Are Symptoms of Civilian Trauma Due To PTSD ?

September 18th, 2011

“Following the Twin Tower terrorist attacks of September 11, 2001 and the July 2005 bombings of the London mass transit system, results of national surveys appeared to indicate that there was an initial stress response affecting large percentages of the population, followed by some form of natural habituation in the majority.

In the National Survey of Stress Reactions conducted by Schuster and colleagues a few days after the September 11th terrorist attacks, 90 per cent of respondents experienced moderate stress levels, while 44 per cent reported high levels of stress in at least one of five substantial stress categories (New Engl J Med, 2001). 
Galea and colleagues found that the closer one lived to Lower Manhattan, the more likely one would suffer from significant stress symptoms (“Psychological Sequelae of the September 11th Terrorist Attacks in New York City.” N Engl J Med, 2002).
Another population sub-group reporting higher trauma-generated stress symptoms were those individuals who spent many hours each day watching the event on television.
Although the TV-exposed group did not experience a direct threat, their elevated stress responses (sometimes referred to as a “vicarious stress syndrome”) appear to correlate with duration of stress exposure (Schlenger, et al. JAMA, 2002).
While a majority of residents in New York experienced substantial stress levels in the weeks following the 9/11 terrorist attacks, Roxane Cohen Silver reported a prevalence rate for full PTSD of only 17 percent after 8 weeks and only 5.8 percent after 6 months (“National Longitudinal Study.” JAMA, 2002).
For the majority of those who initially experienced a high level of stress, symptoms dissipated over time, and after one year only a small percentage of those initially traumatized continued to report significant distress.
In other words, the high initial stress levels reported in the National Surveys by Galea and Stein following the 9/11 attacks declined significantly over the ensuing weeks or months.
At the one year followup, however, only a small percentage of the population had developed PTSD or sought mental health treatment.
These findings were duplicated by the clinical trials conducted following the Madrid and London train and bus bombings, but on a smaller scale. 
In a study conducted 2-3 weeks after the Madrid bombings, 47 percent of subjects showed “significant symptoms of acute stress” (Vasquez, C., P. Perez-Sales, and G. Matt. “PTSD Following the March 11, 2004 Terrorist Attacks in a Madrid Community Sample.” The Spanish Journal of Psychology, 2006).
Dr. James Rubin from the King’s College Institute of Psychiatry in London reported a 31 percent prevalence of significant stress levels among Londoners 11-13 days following the July 2005 terrorist transit bombings (Rubin, G. James, et al. ”Psychological and Behavioral Reactions to the Bombings in London on 7 July 2005: A Cross Sectional Survey of a Representative Sample of Londoners.” British Medical Journal, 2005).
The lower prevalence of substantial stress following the European attacks compared with that reported in the U.S. was attributed to the difference in magnitude of the events as well as the traumatizing effect of wider television coverage of September 11th in the U.S.
Seven months following the attacks on the London mass transit system only one percent of respondents reported having sought mental health counseling.
While this appeared encouraging from a public health perspective, a review of victims of continued war trauma, such as refugees from Vietnam, Cambodia, Bosnia, and Somalia, have demonstrated persistent long-term PTSD symptoms in the range of 20 to 40 percent.
Indeed, followup studies of trauma survivors demonstrate that over time victims “habituate”, developing a certain tolerance or diminution of most symptoms.
Consequently, only a small percentage of such individuals remain in a heightened arousal (with symptoms of stress), or complain of distressing recollections of the traumatic event ("flashbacks”) that would meet the DSM IV requirements for PTSD.
Commenting on the disparate results found in different populations following terrorist attacks, Carmelo Vazquez notes that an important factor relates to the use of different assessment strategies (Vasquez, C., P. Perez-Sales, and G. Matt. “PTSD Following the March 11, 2004 Terrorist Attacks in a Madrid Community Sample.” The Spanish Journal of Psychology, 2006).
