Northridge, California, exhibited distress symptoms of reexperiencing the disaster and hyperarousal, just these symptoms alone were not associated with psychiatric illness and were considered "normal" (McMillen et al., 2000). Regardless of psychiatric disease, information technology is critical to consider functional impairment when evaluating the psychological consequences of a disaster or other traumatic event. Box ii-3 presents examples of other ordinary and expected psychological responses to a disaster.

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Box 2-3

Examples of Reactions of People Who Experience Traumatic Stress. Thoughts Common

In addition to psychiatric disease and distress reactions, experiencing a disaster may effect in alterations in health-related behaviors and produce full general life changes. Substance use is one wellness-related beliefs commonly thought to increase in the backwash of a disaster. Cigarette smoking and alcohol employ may increment in individuals with PTSD after any kind of traumatic event (Shalev et al., 1990). In their all-encompassing review of disaster studies, Norris and colleagues (2002b) observed increased substance utilise in 25 percent of the populations under report. Notwithstanding, increased substance utilize does not necessarily develop into substance apply disorders, and Katz and colleagues (2002) noted that only a small number of studies take looked at substance apply equally an event. Family unit interactions constitute some other area of beliefs that may be influenced by disasters. For example, Adams and Adams (1984) found increased domestic violence and family unit bug in a population of survivors of the Mount Saint Helens eruption. Family relationships and other social variables are an surface area not as frequently studied as other areas discussed hither and are in demand of farther investigation.

Testify suggests that adverse psychological consequences of disaster misemploy over time for the majority of people. The studies included in Norris and colleagues' review suggested that symptoms measured shortly later the disaster were predictive of symptoms at subsequent points in time, and the greatest severity of symptoms was usually experienced inside one year following the disaster; merely a minority of disaster survivors had whatsoever significant and persistent impairment afterward the first twelvemonth.

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. Thus, in society to intervene accordingly, it is important to be able to predict which individuals may experience long-term and serious consequences and to judge the number of individuals that may be afflicted. Predictors of long-term impairment after a disaster include many of those observed in other traumatic events. Moderators of adverse outcomes have been categorized into pre-effect, result, and post-event phases that are consistent with the event phases described in Chapter 1.

Pre-Event. Female gender has been associated with poorer event following disasters, as has depression socioeconomic condition and minority status. The run a risk of PTSD after a disaster is also increased by the presence of a predisaster history of psychiatric illness (Smith et al., 1990; Yehuda, 2002) and particularly by a history of low (Shalev et al., 1998). Nonetheless, Bromet et al. (1982) found no significant difference in mental health outcomes betwixt patients with a psychiatric illness who experienced the 3 Mile Island disaster and a control grouping.

Event. Traditionally, mental health research has classified disasters into two categories: natural and human-caused2 (the latter includes technological disasters such equally hazardous materials spills, aviation disasters, terrorism, and even acts of war) (come across Figure 2-2).

FIGURE 2-2. Categories of disaster.

FIGURE 2-2

Categories of disaster. SOURCE: Ursano (2002).

Although these categories are non e'er mutually sectional, as demonstrated in Figure 2-2,3 there is some evidence to propose that private responses to disaster may vary depending on the type of event. While research in this expanse has typically examined natural disasters versus human being-caused disasters, there is no consensus regarding which events may produce a specific type of response. For instance, Northward and Smith (1990) suggested, based on a review of the disaster literature, that homo-caused disasters may result in higher rates of diagnosable psychiatric illnesses, and others have reported that human-caused disasters effect in more persistent psychopathology (Baum, 1990; Dark-green et al., 1990; Solomon and Green, 1992). Conversely, Rubonis and Bickman (1991) concluded in their review of 52 studies that human-caused disasters resulted in less severe psychopathology4 than natural disasters.

As shown in Figure two-2, a stardom can exist made betwixt inadvertent human-caused disasters such every bit those caused by fault or neglect and intentional human being-acquired disasters such every bit those due to terrorism or mass violence. These two types of human-caused disasters may each lead to different types and severity of psychological consequences. However, research examining this consequence is limited. The review by Norris et al (2002b) used a slightly different classification past disaster type with 3 categories: natural; technological (for instance, oil spills, transportation accidents); and mass violence (for example, shooting sprees, mass suicides, terrorism). Mass violence events were significantly more likely to result in severe impairment in the populations nether study than either technological or natural disasters. Therefore, although research shows that all types of disasters, including intentional and inadvertent human-caused disasters, may cause psychological distress, behavior modify, or psychiatric illness to different degrees, additional studies should place the mechanisms and specific characteristics leading to agin outcomes.

