Terrorism erodes the sense of security and safety people usually feel. This erosion of security is at both the individual level and the community level. Terrorism challenges the natural need of human beings to see the world as predictable, orderly, and controllable. Research has shown that deliberate violence creates longer lasting mental health effects than natural disasters or accidents. The consequences for both individuals and the community are prolonged, and survivors often feel that injustice has been done to them. This can lead to anger, frustration, helplessness, fear, and a desire for revenge. Studies have shown that acting on this anger and desire for revenge can increase rather than decrease feelings of anger, guilt, and distress.
However, the mechanisms for natural recovery from traumatic events are strong. Many trauma experts (Staab, Foa, Friedman) agree that the psychological outcome of communities as a whole will be resilience, not psychopathology. For most, symptoms of fear, anxiety, re-experiencing, avoidance, and hyperarousal, if present, will gradually decrease over time.
Research has shown that those who are most at risk for more severe traumatic stress reactions such as Posttraumatic Stress Disorder (PTSD) are those who have experienced the greatest magnitude of exposure to the traumatic event, such as victims and their families. However, sometimes rescue workers also have direct relationships with or indirect exposure to those who are missing or killed. Therefore, these rescue workers need to cope with their own losses as well as with the demands of the rescue mission. In the case of September 11th, for example, a particularly difficult task for these rescue workers was the identification and removal of the casualties. These activities have been shown to be particularly traumatic and associated with higher rates of PTSD.
Information from past incidents of terrorism
Since the 9/11 attacks, there has been an increasing amount of research about how people are affected by terrorism. A consistent finding is that while most individuals exhibit resilience over time, people most directly exposed to terrorist attacks are at higher risk for developing PTSD. Problems with anxiety, depression, and substance use are also commonly reported among those with PTSD. Predictors of PTSD include being closer to the attacks, being injured, or knowing someone who was killed or injured. Those who watch more media coverage are also at higher risk for PTSD and associated problems.
Below is a list of several major terrorist attacks and the research findings that have resulted.
Madrid Commuter Train Bombing
On March 11, 2004 a commuter train in Spain was bombed, resulting in the death of 190 persons and over 1,200 wounded. In 2005, Madrid's International Summit on Terrorism was held to discuss recommendations on how to improve the fight against terrorism. Further research is underway.
9/11 U.S Terrorist Attacks
On September 11, 2001, the United States was forever changed. Following the single largest terrorist attack ever experienced by this country, thousands died or went missing, tens of thousands knew someone who was killed or injured, and many more witnessed or heard about the attack through media sources and by word of mouth. People at all levels of involvement were affected: victims, bereaved family members, friends, rescue workers, emergency medical and mental-health care providers, witnesses to the event, volunteers, members of the media, and people around the world.
Research on national samples in the U.S. revealed that 3-5 days afterward the attack 44% of Americans reported at least one symptom of PTSD (2). One to two months post-attack, 4% showed probable PTSD nationwide, and prevalence of PTSD in NYC residents was 11% (2). One study found that in American adults, amount of time watching TV coverage was related to PTSD symptoms (1).
Within two months of incident, in the cities attacked prevalence of PTSD was 8% and prevalence of depression was 10% 3. Higher prevalences of PTSD were reported for those closer to the disaster (14-20%) (3-4), and for those actually in the building or injured (30%).
Prevalence of PTSD decreased during the 6 months following the disaster (5), however alcohol and substance use remained high (6). Depression was related to alcohol use increase, and along with PTSD was related to increased cigarette and marijuana use. Manhattan residents overall showed significant increase in the use of all three substances (6).
Oklahoma City Bombing
Almost half of the survivors directly exposed to the blast reported developing problems with anxiety, depression, and alcohol, and over one third of these survivors reported PTSD. Predictors of PTSD, anxiety, and depression included more severe exposure, female gender, and having a psychiatric disorder before the bombing (12). Over a year after the bombing, Oklahomans reported increased rates of alcohol use, smoking, stress, and PTSD symptoms as compared to citizens of another metropolitan city (13).
Children who lost an immediate family member, friend, or relative were more likely to report immediate symptoms of PTSD than children who had not lost a loved one (14). Two years after the bombing, 16% of children and adolescents who lived approximately 100 miles from Oklahoma City reported significant PTSD symptoms related to the event (14). This is an important finding because these youths were not directly exposed to the trauma and were not related to victims who had been killed or injured. PTSD symptomatology was greater in those with more media exposure and in those with indirect interpersonal exposure, such as having a friend who knew someone who was killed or injured (15).
Lockerbie Disaster: The Crash of Pan Am Flight 103
In 1988, a terrorist bomb caused an airline explosion that killed 270 people.
Almost 3/4 of a group of people seeking psychological damages following the crash of Pan Am Flight 103 reported PTSD (16). Over 50% continued t o have PTSD 3 years after the crash (17).
Subway Attack in Japan
A cult released deadly nerve gas on a Tokyo subway in 1995 resulting in 12 deaths and sickness in over 5,500 people.
