The mental health and behavioral consequences of terrorism

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The mental health and behavioral consequences of terrorism
Charles DiMaggio, Sandro Galea
Chapter for: Victims of Crime, third edition. Eds. Robert C Davis, Arthur J Lurigio, Susan Herman
The behavioral consequences of terrorist incidents have received considerable recent attention, much of it driven by the 1995 Oklahoma City bombings and the attacks of September 11, 2001 in the United States. In this chapter we will review the available evidence about the mental health and behavioral consequences of terrorism, consider methodological and research issues that challenge the field, and discuss the evidence for specific prevention and treatment efforts aimed at mitigating the mental health and behavioral consequences of terrorism.

Terrorism is psychological warfare 1, and behavioral disturbance is the primary intent of terrorists. As Lenin stated “The object of terrorism is to terrorize”, and as long ago as the 4th century BCE Sun Tzu advised, “Kill one to terrorize ten thousand.” 2 The more incomprehensible the event, the greater the potential mental health effects. Human intent, as seen in terrorist incidents, may be associated with the greatest risk of behavioral disturbance.3

Definitions of terrorism vary.4 According to the US Department of State, terrorism is “…premeditated, politically motivated violence perpetrated against non-combatant targets by sub-national groups or clandestine agents usually intended to influence an audience".5 A broader definition proposed by public health practitioners states that it is “The intentional use of violence--real or threatened--against one or more non-combatants and/or those services essential for or protective of their health, resulting in adverse health effects in those immediately affected and their community, ranging from a loss of well-being or security to injury, illness, or death.”6
Neither definition captures the sense of chilling brutality associated with what is commonly accepted as terrorism. Perhaps closer to the mark is an evocative description of terrorist violence in Northern Ireland: “One atrocity provoked another, equally inhumane and gruesome, and the whole 20-year history has been pockmarked by some particular incidents of quite indescribable cruelty as man has visited his inhumanity upon his fellow man in some utterly barbaric ways.” 7 It is notable that, prior to 1964, Northern Ireland was “one of the most peaceful societies in Europe”, with only one murder reported in Belfast between 1960-1964.7
The intended consequences of terrorist acts extend beyond those immediately affected. Exposure may be defined in terms of physical proximity to incidents, level of threat and personal loss or injury to family or friends. 8 For example, two thousand seven hundred ninety five people were killed at the World Trade Center as a result of the September 11, 2001 terrorist attacks; an additional 7,467 persons were injured. They had 17,642 family members. Seventeen thousand eight hundred fifty nine rescuers were exposed to the attack as were 32,361 employees and their 87,383 family members. 8 All told, 164,710 persons were directly exposed to this terrorist attack. For every individual killed an additional 59 persons were traumatized. (Figure 1) An additional 4,800,000 residents of the surrounding 10 counties in ways large and small coped with the events of that day. It should be no surprise then, that twenty percent of New York City residents living below Canal Street, in close proximity to the events, met the criteria for post-traumatic stress disorder (PTSD) at some point in the two month period following September 11, 2001.9
Analogously, the 467 terrorist deaths in Northern Ireland in 19727 directly or indirectly affected an additional 27,000 people or 18 per 1000 population. The 472 deaths attributed to the intifada in Israel in the 19 months between 2000 and 200310, affected 4 persons per 1000 population.
Post-Traumatic Stress Disorder
PTSD is likely the most prevalent and debilitating consequence of disasters in general and terrorism in particular.11 There is an emerging consensus in the literature both that PTSD is a likely outcome of terrorism incidents, and that PTSD after such events is frequently accompanied by other behavioral and health disturbances.11 Although the behavioral consequences of terrorist incidents have received considerable recent attention, much of it driven by the Oklahoma City bombings and the attacks of September 11, 2001 in the United States, most of the information on disaster-related PTSD comes from the general disaster literature. It is of note, that of 160 studies in a recent meta-analysis of post-disaster psychiatric disturbance, only 8 specifically addressed terrorism.12