Norris and colleagues (2001) advise that when at least 2 of the post-obit four characteristics of disasters are nowadays, the mental health impact will exist greatest:

  • Widespread harm to property

  • Serious and ongoing fiscal problems

  • Human being error or human intent that caused the disaster

  • High prevalence of trauma (injuries, threat to life, loss of life)

With the exception of "serious and ongoing financial problems," these of import characteristics of disaster experiences are specific to the event phase. Understanding how specific aspects of disasters relate to specific outcomes volition help facilitate planning for mental health interventions in the backwash of disasters.

Post-Issue. The presence or absence of psychosocial back up is significantly associated with outcomes. When people feel that they have been neglected or forgotten past their regime or customs, they are more than likely to have long-term adverse effects from a disaster experience (Norris et al., 2002b). In addition, as mentioned above, ongoing financial stress, job loss, and other mail service-effect negative occurrences are associated with more severe adverse psychological consequences.

Positive Psychosocial Consequences

Although less well documented than the negative effects, the feel of a disaster or other traumatic event may result in a positive bear on on both individuals and the community. A pocket-sized but growing literature exists on the procedure of posttraumatic growth, describing the development of adaptive coping mechanisms and feelings of cocky-efficacy following exposure to traumatic events (e.grand., Calhoun and Tedeschi, 2001). Thus, the experience of a traumatic upshot tin also promote resilience for hereafter traumatic events.

The communal experience of overcoming a disaster may promote greater customs cohesion. Altruism and volunteerism frequently increase in the aftermath of a disaster. These are phenomena that can be beneficial both to those receiving the help and to those who volunteer, since the perception of self-efficacy and the ability to "do something" can help people to cope with the disaster feel.

TERRORISM

Terrorism, a subset of human-caused disasters (Figure two-2), can have a particularly devastating touch on psychological functioning. Terrorism carries with it a potentially greater bear upon than other disasters on distress responses, behavioral change, and psychiatric affliction by virtue of the unique characteristics of terrorism events (see Table two-one).

TABLE 2-1. Characteristics of Disasters of Different Etiologies.

Tabular array ii-1

Characteristics of Disasters of Different Etiologies.

Terrorist attacks, and the threat of a terrorism upshot, may too effect in more astringent psychological consequences than other types of traumatic events due to a perceived lack of command. Perceptions of risk are influenced by the caste to which individuals feel they accept cognition of and control over an exterior result and how familiar and catastrophic the result will exist (for review, see Slovic, 1987). People are more likely to feel that an activity or effect is not dangerous if they can control information technology. Nether these circumstances, it becomes less effective to cope past distancing oneself from the population at gamble if the risk is seemingly random. For example, the degree of public feet resulting from the 2001 Washington, D.C., area sniper attacks was much greater than the feet levels related to the violence that is owned to many Washington, D.C., areas. The event affected many people in the region for weeks. It was easier for people to distance themselves from urban violence (which is controllable by staying abroad from urban centers) than from the sniper attacks that were perceived as more threatening and random than everyday shootings.

In add-on to its distinctive characteristic of intent, terrorism can uniquely disrupt societal performance. Terrorism has the capacity to erode the sense of customs or national security; impairment morale and cohesion; and open the racial or ethnic, economical, and religious cracks that be in our order, equally evidenced past an increase in hate crimes following the September xi, 2001, attacks (Human Rights Watch, 2002; FBI, 2002).

Spectrum of Consequences of Terrorism

Following a terrorism issue, most people volition experience stress-related symptoms across the spectrum of psychological responses every bit illustrated earlier in Figure 2-1. Many of the psychological consequences of terrorism are similar to those seen in the aftermath of other disasters. Withal, the literature specific to the psychological sequelae of terrorist attacks is much more limited in both prevalence and detail than that related to other types of disasters. Similar to research in the broader trauma field, most of these studies take focused on PTSD or symptoms of PTSD as outcomes. Less is known most other, nonpathological outcomes. It is often hard to compare studies because of the use of varying and previously unvalidated measurement instruments. Furthermore, the significance of selected PTSD symptoms for determining longer-term functioning is unclear. Methodological issues regarding this line of inquiry are discussed further at the determination of this chapter. A review of the psychological consequences of terrorist attacks by Gidron (2002) found vi studies that met his criteria for inclusion.5 In this review, Gidron calculated the rate of PTSD for those who were directly exposed to a terrorist attack to exist 28.two percent. Given that the terrorist attacks on the World Merchandise Center and the Pentagon on September eleven, 2001, in add-on to directly impacting thousands of people, may take had more than 100,000 direct witnesses (Schuster et al., 2001) and that millions beyond the land experienced the events through repeated media depictions, it can be presumed that the touch of these events was quite significant. Table 2-2 presents meaning findings from a selected set of studies examining a range of terrorism events.

TABLE 2-2. Sample of Research on Psychological Consequences of Terrorism Events.

