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2
Understanding the Psychological
Consequences of Traumatic Events,
Disasters, and Terrorism
Terrorism is intended to provoke collective fear and uncertainty.
This fear can spread rapidly and is not limited to those experienc-
ing the event directly others that are affected include family mem-
bers of victims and survivors, and people who are exposed through broad-
cast images. Psychological suffering is usually more prevalent than the
physical injuries from a terrorism event. Understanding these psycho-
logical consequences is critical to the nation's efforts to develop interven-
tion strategies at the pre-event, event, and post-event phases that will limit
the adverse 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
chapter then describes the smaller body of research that specifically ex-
amines the consequences of terrorist attacks and discusses how the conse-
quences of terrorism may differ from other types of traumatic events. This
chapter is not meant to represent a thorough review of the trauma and
disaster literature; rather it is intended to highlight some of the salient
and relevant findings that may direct responses to terrorism events. For a
comprehensive review, the reader is referred to Holloway et al. (1997),
Norris et al. (2002a, 2002b), and Rub onis and Bickman (1991~.
TRAUMATIC EVENTS
The effect of traumatic events on human functioning has been a sub-
ject of study for many years. An abundance of research has examined
34
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UNDERSTANDING THE PSYCHOLOGICAL CONSEQUENCES
35
traumatic events ranging from individual events such as motor vehicle
crashes and sexual assaults to community-wide events such as natural
disasters, commercial airplane crashes, and community violence, as well
as global events such as war.
As defined 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 an-
other (APA, 1994~. Traumatic events are usually perceived by the indi-
vidual to be life-threatening, unexpected, and infrequent, and are charac-
terized by high intensity (Ursano et al., 1994~. However, traumatic events
may be repeated within a community, and in such environments the pres-
ence of a threat may become the norm. Evidence suggests that the type
and severity of outcomes often vary according to the type of event (Freedy
and Donkervoet, 1995~.
The effect of exposure to a traumatic event is variable and specific to
the individual; both psychological and physiological responses can vary
widely. Social context, biological and genetic makeup, past experiences,
and future expectations will interact with characteristics of the traumatic
experience to produce the individual's psychological response (Ursano et
al., 1992~. In general, those exposed to a traumatic event 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 as
PTSD are the more severe outcomes of traumatic events, they are also the
best studied. Much of the research literature has focused specifically on
PTSD because it is a recognized and well-defined result of traumatic
events (see Box 2-1~. However, PTSD is just one outcome in a myriad of
consequences resulting from traumatic events.
Spectrum of Consequences of Traumatic Events
The experience of a traumatic event does not necessarily lead to seri-
ous psychological difficulties. As discussed in Chapter 1, there is a spec-
trum of consequences ranging from distress responses such as mild anxi-
ety, to behavioral changes such as mild difficulty sleeping, to the onset of
a diagnosable psychiatric illness (see Figure 1-2~. These consequences
generally can be placed into three categories of severity, which may also
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 alcohol use. These individuals will likely recover
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36 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM
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UNDERSTANDING THE PSYCHOLOGICAL CONSEQUENCES
37
with no required treatment, but may benefit from education and commu-
nity-wide supportive interventions.
· A smaller group may have more moderate symptoms such as per-
sistent insomnia and anxiety and will likely benefit from psychological
and medical supportive interventions.
· A small subgroup will develop psychiatric illnesses such as PTSD
or major depression and will require specialized treatment.
The number of people experiencing each of these outcomes varies di-
rectly with the severity of the event and with proximity of exposure to it.
Most people will experience mild or infrequent symptoms, while only a
few may experience frequent and/or severe symptoms. Because terrorist
attacks may cause violent injury, death, and destruction, there often will
be a targeted population that experiences extreme trauma, a widening
group of family members and friends who are also therefore directly af-
fected, and an even larger community 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 one of these
categories is based not only on the population but also characteristics of
the event itself. Figure 2-1 provides a conceptual illustration of this rela-
tionship between proximity and severity, and outcomes; it should be kept
in mind that this curve is theoretical and proportions will change in some
situations.