Common experiences of those who were exposed to poisonous gas in the subway included anxiety, generalized fear, nightmares, insomnia, depression, and fear of subways (18).
As indicated above, rates of distress and posttraumatic symptoms have been found to be high in individuals studied following terroristic events. Ultimately, reducing the risk of traumatic stress reactions is best accomplished by abolishing trauma in the first place by preventing war, terrorism, and other traumatic stressors. The next best approach is to foster resilience and bolster support so that individuals have a better coping capacity prior to and during traumatic stress. The third best option is the early detection and treatment of traumatized individuals to prevent a prolonged stress response.
Schuster, MA, Stein BD, Jaycox, LH, Collins, RL, Marshall, GN, Elliot, MN, Shou, AJ, Kanouse DE, Morrison, JL and Berry SH (2002). A national survey of stress reactions after the September 11, 2001, terrorist attacks. New England Journal of Medicine, 345(20), 1507-1512.
Schlenger, W.,Caddell, J., Ebert, L., Jordan, B.K., Rourke, K., Wilson, D., Thalji, L., Dennis, J.M., Fairbank, J., & Kulka, R. (2002). Psychological reactions to terrorist attacks: findings from the National Study of Americans' Reactions to September 11. Journal of the American Medical Association, 288(5), 581-588.
Galea, S., Ahern, J., Resnick, H., Kilpatrick, D., Bucuvalas, M., Gold, J., & Vlahov, D. (2002). Psychological sequelae of the September 11 terrorist attacks in New York City. New England Journal of Medicine, Special Report 346, 982-987.
Grieger, T., Fullerton, C., & Ursano, R. J., (2003). Posttraumatic stress disorder, alcohol use, and perceived safety after the terrorist attack on the Pentagon. Psychiatric Services, 54(10), 1380-1382.
Galea, S., Vlahov, D., Resnick, H., Ahern, J., Susser, E.,Gold, J., Bucuvalas, M. & Kilpatrick, D. (2003). Trends of probable post-traumatic stress disorder in New York City after the September 11 terrorist attacks. American Journal of Epidemiology, 158(6), 514-524.
Vlahov, D., Galea, S., Resnick, H., Ahern, J., Boscarino, J., Bucuvalas, M., Gold, J., & Kilpatrick, D. (2002). Increased use of cigarettes, alcohol, and marijuana among Manhattan, New York, residents after the September 11th terrorist attacks. American Journal of Epidemiology, 155(11), 988-996.
Abdel-hamid, A., Lawler, J., & El Sarraj, E. (2004). Gender and other predictors of anxiety and depression in a sample of people visiting primary care clinics in an area of political conflict: Gaza Strip. RAHAT Medical Journal, 2(1), 81-92.
Qouta, S., Punamaki, R., El Sarraj, E. (1995). The relations between traumatic experiences, activity, and cognitive and emotional responses among Palestinian children. International Journal of Psychology, 30(3), 289-304.
Kostelny, K., & Garbarino, J. (1994). Coping with the consequences of living in danger: the case of Palestinian children and youth. International Journal of Behavioral Development, 17(4), 595-611.
Pat-Horenczyk, R. (2004). Post-traumatic distress in Israeli adolescents exposed to ongoing terrorism: selected findings from school-based screenings in Jerusalem and nearby settlements. Journal of Aggression, Maltreatment and Trauma, 9(3/4), 335-347.
Qouta, S., Punamaki, R., & El Sarraj, E. (2003). Prevalence and determinants of PTSD among Palestinian children exposed to military violence. European Child and Adolescent Psychiatry, 12(6), 265-272.
North, C., Nixon S., Shariat, S., Mallonee, S., McMillen, J., Spitzanagel, E., & Smith, E. (1999). Psychiatric disorders among survivors of the Oklahoma City bombing. Journal of the American Medical Association, 282, 755-762.
Smith, D., Christiansen, E., Vincent, R., & Hann, N. (1999). Population effects of the bombing of Oklahoma City. Journal of the Oklahoma State Medical Association, 92, 193-198.
Pfefferbaum, B., Nixon, S., Tucker, P., Tivis, R., Moore, V., Gurwitch, R., Pynoos, R., & Geis, H. (1999). Posttraumatic stress responses in bereaved children after the Oklahoma City bombing. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1372-1379.
Pfefferbaum, B., Gurwitch, R., McDonald, N., Leftwih, M., Sconzo, G., Messenbaugh, A., & Schultz, R. (2000). Posttraumatic stress among children after the death of a friend or acquaintance in a terrorist bombing. Psychiatric Services, 51, 386-388.
Brooks, N.. & McKinlay, W. (1992). Mental health consequences of the Lockerbie disaster. Journal of Traumatic Stress, 5, 527-543.
Scott, R., Brooks, N., & McKinlay, W. (1995). Post-traumatic morbidity in a civilian community of litigants: A follow-up at 3-years. Journal of Traumatic Stress, 8, 403-417.
DiGiovanni, C. (1999). Domestic terrorism with chemical or biological agents: Psychiatric aspects. American Journal of Psychiatry, 156, 1500-1505.
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