Table 2-ii

Sample of Research on Psychological Consequences of Terrorism Events.

Studies taking place exterior of the United States have frequently used like designs to those within the United states, oftentimes focusing on PTSD or symptoms of PTSD. Although limited in number, these international inquiry efforts add useful data to the knowledge-base on psychological consequences of different types of terrorism events. In general, findings regarding the psychological sequelae of terrorist attacks are similar to those seen in United States–based studies; commonly reported effects include PTSD and symptoms of PTSD, major low, and general psychological distress every bit determined by diverse measures. Some of these studies also provide unique perspectives considering they have been carried out on populations that accept been exposed to varying forms of terrorism events such as smaller-scale bombings and shooting attacks (e.g., Abenhaim et al., 1992; Wilson et al., 1997) and a chemical attack (Kawana et al., 2001; Ohbu et al., 1997; Tochigi et al., 2002), while much of the torso of research from the United States has focused on big explosive attacks.

2 of the virtually significant acts of terrorism in the United States, the 1995 Oklahoma City bombing and the attacks of September eleven, 2001, prompted a small, but growing, literature on psychological consequences of terrorism in this state. Inquiry on the Oklahoma Metropolis bombing revealed PTSD in approximately 1-third of survivors of the direct bomb blast six months after the bombing, and nearly three-fourths of these were individuals with no prior history of PTSD (North et al., 1999). North and colleagues (1999) identified a specific constellation of symptoms that was highly predictive of PTSD. Avoidance and numbing symptoms were much more mutual among Oklahoma Metropolis bombing survivors with PTSD. In contrast, the symptoms of intrusive reexperience and hyperarousal were "near universal" among survivors and were not predictive of PTSD when occurring by themselves.

Several studies conducted later on the Oklahoma Metropolis bombing focused on an adolescent population from the Oklahoma Urban center Public School District. More than twoscore pct of the middle school students who participated in one survey reported that they knew someone who was injured in the bombing, while more than 30 percent knew someone who was killed. Seven weeks later on the bombing, 14.6 percent of the youth reported not feeling safe and 34.1 percent reported worrying virtually themselves or their families (Pfefferbaum et al., 1999). This survey of middle school students likewise found that television and emotional exposure to the terrorism effect was associated with posttraumatic stress symptoms (Pfefferbaum et al., 2001b). Schoolhouse officials in Oklahoma City reported a 25 percent decrease in attendance in the kickoff weeks following the bombing. Students' initial apprehension almost returning to school was shared past parents who sought bear witness of better protective measures (Wong, 2001). Teachers and school administrators became concerned most their power to identify future perpetrators and to ensure the safety of students and staff.

A number of authors take investigated the impact of the terrorist attacks of September 11, 2001, on the Us population in general and on New York City residents specifically. Galea and colleagues (2002) examined PTSD symptoms in New York City residents one to ii months subsequently the set on. Results indicated that seven.5 percent of Manhattanites reported criterion symptoms of PTSD that were and then used to estimate the prevalence of the disorder, while xx per centum of those nearly the Globe Merchandise Middle at the time of the attacks reported such symptoms. Schlenger and colleagues (2002) studied a nationally representative cross-sectional sample one to ii months subsequently the attacks using cocky-reported symptoms of PTSD and general psychological distress to measure what they termed "probable PTSD." They found that residents of the New York City metropolitan expanse had the highest rate of likely PTSD in the country at 11.2 percent; the charge per unit in the Washington, D.C., metropolitan area was 2.7 percentage, in other major metropolitan areas 3.half dozen percent, and across the rest of the country 4.0 per centum. A similarly designed nationally representative study by Silver and colleagues (2002) plant that two months after the attacks, 17 percent of the country (non including those residing in New York City) had symptoms of September 11th–related posttraumatic stress, while at six months, this number decreased to five.viii percent. The discrepancy between the rates found past these two studies (4 percentage versus 17 percent) likely reflects the different methodologies and populations used to guess posttraumatic stress. In a national phone survey conducted immediately after September 11, 2001, Schuster et al. (2001) measured the presence of various symptoms of distress responses. The symptoms reported by adults included feeling very upset when reminded of the events (30 percentage), having trouble falling or staying asleep (11 percent), and feeling irritable (9 per centum).

A large study commissioned past the New York City Board of Education examined the psychological consequences of the September 11, 2001, terrorist attacks on 8,266 public school students in grades 4–12 throughout the five boroughs of New York Metropolis six months afterwards the attacks (Hoven et al., 2002). Results indicate widespread distress responses and symptoms of psychiatric illness that were not limited to students in proximity to the World Trade Centre. Prevalence rates of symptoms such as those related to PTSD, generalized anxiety disorder, and separation anxiety were significantly college than would be expected in children not exposed to a traumatic result. Still, because pre-event baseline information are non available for the children surveyed, it is difficult to ascertain whether these findings reverberate exposure to the terrorism event or other features of the population.