The association between severity and/or number of symptoms and
the number of people affected is important to consider when planning
interventions in the aftermath of a community-wide disaster or terrorism
event. The severity and diagnostic constellations of symptoms will dic-
tate what treatment or intervention, if any, is needed. People with mild
symptoms may expect fairly rapid resolution of their symptoms and may
require fairly simple interventions and/or support, such as appropriate
risk communication messages from the media and public health commu-
nity explaining that these symptoms are normal, expected reactions to the
experience of a traumatic event. The minority of people with severe symp-
toms and/or psychiatric illness may require conventional treatment from
the mental health system. This highlights the need for coordination and
collaboration between the public health and mental health communities
in order to address the needs of diverse populations across the spectrum
of symptoms and manifestations.
Traumatic Events in Children and Adolescents
The childhood experience of traumatic events induces immediate bio-
logical and psychological reactions, some of which may persist for an ex-
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38 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM
Many
c'
Q
To
Q
To
Q
A
Few
Examples of
mild reactions:
· Insomnia
· Worry
· Feeling upset
-
Examples of
moderate reactions:
· Persistent insomnia
· Anxiety
-
Examples of
severe reactions:
· PTSD
· Depression
Mild/Few
Severity or number of symptoms
Severe/Many
-
FIGURE 2-1 Severity of psychological reactions experienced by the population
following a traumatic event.
NOTE: Indicative only.
tended period. The psychological symptoms of traumatic events in chil-
dren and adolescents are similar to those recognized in adults, but often
appear as age-appropriate expressions of the stressful event. See Box 2-2
for examples of possible reactions of children to traumatic events.
Youth who have been exposed to violence have been more likely to
develop psychological problems and have 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 com-
munity violence develop PTSD (Berman et al., 1996; Fitzpatrick and
Boldizar, 1993~. Youth exposed to traumatic events also can develop de-
pression, other anxiety disorders, substance use disorders, and problems
with school performance (Brent et al., 1995; Clarke et al., 1995; Saigh et al.,
1997; Singer et al., 1995; Weine et al., 1995~. Widespread negative psycho-
logical effects have also been reported following acts of violence on high
school campuses, such as the school shootings at Columbine High School
in Littleton, Colorado, and Santana High School in Santee, California.
Biological research has demonstrated that, like adults, children ex-
posed to traumatic events show alterations in stress hormone systems.
However, a unique difference among children is the association of expo-
sure to traumatic events with measurable discrepancies in neurophysi-
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UNDERSTANDING THE PSYCHOLOGICAL CONSEQUENCES
39
ological development. It is believed that prolonged levels of significant
stress may adversely affect the neurophysiological development of young
children in ways that may have long-term consequences for behavioral
responses to stress and later psychiatric illness (for reviews, see De Bellis,
2001; Glaser, 2000~. It is difficult to draw definitive conclusions from this
research, however, since findings are frequently confounded with preex-
isting risk factors for experiencing a traumatic event that are also associ-
ated with differences in brain physiology.
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40 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM
DISASTERS
A subset of the broader trauma literature has focused on the psycho-
logical consequences of disasters. Disasters differ from other forms of
traumatic events in that, by definition, they are likely to affect larger seg-
ments 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 adverse outcomes following disasters (see, 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 Green (1992) revealed that most authors re-
ported negative psychological consequences of disasters. Norris and col-
leagues (2002b) reviewed 177 articles that examined 80 different disas-
ters.~ The authors organized the most frequently documented negative
sequelae of disasters into five categories:
· Specific psychiatric illnesses (for example, PTSD, depression)
· Nonspecific distress (symptoms without a specific diagnosis, such
as demoralization, perceived stress, and negative affect)
· Health problems and concerns (for example, somatic complaints,
sleep disruption, increased use of sick leave)
· Chronic problems in living (for example, social disruption, fam-
ily conflict, financial and occupational stress)
· Psychosocial resource loss (for example, decreases in social par-
ticipation and perceived support)
The authors suggest that children were the segment of the population at
greatest risk for psychological trauma, behavioral changes, and impair-
ment. Research suggests that disasters experienced at a younger age may
have long-term psychological consequences. One study followed a group
of adolescents who experienced the sinking of a ship, and found that more
than a third of those adolescents who developed PTSD subsequent to the
disaster still had PTSD at either five or eight years follow-up (Yule et al.,
2000~.
~ Norris et al. (2002a, 2002b) included in their sample disasters due to "mass violence."
These types of disasters comprised 9 percent of their sample, and may include acts of
terrorism.
