Traumatic Stress Following Terrorist Attacks – The Accumulative Effect

November 18th, 2010

War Torn Civilian Victims of Political Terrorism

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.

At the one year follow-up, however, only a small percentage of the population had developed PTSD or sought mental health treatment.

In the national survey of stress reactions conducted by Schuster and colleagues a few days after the September 11th terrorist attacks, 90 percent of respondents experienced moderate stress levels, while 44 percent 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 this group did not personally experience a threat to their lives, they developed the so-called “vicarious stress syndrome” (Schlenger, et al. JAMA, 2002).

While a majority of residents in New York experienced substantial stress levels in the weeks following the 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.

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, Munoz found that 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: 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.

Dr. Rubin repeated his study again seven months later (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 the British study, participants were asked whether five stress symptoms had been experienced in the past 3 weeks as a result of the London bombings. 

These symptoms were:

1. Feeling upset when reminded of the event

2. Repeated disturbing memories, thoughts, or dreams

3. Difficulty concentrating

4. Trouble falling or staying asleep

5. Feeling irritable or angry

Substantial stress was recorded when any of these symptoms were experienced on a frequent or extreme level measured on a 4-point scale.

Sense of threat was measured on a 4-point scale rating whether participants felt that their own lives or those of close friends or relatives were in danger as a consequence of terrorism.

Their sense of safety while travelling was assessed separately for travel by tube, train, bus, and car, and for travelling into central London using a 4-point score ranging from “very safe” to “very unsafe.”

Outcome Variables and Carry-Over Effect Over Time

In the 2006 London survey, 11 percent of respondents reported substantial stress symptoms, compared with 27 percent for the 2005 survey.

43 percent, compared with 52 percent, continued to believe that their life was in danger from terrorism.

12 percent reported feeling very unsafe while travelling, compared with 19 percent in 2005.

19 percent reported actually travelling less often in 2006, while in the previous year 30 percent had reported that they intended to travel less.

(This did not vary significantly from the Widmeyer poll survey reporting that 20 percent of American adults were avoiding travel two years following the 9/11 attacks.)

17 percent reported that they had shopped less in central London.

61 percent reported in 2006 that the bombings had altered their view of the world.

Dr. Rubin also found that the escalated stress response initially reported among those having communication breakdowns did not persist in the follow-up study.

However a new stress indicator emerged in the form of those who initially feared that a close friend or relative had been hurt or killed, which correlated with the persistence of “worry.”

Despite the prolongation of substantial stress found in 11 percent of the population in London surveyed, a heightened perception of danger reported in 12 percent, and a 19 percent curtailment in travel, only 1 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.

For instance, regarding the lasting consequences of the war in Bosnia and Herzegovina, Nadezda Savjak conducted a study in the Republic of Srpska. There was a population of 420,000; 12,000 people had been killed and several thousand remained missing.

“With the passing of time, the population began to process the accumulative adversities of loss of nuclear family and close friends, the witnessing of violence, and the experience of direct threat to life” (Savjak, Nadezda. “Multiple Traumatization as Risk Factor of Post-Traumatic Stress Disorder.” PSIHOLOGIJA, 2003).

Commenting on the results of high persistence of PTSD in Bosnia, Dr. Savjak stated, “We face chronic stress originating from destroyed physical and socioeconomic infrastructure, economic slump, unemployment, uncertainty.”

In this article, I explore the information gleaned from several studies of continued war trauma that might explain such a profound escalation of PTSD among those exposed to continued civil war or repeated terrorist attacks. 

I have also reexamined the earlier results of the London and New York bombings to find clues that may have initially been overlooked.

The findings by Dr. Rubin point to a persistence of sub-threshold symptoms which I would refer to as a “sinister disquiet.” 

While not raising a red flag in his initial study, changes can be noted in the 7-month follow-up study suggesting a subtle shift in psychological functioning, ranging from altered perception of the world, to concerns about personal safety, and continued avoidant behaviors in a significant percentage of the population.

Dr. Rubin’s community surveys carry additional weight since the U.S. studies typically extended for only 2-3 months following the event.

In fact, 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).

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. 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.

At the same time, Blanchard cautions that the findings of “substantial stress” using self-report tools might lead to an overestimation of epidemiological needs for psychological intervention (“A Cautionary Note About the Measurement of Psychological Trauma.” The Spanish Journal of Psychology Vol. 9, 2006).

This note of caution is repeated by Dr. Wessely: “Having substantial stress does not mean having a mental disorder” (Wessely, S. Psychiatry (2004): 67, 153-157).

Indeed, follow-up 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 state of hyper-vigilance, reporting distressing traumatic recollections or "flashbacks" of the event.

However, while the follow-up study by Dr. Rubin suggests that most respondents were not sufficiently symptomatic to seek treatment, a high percentage of such victims continued to engage in avoidant behaviors – presumably an avoidance defense to shield themselves against further trauma triggers.

If one were to anticipate the effects on public health of more frequent and enduring terror attacks, one could examine several other representative trauma populations.

Two trauma groups may have relevance to this discussion.

The first is described in an article by Avi Bleich and colleagues who studied mental health resiliency following 44 months of terrorism (Bleich, Avi, et al. BMC Medicine, 2006).