Similar to findings in the disaster mental health literature, some evidence indicates that terrorism events may lead to increases in substance use. One survey of residents of New York, Connecticut, and New Jersey found that 21 per centum of cigarette smokers reported an increment in smoking after the attacks (Melnik et al., 2002). Similarly, Vlahov and colleagues (2002) reported increases in substance use, including alcohol, in New York City and the surrounding areas in the months later September 11, 2001. In comparing, a study of survivors of the Oklahoma City bombing found no new cases of diagnosable substance use disorder subsequent to the attack (North et al., 1999). It is important to make a distinction betwixt increases in substance utilize and substance abuse. Data indicating a simple increase in alcohol or tobacco utilize exercise non necessarily indicate problematic or long-continuing behavior changes.

Other behaviors and outcomes reflecting functional impairment afterwards terrorism events are in demand of further report. Schoolhouse dropout rates, divorce, and domestic or interpersonal violence and disharmonize are potential future enquiry topics in this area. Increases in school or piece of work absenteeism, which may indicate functional impairment, have been noted post-obit terrorist attacks. A survey past Melnik and colleagues (2002) found that 27 percentage of respondents who were working in New York Metropolis at the fourth dimension of the September 11, 2001, attacks missed work in the following days. This was due primarily to transportation issues caused by increased security measures such as surveillance of bridges and tunnels leading into Manhattan. Increased absenteeism from work or schoolhouse has as well been reported afterward other violent events. For instance, during the serial sniper attacks in the Washington, D.C., metropolitan area in October 2002, a significant increase in school absences occurred, with attendance rates equally depression equally 10 per centum at several elementary schools almost one of the shooting sites (Schulte, 2002). Even so, this behavior may exist considered an appropriate response rather than a distress response because one of the victims of the sniper was a child who was shot while walking from a car into a school. A similar stardom can be made when looking at behavioral responses to the anthrax attacks of 2001. An average citizen using gloves to open mail may have been considered to manifest an adverse behavioral alter related to psychological distress. However, if the person was a staff member in ane of the offices specifically targeted in the anthrax mailings, the utilize of gloves might be considered an advisable response.

Health care seeking by individuals who are not actually at risk or injured, merely seek health care due to fearfulness and anxiety, has been observed in response to terrorism events. This phenomenon was noted following the sarin poisoning in the Tokyo subway and during the anthrax attacks in the fall of 2001 when tens of thousands of people who were non at adventure for exposure obtained prescriptions for the antibiotics ciprofloxacin and doxycycline (Shaffer et al., 2003). Accurate and timely risk advice becomes peculiarly of import in limiting the potential stress on the wellness intendance system because unaffected individuals inundation services. This blazon of behavior is about likely to occur in the event of chemical, biological, radiological, or nuclear set on and is discussed farther below in the section detailing the consequences of these types of terrorism.

Moderators of Agin Outcomes after Terrorist Attacks: Identifying Vulnerable Populations

Research from the disaster mental wellness field has developed models that stratify groups based on exposure level. These levels include those indirectly or remotely affected—individuals who are not in close geographic proximity to the incident, but who witness the event through the media; those who are negatively exposed through secondary effects such as an economic downturn; and those who experience the decease of or immediate risk to a loved one from the terrorism event (i.e., relatives, friends, coworkers, rescue workers, witnesses). The populations that volition exist directly affected may vary according to the blazon of issue (e.g., bombing; hijacking; chemic, biological, radiological, or nuclear attack). For example, a biological assail on the U.S. food supply may have a direct impact on agricultural workers through both physical and economical effects, and the resulting disruption may have an indirect affect on society equally a whole. Given the large number of individuals, from those remotely to those directly exposed, who may be afflicted by a terrorism result, it is important to recognize variations among these exposed subpopulations in order to place those who are most vulnerable to the psychological consequences of the event. This will allow for the focus of express resource on prevention and intervention for those virtually in need.

Virtually all members of communities affected past terrorism are vulnerable to negative psychological outcomes. The type of vulnerability may vary substantially and may not always be obvious. Diverse variables that may raise the prediction of adverse outcomes following a terrorism upshot are presented below in pre-event, effect, and post-outcome temporal categories.

Pre-Effect. Shalev (2001) reviewed a previously conducted meta-analysis examining predictors of agin outcomes for traumatic events in general and concluded that preexisting factors accept less influence on an individual than the disaster itself and subsequent factors such as community support. Some models of response propose that the affect 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-effect characteristics go less of import. Regardless, these preexisting factors are useful to consider when planning service delivery because they allow for a better understanding of those who may exist at increased risk and require particular attention.