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UNDERSTANDING THE PSYCHOLOGICAL CONSEQUENCES
41
It is important to note that many psychological reactions to disasters
are considered ordinary responses to stress. For example, almost half of
the survivors of an earthquake in Northridge, California, exhibited dis-
tress symptoms of reexperiencing the disaster and hyperarousal, but
these symptoms alone were not associated with psychiatric illness and
were considered "normal" (McMillen et al., 2000~. Regardless of psychi-
atric illness, it is critical to consider functional impairment when evaluat-
ing the psychological consequences of a disaster or other traumatic event.
Box 2-3 presents examples of other ordinary and expected psychological
responses to a disaster.
In addition to psychiatric illness and distress reactions, experiencing a
disaster may result in alterations in health-related behaviors and produce
general life changes. Substance use is one health-related behavior com-
monly thought to increase in the aftermath of a disaster. Cigarette smok-
ing and alcohol use may increase in individuals with PTSD after any kind
of traumatic event (Shalev et al., 1990~. In their extensive review of disas-
ter studies, Norris and colleagues (2002b) observed increased substance
use in 25 percent of the populations under study. However, increased
substance use does not necessarily develop into substance use disorders,
and Katz and colleagues (2002) noted that only a small number of studies
have looked at substance use as an outcome. Family interactions consti-
tute another area of behavior that may be influenced by disasters. For
example, Adams and Adams (1984) found increased domestic violence
and family problems in a population of survivors of the Mount Saint
Helens eruption. Family relationships and other social variables are an
area not as frequently studied as other areas discussed here and are in
need of further investigation.
Evidence suggests that adverse psychological consequences of disas-
ter dissipate over time for the majority of people. The studies included in
Norris and colleagues' review suggested that symptoms measured shortly
after the disaster were predictive of symptoms at subsequent points in
time, and the greatest severity of symptoms was usually experienced
within one year following the disaster; only a minority of disaster survi-
vors had any significant and persistent impairment after the first year.
Moderators of Adverse Outcomes After Disasters
As discussed, many of the initial reactions to disasters can be consid-
ered ordinary distress responses to traumatic events and the symptoms
will dissipate over time. Thus, in order to intervene appropriately, it is
important to be able to predict which individuals may experience long-
term and serious consequences and to estimate the number of individu-
als that may be affected. Predictors of long-term impairment after a di-
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42 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM
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UNDERSTANDING THE PSYCHOLOGICAL CONSEQUENCES
43
saster include many of those observed in other traumatic events. Mod-
erators of adverse outcomes have been categorized into pre-event, event,
and post-event phases that are consistent with the event phases described
in Chapter 1.
Pre-Event. Female gender has been associated with poorer outcome fol-
lowing disasters, as has low socioeconomic status and minority status.
The 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 depression (Shalev et al., 1998~. However,
Bromet et al. (1982) found no significant difference in mental health out-
comes between patients with a psychiatric illness who experienced the
Three Mile Island disaster and a control group.
Event. Traditionally, mental health research has classified disasters into
two categories: natural and human-caused (the latter includes techno-
logical disasters such as hazardous materials spills, aviation disasters, ter-
rorism, and even acts of war) (see Figure 2-2~.
Although these categories are not always mutually exclusive, as dem-
onstrated in Figure 2-2,3 there is some evidence to suggest that individual
responses to disaster may vary depending on the type of event. While
research in this area has typically examined natural disasters versus hu-
man-caused disasters, there is no consensus regarding which events may
produce a specific type of response. For example, North and Smith (1990)
suggested, based on a review of the disaster literature, that human-caused
disasters may result in higher rates of diagnosable psychiatric illnesses,
and others have reported that human-caused disasters result in more per-
sistent psychopathology (Baum, 1990; Green et al., 1990; Solomon and
Green, 1992~. Conversely, Rub onis and Bickman (1991) concluded in their
review of 52 studies that human-caused disasters resulted in less severe
psychopathology than natural disasters.
As shown in Figure 2-2, a distinction can be made between inadvert-
ent human-caused disasters such as those caused by error or neglect and
2 Other typologies categorize disasters differently. One alternative uses three categories:
natural events, technological events, and willful human acts including terrorism.
3 An example of a disaster that would fall into the area of overlap between human-made
and natural disasters is the 1972 Buffalo Creek Flood. This disaster was caused by a combi-
nation of heavy rains and poorly constructed dams. For a discussion of the "blurring" be-
tween the distinctions of naturally occurring and human-made disasters, see Weisaeth
(1994~.