Dr. Vasquez comments that “Some of the studies focused on the most extreme responses”, adding that instruments used to assess whether survivors meet criteria for PTSD may not be as useful as symptom scales using a dimensional approach that include different degrees of sub-threshold stress reactions.
Investigators were curious whether bombing survivors, while not sufficiently symptomatic to seek treatment, continued to exhibit subliminal symptoms such as a persistence of sense of threat; or whether they engaged in avoidant behaviors in order to shield themselves against further trauma triggers.
Dr. James Rubin did a repeat study of the London mass transit bombings  after seven months, looking for clues that may have been initially overlooked (Rubin, G. James, et al. “Enduring Consequences of Terrorism: 7-Month Follow-Up Survey of Reactions to the Bombings in London on July 7, 2005.” British Journal of Psychiatry, 2007).
In addition to the severity of stress symptoms experienced in the original study (such as feeling upset, irritable or angry; or experiencing disturbing memories, thoughts, or distressing dreams), additional indicators of persistent sense of threat was explored using a 4-point score ranging from feeling “very safe” to “very unsafe”.
These included:
1) Sense of personal threat 
2) Whether participants whose close friends or relatives were in danger as a consequence of terrorism continued to worry about their safety.
3) Sense of safety while travelling for travel by tube, train, bus, and car 
4) Actual travelling into central London was assessed independently
Results of the London followup population survey indicated persistence of the following symptoms:
11 percent of the population in London continued to experience trauma-related stress symptoms 
12 percent reported feeling very unsafe while travelling 
19 percent reported actually travelling less often 
17 percent reported that they had shopped less in central London
61 percent reported in 2006 that the bombings had negatively altered their view of the world.
    The one long-term U.S study conducted in December of 2003 based on an opinion poll indicated that 20 percent of respondents also reported persistent avoidance behaviors two years following the Twin Tower attacks (“Threat of Terrorism and Mental Health: A Public Opinion Poll.” Widmeyer Communications, 2004).
While not raising a red flag in the initial study, Dr. Rubin’s findings on followup suggest a persistence of sub-threshold symptoms, which I would refer to as a “sinister disquiet” (Rubin, G. James, et al. “Enduring Consequences of Terrorism: 7-Month Follow-Up Survey of Reactions to the Bombings in London on July 7, 2005.” British Journal of Psychiatry, 2007).
While the followup study indicates that most respondents were not sufficiently symptomatic to seek treatment, a significant percentage exhibited residual trauma-related symptoms.
Some of these changes are physiological, some are perceptual, but all point to a heightened sense of danger.
Both in the Widmeyer poll and the seven-month London followup study, one out of five surveyed engaged in travel-avoidant behaviors – presumably as a defense against further trauma triggers.
When traumatic stress overwhelms the brain’s stress circuitry, the hippocampus fails to switch-down sympathetic arousal levels to the extent that allows the psyche to "process" the trauma.
Instead, “unmetabolized” trauma fragments are left to float freely and "ferment”. Neurobiologists explain this phenomenon as "limbic kindling” or “long-term potentiation”.
This refers to the fact that stress-circuits allowed to “overheat” too frequently become more easily prone to reactivation, even when the threat is trivial.
When a trauma is not “put to rest”, stress circuits in the limbic brain, sympathetic nervous system, and adrenal glands remain "primed" to be reactivated as "alert systems" to further trauma triggers.
Some of the shifts in sense of threat, worry, and curtailment of travel reflect an exposure-adjusted amplification of Dr. Rubin’s findings several months following a single large-scale attack in London.
A more extreme example is found among those survivors with PTSD who constantly scan their environment with heightened vigilance, searching for threat-cues (McNally, et al. “Selective Processing of Threat Cues.” J. Abnormal Psych, 1990).
The Task Force on War Related Stress first proposed a two-factor model of trauma (based on severity of stress and pre-morbid functioning), but then recognized a third contributing factor, namely the safety of the holding environment following the trauma.