Gender, age, feel, and personality have all been implicated in moderating adverse outcomes. Female person gender has been associated with worse brusk-term outcomes in a number of studies of the general population after September 11, 2001 (east.thousand., North et al., 1999; Schlenger et al., 2002; Silver et al., 2002). Prior marital separation and preexisting physical illness have also been implicated in predicting greater psychological distress subsequently these events (Silver et al., 2002).

Every bit in studies of disasters, the pre-event experience of traumatic events may exist related to psychological consequences following terrorism events. For instance, the investigation of New York City public school students later on September xi, 2001, found that nearly ii-thirds of the students surveyed reported ane or more prior traumatic events such every bit seeing someone killed or seriously injured and experiencing the tearing or adventitious decease of a family member. In this sample, a history of prior traumatic events was associated with significantly increased rates of symptoms consistent with PTSD (Hoven et al., 2002). It is hard, however, to discern the relative contributions of the prior traumatic events and the actual terrorism event to the reported symptoms given the lack of pre-event baseline data in this population.

Age has been identified every bit possibly moderating psychological responses to terrorism. While several studies examining developed populations take constitute no pregnant influence of age on the severity of psychological responses to terrorist attacks (e.g., Abenhaim et al., 1992), the psychological impact of terrorist attacks on children and adolescents is oft noted equally an area of concern as described above. One study reported that students in the 4th and 5th grades were significantly more likely than those in grades half-dozen through twelve to endorse symptoms consistent with PTSD later on the September 11, 2001, terrorist attacks (Hoven et al., 2002). Further inquiry is needed to determine if children and adolescents are at greater risk for psychological consequences than adults.

The disaster literature has also identified ethnic and racial minority status equally a potential moderating cistron on agin outcomes. Norris and colleagues (2002b) reviewed studies that included ethnicity as a variable and plant that among adults, indigenous majority groups had better outcomes after disasters than minorities in all of the samples. Among youth, nevertheless, the results were more than variable. The enquiry base examining racial and indigenous minority status as a factor predicting outcomes to terrorism events is extremely limited, although a few studies provide some indication. For case, Galea et al. (2002) found that Hispanic ethnicity predicted symptoms consequent with both PTSD and depression amongst Manhattan residents later the September eleven, 2001, terrorist attacks. Similar results were found amidst New York City public schoolhouse students after those attacks; Hispanic students were more likely than either African-American, white, or Asian students to accept symptoms of PTSD (Hoven et al., 2002).

Findings from the disaster mental health literature accept indicated that kickoff responders and rescue workers are a population at risk for agin psychological outcomes after responding to disasters (eastward.one thousand., Duckworth, 1986; Jones, 1985; Weiss et al., 1995), likely due to their direct and ofttimes ongoing exposure to traumatic experiences. Findings later on terrorism events reveal similar results. One report of New York City Fire Department rescue workers found a seventeenfold increase in stress-related incidents (e.m., depression, feet disorders, bereavement issues) during the 11-month flow post-obit the September 11, 2001, attacks as compared to the xi-month period preceding the attacks (Banauch et al., 2002). These information, nevertheless, may not represent the typical experiences of first responders and rescue workers considering of the deaths of so many beau firefighters in the immediate aftermath of the attacks. North and colleagues (2002b) found a PTSD rate of thirteen percent amid rescue workers in Oklahoma City. PTSD was associated with more days spent working at the site and more fourth dimension spent in the cardinal bombing pit. However, this written report compared rescue workers to main victims of the bombings and found that PTSD was significantly lower among rescue workers. The authors speculated that this may be related to characteristics of rescue workers such as preparedness, experience with job-related traumatic events, and cocky-selection for the type of piece of work, as well as lower injury rates amidst rescue workers and exposure to education and debriefing aimed at mitigating psychological consequences (North et al., 2002b).

Event. While it is articulate that sure populations may be particularly vulnerable to agin outcomes post-obit a terrorism issue, in that location are factors related to the event itself that may affect the degree of impact. Findings from the disaster and other trauma literature have suggested that the duration and intensity of exposure to the traumatic event, including indirect exposures such as traumatic grief and loss, are some of the most important predictors of an adverse impact on subsequent functioning. 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 straight physical trauma or threat of trauma; others, such as family unit members and friends, will experience grief and loss; and a wider population will exist affected by secondary adversities and a full general climate of fearfulness. Silver and colleagues (2002) found that the degree of exposure to the September 11, 2001, attacks (as measured past a composite of proximity to the diverse attack sites, presence at a site, contact with a victim whether visually or by phone during the attacks, and caste of watching the events live on TV) was significantly predictive of psychological distress, more so than the caste of loss,half-dozen although both exposure and degree of loss were associated with distress. Similarly, Schlenger et al. (2002) suggested that the amount of fourth dimension spent watching television coverage predicted both PTSD symptomatology and full general distress, although these authors were conscientious to annotation that this clan did non necessarily imply causation (east.thou., more symptomatic people could have been drawn to watching the boob tube news coverage). Encounter Box ii-4 for boosted information on the role of the media during terrorism events.