4 Psychopathology was defined as any psychological problems, pathologies, or impairment
suffered by victims of disasters.
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44 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM
Disasters
Human-caused
-
/
-
-
Tl
Error or
neglect
-
errorlsm I
-
FIGURE 2-2 Categories of disaster.
SOURCE: Ursano (2002~.
Natural
-
\
/
intentional human-caused disasters such as 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 issue is limited. The review by Norris et al (2002b)
used a slightly different classification by disaster type with three catego-
ries: natural; technological (for example, oil spills, transportation acci-
dents); 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 under study than either techno-
logical or natural disasters. Therefore, although research shows that all
types of disasters, including intentional and inadvertent human-caused
disasters, may cause psychological distress, behavior change, or psychiat-
ric illness to different degrees, additional studies should identify the
mechanisms and specific characteristics leading to adverse outcomes.
Norris and colleagues (2001) propose that when at least two of the
following four characteristics of disasters are present, the mental health
impact will be greatest:
Widespread damage to property
· Serious and ongoing financial problems
· Human 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
important characteristics of disaster experiences are specific to the event
phase. Understanding how specific aspects of disasters relate to specific
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UNDERSTANDING THE PSYCHOLOGICAL CONSEQUENCES
53
City and the surrounding areas in the months after September 11, 2001.
In comparison, 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 between
increases in substance use and substance abuse. Data indicating a simple
increase in alcohol or tobacco use do not necessarily indicate problematic
or long-standing behavior changes.
Other behaviors and outcomes reflecting functional impairment after
terrorism events are in need of further study. School dropout rates, di-
vorce, and domestic or interpersonal violence and conflict are potential
future research topics in this area. Increases in school or work absentee-
ism, which may indicate functional impairment, have been noted follow-
ing terrorist attacks. A survey by Melnik and colleagues (2002) found that
27 percent of respondents who were working in New York City at the
time of the September 11,2001, attacks missed work in the following days.
This was due primarily to transportation problems caused by increased
security measures such as surveillance of bridges and tunnels leading into
Manhattan. Increased absenteeism from work or school has also been
reported after other violent events. For example, during the serial sniper
attacks in the Washington, D.C., metropolitan area in October 2002, a sig-
nificant increase in school absences occurred, with attendance rates as low
as 10 percent at several elementary schools near one of the shooting sites
(Schulte, 2002~. However, this behavior may be considered an appropri-
ate 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 distinction 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
change related to psychological distress. However, if the person was a
staff member in one of the offices specifically targeted in the anthrax mail-
ings, the use of gloves might be considered an appropriate response.
Health care seeking by individuals who are not actually at risk or
injured, but seek health care due to fear and anxiety, has been observed in
response to terrorism events. This phenomenon was noted following the
satin poisoning in the Tokyo subway and during the anthrax attacks in
the fall of 2001 when tens of thousands of people who were not at risk for
exposure obtained prescriptions for the antibiotics ciprofloxacin and
doxycycline (Shaffer et al., 2003~. Accurate and timely risk communica-
tion becomes particularly important in limiting the potential stress on the
health care system because unaffected individuals flood services. This
type of behavior is most likely to occur in the event of chemical, biologi-
cal, radiological, or nuclear attack and is discussed further below in the
section detailing the consequences of these types of terrorism.
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54 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM
Moderators of Adverse Outcomes after Terrorist Attacks:
Identifying Vulnerable Populations
Research from the disaster mental health 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 death of or immediate
risk to a loved one from the terrorism event (i.e., relatives, friends, co-
workers, rescue workers, witnesses). The populations that will be directly
affected may vary according to the type of event (e.g., bombing; hijacking;
chemical, biological, radiological, or nuclear attack). For example, a bio-
logical attack on the U.S. food supply may have a direct impact on agri-
cultural workers through both physical and economic effects, and the re-
sulting disruption may have an indirect impact on society as a whole.
Given the large number of individuals, from those remotely to those di-
rectly exposed, who may be affected by a terrorism event, it is important
to recognize variations among these exposed subpopulations in order to
identify those who are most vulnerable to the psychological consequences
of the event. This will allow for the focus of limited resources on preven-
tion and intervention for those most in need.
Virtually all members of communities affected by terrorism are vul-
nerable to negative psychological outcomes. The type of vulnerability
may vary substantially and may not always be obvious. Diverse vari-
ables that may enhance the prediction of adverse outcomes following a
terrorism event are presented below in pre-event, event, and post-event
temporal categories.