Dr. Bleich notes, citing statistics obtained from the Israeli Ministry of Foreign Affairs Government website (April 2006), that between 2000 and 2004, 1,030 Israelis had been killed and 5,788 injured by 13,000 terror attacks.  

This means that 0.1 percent of the population of the Jewish State had been killed or physically injured by acts of terrorism, which would translate per capita to the equivalent of 300,000 casualties in the U.S.

Bleich’s report indicates that in addition to those killed or injured directly, more than one in ten respondents had witnessed a terrorist attack firsthand.

With regard to PTSD symptoms, 35.9 percent of respondents in a national survey endorsed one or more “re-experiencing” items, 51.7 percent showed one or more avoidance or numbing symptoms, 47.7 percent reported hyper-arousal symptoms, 27.1 percent had dissociative symptoms, 44.1 percent experienced general distress, and 15.4 percent were functionally impaired.

In terms of the effect of repeated terrorism on public attitude, 47 percent of respondents felt that their lives were in danger, while 54.1 percent believed that the lives of family members or acquaintances were in danger.

Some of these shifts in attitude reflect an exposure-adjusted amplification of Dr. Rubin’s findings several months following a single large-scale attack in London.

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):96-113).

The 10,000 Jewish settlers removed from Gush Katif by the I.D.F. show a picture identical to that described by Goderez (Rabbi Shalom Ber Wolpe, personal communication, November 2009).

Dr. Sadavoy also explains this phenomenon, quoting multiple sources that include the Task Force on War-Related Stress, cautioning how social upheaval and isolation can compound previous trauma (Sadavoy, Joel. “Survivors: A Review of Late-Life Effects of Prior Psychological Trauma.” American Journal of Geriatric Psychiatry, 1997).

While the Task Force on War Related Stress proposed a two-factor model of trauma based on severity of stress and pre-morbid functioning, it also recognized the potential detrimental role of post-trauma influences such as isolation, hostility, or rejection (Hobgoll, S., et al. “War-Related Stress.” American Journal of Psychology, 1991).

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.”

For society at large, that alliance depends on the support of a political movement that gives a voice to the disempowered (Herman, Judith. Trauma and Recovery. Basic Books (1992): 9).

Traumatized individuals, in order to begin the process of healing, need a safe holding environment.

All of the trauma research supports the notion that only when the survivor is convinced that that there is no persistent threat to self or significant others, can stress levels begin to diminish.

The next priority for the victim is the availability of food, shelter, medical and other basic resources, 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.

This is where social and political context contribute or hinder recovery at various levels.

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 is dignified or degraded.

In her chapter titled “A Forgotten History,” Herman applies the impact of social and political context from victims of spousal abuse to returnees from combat.

For victims of rape and spousal abuse, feminist organizations had to vindicate the rights of women and campaign publically against the sexual exploitation of women and children.

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.

As one psychiatrist reported, regarding young veterans returning from Vietnam, “A lot of them were hurting. But they didn’t want to go the Veterans’ Administration for help” (“Interview with Chaim Shatan.” Montreal, Quebec: McGill News, 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. Washington, D.C.: Legacies of Vietnam Vols. 1-5, 1981).

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.

“In order to escape accountability, the perpetrator does everything in his power to promote forgetting. 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. “A Forgotten History.” Trauma and Recovery. Basic Books (1992): 8-9).

In the current war against Jihad, the success of radical organizations in inverting truth and reality has prevailed.

The fact that the World Court has allowed the perpetrators of terror to define reality in legal rulings, such as those contained in the Goldstone Report, may turn out to be the prevailing contribution in the defeat in the war on terror. 

(The Goldstone Report, published in September 2009, seriously harmed the international image of the State of Israel and the Israel Defense Forces. Prime Minister Benjamin Netanyahu stressed the gravity of the report’s impact in his December 23, 2009 address to the Knesset plenum: "There are three primary threats facing us today: the nuclear threat, the missile threat and what I call the Goldstone threat… Goldstone has become the code for a much broader phenomenon: the attempt to negate the legitimacy of our right to self-defense.”) 

In conclusion, understanding the mental health implications of victims of terror requires continued attention to the accumulation and reemergence of symptoms (not necessarily physical) following discrete trauma events. In order to address the public health issue at a global level, this requires recognition of how society and the law acknowledge the role of its own bias.”

2 Responses to “Traumatic Stress Following Terrorist Attacks – The Accumulative Effect”

  1. Hello! Thank you for this post but are you really sure about what you’re saying? Do you have more sources for us? thank you

    • btrappler says:

      The simple answer to your question is “Yes. I know what I`m saying”.
      If you want specifics I can provide reference material.
      My articles have often been co-authored by other experts such as Stephen Friedman, Director of the Anxiety Clinic at S.U.N.Y.,N.Y.,
      Carl Cohen, Chairman of Geriatric Psychiatry at S.U.N.Y., N.Y., and Jean Endicott, Director of Biological Research, Columbia University.
      My book on Trauma was, among others, endorsed by Carolyn Wells, Director of Community Mental Health Services, N.Y. Office of Mental Health.I have been published in the American J. of Psychiatry
      and American J. of Geriatric Psychiatry. My papers have been presented at annual Conventions of the American Association of Psychiatry and American Association of Geriatric Psychiatry.
      I have also refereed for several journals including “The International Journal of Traumatic Stress”, regarded by many as the premier Journal on Psychological Trauma.

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