Box Icon

Box 2-4

Role of the Media During Terrorism Events. Speculation well-nigh the communicability of terror through media accounts has increased recently. Some evidence has revealed an association between exposure to media accounts of terrorist acts and psychological (more...)

Other important event-related characteristics include the duration and type of set on. Dissimilar other disasters, terrorism events may manifest equally a unmarried massive assault (eastward.g., Oklahoma City bombing), multisite consequence (e.g., events of September 11, 2001), multisite continuous or repeated events (due east.g., anthrax attacks of 2001), or continuous or repeated events (e.g., terrorist attacks in Northern Ireland) (Ursano, 2002). The mechanism or blazon of attack too may moderate outcomes. Biological and radiological attacks may involve considerable on-going exposure to the threat and delayed emergence of physical symptoms, while an assault with conventional explosives will probable exist a discrete upshot with obvious and more than firsthand injuries. The effects of cyberterrorism events, which have not been adequately studied, are largely unknown. These characteristics of terrorism events can determine the caste of population exposure, and the severity and magnitude of psychological consequences.

Hoaxes and copycat events may initially result in psychological consequences similar to those of bodily terrorism events. Although the research base is extremely limited, the psychological impact of a hoax may exist as swell as that of a true threat. For instance, Dougherty, et al. (2001) examined the psychological impact on victims of two incidents of anthrax threats that were after adamant to be hoaxes and establish show of distress symptoms. Results revealed that victims often reported a number of posttraumatic stress symptoms even subsequently the hoax was announced. A similar relationship with adverse psychological consequences may exist with false alarms for terrorism events, although inquiry in this area is besides express. False alarms and warnings that are given to people not at adventure have implications for futurity preparedness and response since a "cry-wolf" syndrome may result in which people become less responsive to hereafter warnings (NRC, 2002b).

Post-Event. A number of post-event factors may also help place those at increased chance for negative psychological outcomes. The investigation by Galea and colleagues (2002) examining residents of Manhattan after the September eleven, 2001, terrorist attacks constitute that postal service-event factors predicting PTSD symptoms included panic attack during or shortly subsequently the attacks, and loss of possessions due to the attacks. Similarly, post-event factors predicting depression included panic set on 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 showroom some manifestation of distress in the aftermath of a terrorism event, several specific symptoms have been identified equally being more than predictive of later psychiatric illness. These symptoms include feeling numb, withdrawn, or disconnected; isolation from others; and avoiding activities, places, or people that bring back memories of the event (Northward et al., 1999, see also Box two-3). It may be of import to screen for these specific symptoms during the postal service-event period in order to identify individuals who may require mental wellness intendance. The ways in which people cope with the stress of a terrorism consequence is also predictive of later on outcomes. Silver and colleagues (2002) found that those who used active copingvii had less distress than those who demonstrated denial, defeatism, and cocky-lark—indicating disengagement with coping—had greater distress.

Secondary and Community Consequences

Considering terrorism, dissimilar natural disasters or homo-caused technological failures, is a purposeful act by an individual or a group of individuals, terrorist acts are frequently perceived to be perpetrated by a specific ethnic, racial, or religious group. Recently, argue has increased about the controversial practice of profiling based on these characteristics for police force enforcement purposes in the identification of potential terrorists. In improver, discrimination or stigmatization of the identified racial, ethnic, or religious group are potential outcomes of such perceptions, and may constitute threats to community cohesion and to the psychological well-being of those who are the targets of bigotry. Community cohesion can decrease as neighbors become suspicious of strangers and of ane some other. A multiethnic and multicultural population might exacerbate these fears. Afterwards the terrorist attacks on September 11, 2001, the number of hate crimes confronting Arabs, Muslims, and those perceived to be Arab or Muslim rose sharply (Human Rights Sentinel, 2002). Violent acts included murder, concrete assaults, arson, vandalism of places of worship and other belongings damage, death threats, and public harassment. About of these incidents occurred between September xi, 2001, and Dec 2001. According to Federal Bureau of Investigation (FBI, 2002) statistics, the number of anti-Muslim hate crimes rose from 28 in 2000 to 481 in 2001. Similar increases in the numbers of anti-Muslim hate crimes have been reported in relation to the Oklahoma City bombing, the crash of TWA Flying #800, and the Persian Gulf War (Man Rights Scout, 2002).