Pre-Event. Shalev (2001) reviewed a previously conducted meta-analysis
examining predictors of adverse outcomes for traumatic events in general
and concluded that preexisting factors have less influence on an indi-
vidual than the disaster itself and subsequent factors such as community
support. Some models of response propose that the impact of pre-exist-
ing factors is confounded with the dose of exposure; when the dose is less,
the impact of pre-existing factors is more evident, and as the magnitude
of the event increases, pre-event characteristics become less important.
Regardless, these preexisting factors are useful to consider when plan-
ning service delivery because they allow for a better understanding of
those who may be at increased risk and require particular attention.
Gender, age, experience, and personality have all been implicated in
moderating adverse outcomes. Female gender has been associated with
worse short-term outcomes in a number of studies of the general popula-
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UNDERSTANDING THE PSYCHOLOGICAL CONSEQUENCES
55
lion after September 11,2001 (e.g., North et al., 1999; Schlenger et al., 2002;
Silver et al., 2002~. Prior marital separation and preexisting physical ill-
ness have also been implicated in predicting greater psychological dis-
tress after these events (Silver et al., 2002~.
As in studies of disasters, the pre-event experience of traumatic events
may be related to psychological consequences following terrorism events.
For example, the investigation of New York City public school students
after September 11,2001, found that nearly two-thirds of the students sur-
veyed reported one or more prior traumatic events such as seeing some-
one killed or seriously injured and experiencing the violent or accidental
death of a family member. In this sample, a history of prior traumatic
events was associated with significantly increased rates of symptoms con-
sistent with PTSD (Hoven et al., 2002~. It is difficult, however, to discern
the relative contributions of the prior traumatic events and the actual ter-
rorism event to the reported symptoms given the lack of pre-event
baseline data in this population.
Age has been identified as possibly moderating psychological re-
sponses to terrorism. While several studies examining adult populations
have found no significant influence of age on the severity of psychologi-
cal responses to terrorist attacks (e.g., Abenhaim et al., 1992), the psycho-
logical impact of terrorist attacks on children and adolescents is frequently
noted as an area of concern as described above. One study reported that
students in the fourth and fifth grades were significantly more likely than
those in grades six through twelve to endorse symptoms consistent with
PTSD after the September 11, 2001, terrorist attacks (Hoven et al., 2002~.
Further research 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 as a potential moderating factor on adverse outcomes. Norris and
colleagues (2002b) reviewed studies that included ethnicity as a variable
and found that among adults, ethnic majority groups had better outcomes
after disasters than minorities in all of the samples. Among youth, how-
ever, the results were more variable. The research base examining racial
and ethnic minority status as a factor predicting outcomes to terrorism
events is extremely limited, although a few studies provide some indica-
tion. For example, Galea et al. (2002) found that Hispanic ethnicity pre-
dicted symptoms consistent with both PTSD and depression among Man-
hattan residents after the September 11, 2001, terrorist attacks. Similar
results were found among New York City public school students after
those attacks; Hispanic students were more likely than either African-
American, white, or Asian students to have symptoms of PTSD (Hoven et
al., 2002~.
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56 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM
Findings from the disaster mental health literature have indicated that
first responders and rescue workers are a population at risk for adverse
psychological outcomes after responding to disasters (e.g., Duckworth,
1986; Tones, 1985; Weiss et al., 1995), likely due to their direct and often
ongoing exposure to traumatic experiences. Findings after terrorism
events reveal similar results. One study of New York City Fire Depart-
ment rescue workers found a seventeenfold increase in stress-related inci-
dents (e.g., depression, anxiety disorders, bereavement issues) during the
11-month period following the September 11, 2001, attacks as compared
to the 11-month period preceding the attacks (Banauch et al., 2002~. These
data, however, may not represent the typical experiences of first respond-
ers and rescue workers because of the deaths of so many fellow firefighters
in the immediate aftermath of the attacks. North and colleagues (2002b)
found a PTSD rate of 13 percent among rescue workers in Oklahoma City.
PTSD was associated with more days spent working at the site and more
time spent in the central bombing pit. However, this study compared
rescue workers to primary 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 pre-
paredness, experience with job-related traumatic events, and self-selec-
tion for the type of work, as well as lower injury rates among rescue work-
ers and exposure to education and debriefing aimed at mitigating
psychological consequences (North et al., 2002b).