Survivors coped poorly when the social or political environment to which they returned was rejecting or demeaning, such as the “Post-Vietnam Syndrome” (Hobgoll, S., et al. “War Related Stress.” American Journal of Psychology, 1991).
Dr. Sadavoy also explains this phenomenon, quoting multiple sources that caution how social upheaval and isolation bode poorly for trauma victims (Sadavoy, Joel. “Survivors: A Review of Late-Life Effects of Prior Psychological Trauma.” American Journal of Geriatric Psychiatry, 1997).
In her chapter on “A Forgotten History”, Judith Herman states: “To hold traumatic reality in consciousness, requires a social context that affirms and protects the victim… that joins the victim and the witness in a common alliance” (Trauma and Recovery. Basic Books, 1992: 9).
For society at large, that alliance depends on support at a political level that gives a voice to the disempowered (Herman, Judith. Trauma and Recovery. “A Forgotten History.” Basic Books, 1992: 9).
All of the trauma research supports the notion, that only when the survivor is convinced that that the threat to self and significant others has been removed can stress levels begin to diminish.
For victims traumatized by natural disasters or large-scale attacks on civil society, the priority for the victim becomes the availability of food, shelter, medical and other basic necessities, and the ability to communicate with the outside world.
Only then can the survivor begin to reemerge and attempt to make sense of a world whose landscape may be permanently altered.
Likewise, for victims of rape and spousal abuse, feminist organizations had to publically vindicate the rights of women by publically campaigning against the sexual exploitation of women and children.
In her chapter titled “A Forgotten History”, Herman applies the impact of social and political context to both victims of spousal abuse, as well as returnees from combat (Herman, Judith. Trauma and Recovery. Basic Books, 1992: 9).
During World War II and Vietnam, soldiers suffering from “war neurosis” were branded as malingers and “moral invalids”. Little attention was paid to the plight of men in combat overwhelmed by the trauma of war.
In both of these victim populations, there was little public interest or even legal representation.
While the victims suffered, their realities were simply ignored.
Vietnam veterans encountered unprecedented rejection and indifference by mainstream society (“Interview with Chaim Shatan.” McGill News. Montreal, Quebec: February 1983).
Between 1970 and 1980, sufficient political pressure from various pro-veteran organizations finally led to a legal mandate for a psychological treatment program to be developed within the Veterans’ Administration (Egendorf, A., et al. Legacies of Vietnam. Washington, D.C.: Vols. 1-5, 1981).
Whether terror is committed at an interpersonal or collective level, the perpetrator does everything in his power to escape accountability. 
“If the victim cannot be silenced, the perpetrator attacks his victim’s credibility… the more powerful the perpetrator, the greater his prerogative to name and define reality” (Herman, Judith. Trauma and Recovery. “A Forgotten History.” Basic Books, 1992: 8-9).
Another trauma model that may prove relevant to public health in the U.S. is described by Dr. Goderez following the course of symptoms in Vietnam veterans over a 30 year period.
In a publication describing the “warrior syndrome”, Goderez describes a picture of significantly disturbed social adaptation. A large percentage of returning veterans exhibited an inability to adjust to civilian life after returning from combat. 
The “warrior syndrome” is characterized by a poor work history, severely disrupted interpersonal relationships, drug and alcohol use, belligerence, self-destructive behaviors, chronic health problems, and marginal lifestyles (Goderez, B. “The Warrior Syndrome.” Menninger Clinic Bulletin 51 (1987): pages 96-113).
This is where social and political context contribute or hinder recovery at various levels.
The struggle for personal dignity appears to be a challenge for the victim at the individual and collective level.
Herman emphasizes the importance of family, friends, mental health professionals, and society at large in affirming and protecting victims isolated or delegitimized by their predators.
The extent to which a society sympathizes with the plight of the victim will influence whether the problem is dismissed or addressed, and whether the victim becomes degraded or dignified. The struggle for personal dignity appears to be a challenge for the victim at the individual level and a focus for public health planning at a collective level.”

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