In contrast, terrorism events, like other disaster events, can also produce unique positive outcomes for the community. Considering terrorism is generally directed at a population or subpopulation, there is oft a meaning growth of patriotism and pride for the population following the effect. For example, subsequently the terrorism events on September 11, 2001, many people reported an increased appreciation for the freedom afforded by living in the United States (Silver et al., 2002). People also reported closer relationships with their family members subsequent to those attacks (Silver et al., 2002).

Chemical, Biological, Radiological, and Nuclear Terrorism

Chemic, biological, radiological, and nuclear terrorism (CBRN) deserves special mention, given the unique characteristics. Such threats are unfamiliar, commonly undetectable while they are dangerous, and often perceived as specially reprehensible and unfair. These qualities present additional psychological challenges. The presence of an "incubation period" in which an individual may take been exposed to an agent but may not know the outcome is some other unique and potentially stressful aspect of CBRN terrorism. In the case of a bombing or other physical terrorist assault, the individual will know immediately whether or not he or she has been physically harmed.

A particularly difficult claiming 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 amanuensis from directly neuropsychological or behavioral changes due to exposure to the agent. The initial presentation of a chemic and biological weapon set on may be neuropsychological symptoms. For instance, astute poisoning with a sub-lethal dose of an organic phosphorus chemical compound (eastward.k., sarin) produces cerebral impairments characterized by confusion, difficulty in concentration, and drowsiness (Jones, 1995); individuals exposed to cyanide may initially present with anxiety and agitation, reflecting tissue hypoxia (Baskin and Rockwood, 2002); and exposure to fungal toxins tin result in psychosis, somatic complaints, anxiety, agitation, and involuntary movements (Benedek et al., in press). Furthermore, physical manifestations of panic such as shortness of breath might exist mistaken as symptoms of infection or contamination, which then becomes a cocky-reinforcing cycle as the private'due south panic is increased by the shortness of jiff, resulting in an exacerbation of this symptom.

Individuals with nonspecific somatic complaints such as nausea or weakness volition be a great business concern in the outcome of biological or chemical attacks when the presenting symptoms of exposure may exist nonspecific and like to other common conditions. For example, during the anthrax attacks in fall of 2001, the initial symptoms of infection mimicked viral syndrome and influenza-like symptoms. Many emergency physicians and main care physicians were overwhelmed with individuals concerned about their exposure and requesting testing and/or treatment for anthrax exposure, which may or may not have occurred and for which tests were non always available. The extensive publicity most the anthrax threat likely increased self-monitoring for symptoms. This scenario was also seen among the Israeli civilian population during the Gulf War when people went to hospitals concerned that they had been exposed to nervus gas from Iraqi Scud missiles (Golan et al., 1992). The 1995 terrorist attack involving the nervus amanuensis sarin in the Tokyo subway arrangement besides illustrated this phenomenon. Nearly 75 per centum of those who went to the hospital and were reported every bit "injured" showed no furnishings of exposure to sarin (Lillibridge et al., 1995). An investigation conducted by Ohbu and colleagues (1997) examined various psychological distress responses in survivors of the sarin gas assault. The individuals reported symptoms such equally fear of subways (32 percent), sleep disturbances (29 percentage), flashbacks (16 per centum), and irritability (10 percent).

RESEARCH CHALLENGES AND NEEDS

Conducting enquiry on the psychological consequences of terrorism and testing interventions in this setting are extraordinarily difficult given the anarchy, unpredictability, and other complexities of major disasters. Consequently, studies often have to proceed in the absence of rigorous research methodologies, producing results whose validity may exist questionable, unreliable, and not applicable to the disaster setting or population of involvement. Furthermore, the length of fourth dimension typically needed for the approval and broadcasting of funding may make it difficult to initiate enquiry soon subsequently a disaster occurs, which so results in findings that practise not reflect the total time-course of response and recovery. The need to run across requirements of institutional review boards and other regulatory agencies besides contributes to the time needed before commencement of enquiry. Barriers such as these ultimately result in gaps in disquisitional cognition needed to direct interventions in settings of terrorism.

The model depicted in Tables 1-3, 1-5, and 1-half dozen is a potentially comprehensive structure for directing future research, and providing a framework for research to recognize and address the gaps. Much has however to be learned even on the bones epidemiologic level, such equally the incidence of psychiatric illnesses in various disaster populations when comparing terrorism with other kinds of events. Researchers employ various instruments to mensurate many different variables then that comparison betwixt studies is hard if not impossible. Intervention studies are exponentially more difficult to acquit than epidemiologic research because of both the need to enter the field speedily before other interventions accept contaminated the course of recovery in the population and the need to apply standard methods of handling evaluation such as randomized, double-blind, placebo-controlled studies. Therefore, even less is known about the effectiveness of interventions for traumatic stress following disasters and terrorism. The field has resorted to applying interventions adult for other populations that are untested in disaster settings, some of which may be unhelpful or possibly fifty-fifty harmful. Even more complex than epidemiologic and treatment effectiveness inquiry in disaster settings are studies of community systems of response to disasters and terrorism.