Event. While it is clear that certain populations may be particularly vul-
nerable to adverse outcomes following a terrorism event, there 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 du-
ration and intensity of exposure to the traumatic event, including indirect
exposures such as traumatic grief and loss, are some of the most impor-
tant 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 direct physical trauma or threat of trauma; others,
such as family members and friends, will experience grief and loss; and a
wider population will be affected by secondary adversities and a general
climate of fear. Silver and colleagues (2002) found that the degree of ex-
posure to the September 11, 2001, attacks (as measured by a composite of
proximity to the various attack sites, presence at a site, contact with a
victim whether visually or by phone during the attacks, and degree of
watching the events live on TV) was significantly predictive of psycho-
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UNDERSTANDING THE PSYCHOLOGICAL CONSEQUENCES
57
logical distress, more so than the degree of loss,6 although both exposure
and degree of loss were associated with distress. Similarly, Schlenger et
al. (2002) suggested that the amount of time spent watching television
coverage predicted both PTSD symptomatology and general distress, al-
though these authors were careful to note that this association did not
necessarily imply causation (e.g., more symptomatic people could have
been drawn to watching the television news coverage). See Box 2-4 for
additional information on the role of the media during terrorism events.
Other important event-related characteristics include the duration and
type of attack. Unlike other disasters, terrorism events may manifest as a
single massive attack (e.g., Oklahoma City bombing), multisite event (e.g.,
events of September 11, 2001), multisite continuous or repeated events
(e.g., anthrax attacks of 2001), or continuous or repeated events (e.g., ter-
rorist attacks in Northern Ireland) (Ursano,2002~. The mechanism or type
of attack also may moderate outcomes. Biological and radiological at-
tacks may involve considerable on-going exposure to the threat and de-
layed emergence of physical symptoms, while an attack with conventional
explosives will likely be a discrete event with obvious and more immedi-
ate injuries. The effects of cyberterrorism events, which have not been
adequately studied, are largely unknown. These characteristics of terror-
ism events can determine the degree of population exposure, and the se-
verity and magnitude of psychological consequences.
Hoaxes and copycat events may initially result in psychological con-
sequences similar to those of actual terrorism events. Although the re-
search base is extremely limited, the psychological impact of a hoax may
be as great as that of a true threat. For example, Dougherty, et al. (2001)
examined the psychological impact on victims of two incidents of anthrax
threats that were later determined to be hoaxes and found evidence of
distress symptoms. Results revealed that victims frequently reported a
number of posttraumatic stress symptoms even after the hoax was an-
nounced. A similar relationship with adverse psychological consequences
may exist with false alarms for terrorism events, although research in this
area is also limited. False alarms and warnings that are given to people
not at risk have implications for future preparedness and response since a
"cry-wolf" syndrome may result in which people become less responsive
to future warnings (NRC, 2002b).
Post-Event. A number of post-event factors may also help identify those
at increased risk for negative psychological outcomes. The investigation
6 Severity of loss was assessed using a 6-level continuum, with O indicating no loss; 1,
property loss of someone close; 2, personal loss of property; 3, injury of someone close; 4,
death of someone close; and 5, personal injury in the attacks.
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58 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM
by Galea and colleagues (2002) examining residents of Manhattan after
the September 11, 2001, terrorist attacks found that post-event factors pre-
dicting PTSD symptoms included panic attack during or shortly after the
attacks, and loss of possessions due to the attacks. Similarly, post-event
factors predicting depression included panic attack during or shortly af-
ter the attacks, death of a friend or relative during the attacks, and job loss
due to attacks.
Although many people will exhibit some manifestation of distress in
the aftermath of a terrorism event, several specific symptoms have been
identified as being more predictive of later psychiatric illness. These
symptoms include feeling numb, withdrawn, or disconnected; isolation
from others; and avoiding activities, places, or people that bring back
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UNDERSTANDING THE PSYCHOLOGICAL CONSEQUENCES
59
memories of the event (North et al., 1999, see also Box 2-3~. It may be
important to screen for these specific symptoms during the post-event
period in order to identify individuals who may require mental health
care. The ways in which people cope with the stress of a terrorism event
is also predictive of later outcomes. Silver and colleagues (2002) found
that those who used active copings had less distress than those who dem-
onstrated denial, defeatism, and self-distraction indicating disengage-
ment with coping had greater distress.
Secondary and Community Consequences
Because terrorism, unlike natural disasters or human-caused techno-
logical failures, is a purposeful act by an individual or a group of indi-
viduals, terrorist acts are often perceived to be perpetrated by a specific
ethnic, racial, or religious group. Recently, debate has increased about
the controversial practice of profiling based on these characteristics for
law enforcement purposes in the identification of potential terrorists. In
addition, 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 discrimination. Community cohe-
sion can decrease as neighbors become suspicious of strangers and of one
another. A multiethnic and multicultural population might exacerbate
these fears. After the terrorist attacks on September 11, 2001, the number
of hate crimes against Arabs, Muslims, and those perceived to be Arab or
Muslim rose sharply (Human Rights Watch, 2002~. Violent acts included
murder, physical assaults, arson, vandalism of places of worship and other
property damage, death threats, and public harassment. Most of these
incidents occurred between September 11, 2001, and December 2001. Ac-
cording to Federal Bureau of Investigation (FBI, 2002) statistics, the num-
ber 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 Flight #800,
and the Persian Gulf War (Human Rights Watch, 2002~.
In contrast, terrorism events, like other disaster events, can also pro-
duce unique positive outcomes for the community. Because terrorism is
generally directed at a population or subpopulation, there is often a sig-
7 Active coping strategies are behavioral or psychological responses intended to change
the nature of the stressor itself or the way in which one thinks about it. Turning to others for
support and attempting to gain more information about the stressor are examples of active
coping strategies.
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60 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM
nificant growth of patriotism and pride for the population following the
event. For example, after 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 at-
tacks (Silver et al., 2002~.
Chemical, Biological, Radiological, and Nuclear Terrorism
Chemical, biological, radiological, and nuclear terrorism (CBRN) de-
serves special mention, given the unique characteristics. Such threats are
unfamiliar, usually undetectable while they are dangerous, and often per-
ceived as particularly reprehensible and unfair. These qualities present
additional psychological challenges. The presence of an "incubation pe-
riod" in which an individual may have been exposed to an agent but may
not know the outcome is another unique and potentially stressful aspect
of CBRN terrorism. In the case of a bombing or other physical terrorist
attack, the individual will know immediately whether or not he or she has
been physically harmed.
A particularly difficult challenge that may present in cases of CBRN
terrorism is the differentiation of apparent anxiety in people due to the
possibility of exposure to a chemical or biological agent from direct neu-
ropsychological or behavioral changes due to exposure to the agent. The
initial presentation of a chemical and biological weapon attack may be
neuropsychological symptoms. For example, acute poisoning with a sub-
lethal dose of an organic phosphorus compound (e.g., sarin) produces
cognitive impairments characterized by confusion, difficulty in concen-
tration, 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 can result in
psychosis, somatic complaints, anxiety, agitation, and involuntary move-
ments (Benedek et al., in press). Furthermore, physical manifestations of
panic such as shortness of breath might be mistaken as symptoms of in-
fection or contamination, which then becomes a self-reinforcing cycle as
the individual's panic is increased by the shortness of breath, resulting in
an exacerbation of this symptom.
Individuals with nonspecific somatic complaints such as nausea or
weakness will be a great concern in the event of biological or chemical
attacks when the presenting symptoms of exposure may be nonspecific
and similar to other common conditions. For example, during the an-
thrax attacks in fall of 2001, the initial symptoms of infection mimicked
viral syndrome and influenza-like symptoms. Many emergency physi-
cians and primary care physicians were overwhelmed with individuals
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61
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 not always available. The extensive publicity about the an-
thrax 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
nerve gas from Iraqi Scud missiles (Golan et al., 1992~. The 1995 terrorist
attack involving the nerve agent satin in the Tokyo subway system also
illustrated this phenomenon. Almost 75 percent of those who went to the
hospital and were reported as "injured" showed no effects of exposure to
satin (Lillibridge et al., 1995~. An investigation conducted by Ohbu and
colleagues (1997) examined various psychological distress responses in
survivors of the satin gas attack. The individuals reported symptoms
such as fear of subways (32 percent), sleep disturbances (29 percent), flash-
backs (16 percent), and irritability (10 percent).