Throughout this affiliate, we have highlighted areas where additional and more rigorous research is necessary. These areas include the psychological consequences and response implications of hoaxes and false alarms, and of attacks with conventional explosives or a CBRN weapon such every bit the release of a highly infectious disease. In addition, enquiry 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 corruption outcomes later on a terrorism event, and on interventions for these behaviors. The role of media images in spreading terror remains unclear, and should be examined likewise, so that potentially agin psychological consequences tin exist minimized. Finally, the identification of factors that may influence customs and individual resilience is required in social club to inform time to come interventions. As noted throughout this affiliate, a lack of indicators of the population's psychological health prior to terrorism events limits the conclusions that can be drawn from research conducted later on events. Ongoing surveillance will be of benefit in determining the psychological consequences of events and effectiveness of specific interventions.

SUMMARY

The trauma and disaster literature provides some indication of how individuals and communities may react to terrorism events. Enquiry examining the psychological consequences of terrorism, although in its infancy, indicates that psychological difficulties will certainly result for many. About of those with psychological consequences volition present with mild distress symptoms and behavioral changes, while only a few may present with severe symptoms that meet the criteria for psychiatric disease. The malicious intent and unpredictable nature of terrorism may acquit a particularly devastating affect for those directly and indirectly affected. However, despite the devastating nature of terrorism, community cohesion and posttraumatic growth are possible.

Although psychological furnishings of terrorism are virtually certain, relatively little is known about particular consequences for various subgroups of the population or how people may react to different types of events. There is some prove that children, survivors of past traumatic events (including refugees), ethnic minority populations, and those with preexisting psychiatric illness may be peculiarly vulnerable to psychological consequences, although some of these information are contradictory. Events of closer proximity, longer duration, and greater intensity might exist expected to result in increased psychological consequences.

The broader trauma literature may begin to assist direct prevention and intervention efforts in response to terrorism events. However, it is no longer sufficient to rely on data obtained from research on other kinds of traumatic events considering disasters, and particularly terrorism, differ in central ways. Continued research examining the psychological consequences from a range of disaster and traumatic events volition help amend agreement of the impact and provide evidence to target interventions.

Finding ii: Terrorism and the threat of terrorism will take psychological consequences for a major portion of the population, not merely a small minority. Enquiry studies that have examined a range of terrorism events indicate that psychological reactions and psychiatric symptoms conspicuously develop in many individuals. To optimize the overall wellness and well beingness of the population, and to improve the overall response to terrorism events, it is necessary that these potential consequences be addressed preventively besides as throughout the phases of an event.

i

Norris et al. (2002a, 2002b) included in their sample disasters due to "mass violence." These types of disasters comprised 9 per centum of their sample, and may include acts of terrorism.

2

Other typologies categorize disasters differently. One culling uses three categories: natural events, technological events, and willful homo acts including terrorism.

iii

An example of a disaster that would fall into the area of overlap betwixt human-made and natural disasters is the 1972 Buffalo Creek Flood. This disaster was caused by a combination of heavy rains and poorly synthetic dams. For a give-and-take of the "blurring" between the distinctions of naturally occurring and human-fabricated disasters, see Weisaeth (1994).

4

Psychopathology was divers equally any psychological problems, pathologies, or impairment suffered past victims of disasters.

5

These criteria were: inclusion of subjects who were direct victims of terrorist attacks (terrorist attack defined equally a "deliberate man-made violent issue with a political motive"); subjects assessed with reliable PTSD instruments or with instruments based on DSM criteria; studies published in English between 1980 and 2001. The 6 studies that met the criteria were: Abenhaim et al., 1992; Amir et al., 1998; Curran et al., 1990; Shalev, 1992; Trapler and Friedman, 1996; Wilson et al., 1997. A summary of results from each of these studies can exist establish in Tabular array 2-2.

6

Severity of loss was assessed using a half-dozen-level continuum, with 0 indicating no loss; 1, property loss of someone shut; two, personal loss of property; iii, injury of someone close; 4, expiry of someone close; and 5, personal injury in the attacks.

7

Agile coping strategies are behavioral or psychological responses intended to change the nature of the stressor itself or the mode in which 1 thinks most it. Turning to others for support and attempting to gain more information near the stressor are examples of agile coping strategies.

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Source: https://www.ncbi.nlm.nih.gov/books/NBK221638/

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