RESEARCH CHALLENGES AND NEEDS
Conducting research on the psychological consequences of terrorism
and testing interventions in this setting are extraordinarily difficult given
the chaos, 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 be ques-
tionable, unreliable, and not applicable to the disaster setting or popula-
tion of interest. Furthermore, the length of time typically needed for the
approval and dissemination of funding may make it difficult to initiate
research soon after a disaster occurs, which then results in findings that
do not reflect the full time-course of response and recovery. The need to
meet requirements of institutional review boards and other regulatory
agencies also contributes to the time needed before commencement of
research. Barriers such as these ultimately result in gaps in critical knowl-
edge needed to direct interventions in settings of terrorism.
The model depicted in Tables 1-3, 1-5, and 1-6 is a potentially compre-
hensive structure for directing future research, and providing a frame-
work for research to recognize and address the gaps. Much has yet to be
learned even on the basic epidemiologic level, such as the incidence of
psychiatric illnesses in various disaster populations when comparing ter-
rorism with other kinds of events. Researchers use various instruments
to measure many different variables so that comparison between studies
is difficult if not impossible. Intervention studies are exponentially more
difficult to conduct than epidemiologic research because of both the need
to enter the field quickly before other interventions have contaminated
the course of recovery in the population and the need to apply standard
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62 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM
methods of treatment evaluation such as randomized, double-blind, pla-
cebo-controlled studies. Therefore, even less is known about the effec-
tiveness of interventions for traumatic stress following disasters and ter-
rorism. The field has resorted to applying interventions developed for
other populations that are untested in disaster settings, some of which
may be unhelpful or possibly even harmful. Even more complex than
epidemiologic and treatment effectiveness research in disaster settings are
studies of community systems of response to disasters and terrorism.
Throughout this chapter, we have highlighted areas where additional
and more rigorous research is necessary. These areas include the psycho-
logical consequences and response implications of hoaxes and false
alarms, and of attacks with conventional explosives or a CBRN weapon
such as the release of a highly infectious disease. In addition, research
that refines possible population-based predictors of adverse outcomes af-
ter terrorism events, including ethnicity, age, and other pre-existing char-
acteristics, is needed to guide future outreach and intervention efforts.
Evidence is lacking on substance abuse outcomes after a terrorism event,
and on interventions for these behaviors. The role of media images in
spreading terror remains unclear, and should be examined as well, so that
potentially adverse psychological consequences can be minimized. Fi-
nally, the identification of factors that may influence community and in-
dividual resilience is required in order to inform future interventions. As
noted throughout this chapter, a lack of indicators of the population's
psychological health prior to terrorism events limits the conclusions that
can be drawn from research conducted after events. Ongoing surveil-
lance 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. Research
examining the psychological consequences of terrorism, although in its
infancy, indicates that psychological difficulties will certainly result for
many. Most of those with psychological consequences will present with
mild distress symptoms and behavioral changes, while only a few may
present with severe symptoms that meet the criteria for psychiatric ill-
ness. The malicious intent and unpredictable nature of terrorism may
carry a particularly devastating impact for those directly and indirectly
affected. However, despite the devastating nature of terrorism, commu-
nity cohesion and posttraumatic growth are possible.
Although psychological effects of terrorism are virtually certain, rela-
tively little is known about particular consequences for various subgroups
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of the population or how people may react to different types of events.
There is some evidence that children, survivors of past traumatic events
(including refugees), ethnic minority populations, and those with preex-
isting psychiatric illness may be especially vulnerable to psychological
consequences, although some of these data are contradictory. Events of
closer proximity, longer duration, and greater intensity might be expected
to result in increased psychological consequences.
The broader trauma literature may begin to help direct prevention
and intervention efforts in response to terrorism events. However, it is no
longer sufficient to rely on information obtained from research on other
kinds of traumatic events because disasters, and particularly terrorism,
differ in fundamental ways. Continued research examining the psycho-
logical consequences from a range of disaster and traumatic events will
help improve understanding of the impact and provide evidence to target
interventions.
Finding 2: Terrorism and the threat of terrorism will have psycho-
logical consequences for a major portion of the population, not
merely a small minority. Research studies that have examined a
range of terrorism events indicate that psychological reactions and
psychiatric symptoms clearly develop in many individuals. To op-
timize the overall health and well being of the population, and to
improve the overall response to terrorism events, it is necessary that
these potential consequences be addressed preventively as well as
throughout the phases of an event.
Representative terms from entire chapter:
traumatic events