First described in the 1980’s and included in the Diagnostic and Statistical Manual Third Edition (DSM-III) 13 the diagnosis of PTSD arose largely in response to the experiences of war veterans. To qualify for a diagnosis an individual required at least one eligible traumatic event (a "criterion A" stressor), a symptom of re-experiencing the trauma (intrusion), a numbing or blunting of affect (avoidance) and at least 2 symptoms of hypervigilance and startling (arousal). The diagnostic criteria underwent revision in the 1987 DSM-III-R14 when the requirement of at least one month’s duration was added and again, in DSM-IV15 when the individual’s perception of the event was added to the criteria.
Work impairment associated with PTSD is as great or greater than that seen in major depressive disorder, and is associated with increased rates of medical utilization.16 The general population rate of PTSD has been estimated at between 5.4%16 and 7.8%.17 Left untreated, PTSD is thought to last between 36 to 64 months, but can persist for as long as a decade; time to remission can be reduced by half with treatment. 18 16 Over the course of a lifetime, one half of the general population will meet a “Criteria A” stressor at some point; about one third of these individuals will develop PTSD.18
Reports of the prevalence of PTSD among victims of man-made disasters vary greatly. Rate are highest for victims and survivors, from 25% of individuals exposed to a 1991 Killeen, Texas, mass shooting up to 75% of individuals in a 1988 oil rig fire. Prevalence rates among rescuers vary from 5 to 40%. Thirteen percent of Oklahoma City firefighters met criteria for PTSD several months later. Nearly half of the Australian firefighters involved in battling a bush fire in 1993 had PTSD at some point in the first two years following the incident. The prevalence of PTSD in the general population after a disaster is lower. Seven to 11% of New York City residents met criteria for PTSD after September 11th and 9% of Alaskans were reported to have PTSD after the Exxon Valdez incident.11
In the first weeks following the September 11, 2001 terrorist attacks, 1 in 10 New York area residents met the criteria for PTSD. 19 There were estimates that 520,000 people in New York City (NYC) and the surrounding areas would experience symptoms of PTSD and that 129,000 would seek treatment.8 7.6% of New York City residents reported using mental health services in the 30-day period 5 months after September 11th.20 A year later, NYC residents continued to be ‘very concerned’ about future terrorist attacks.21
Although the number of studies that has considered PTSD after terrorism specifically is limited, one review of the topic suggested that that in the year following terrorist incidents PTSD prevalence in directly affected populations varies between 12% and 16%, and that this prevalence can be expected decline 25% over the course of that year.22 However, in contrast, some researchers have found evidence of persistently elevated prevalence of psychological distress many months after and at long distances from the events of September 11, 2001 23. There is also evidence of resilience in the face of terrorism. 16 24 Among US military veteran’s, there was no significant increase in the utilization of mental health services for the treatment of PTSD in the New York City area, 25 and among a national sample of veteran’s with a pre-existing diagnosis of PTSD, there was, in fact, evidence of less severe symptoms on admission after September 11, 2001 than before.26

Correlates of PTSD

Gender and prior psychiatric diagnoses are strongly associated with subsequent PTSD and may be useful triage factors for outreach or treatment, particularly when taken together with such variables as direct exposure to events as either a survivor or rescuer.
In one review, 94% of studies that looked at gender found that being female was associated with an increased risk of post-disaster behavioral health disturbance,3 with women reported as being twice as likely to develop PTSD. 18 Marriage and parenthood are also associated with increased risk. 12 Taken together, these associations point to the potential common mediating factor of an imbalance of resources, or the stress of caring for others and being obligated to provide more resources than are received. 3
While minority status and lower socioeconomic status are associated with increased risk of post-disaster behavioral diagnoses, this is likely due, at least in part, to increased risk of exposure. 12 For example, after the events of the September 11, 2001 terrorist attacks, New York City residents of lower socioeconomic status were two and half times more likely to develop PTSD 9 and there were reports of increased alcohol and tobacco use among drug users, although there was no change in heroin or cocaine use.27
Particularly relevant to acts of terrorism, human intent underlying a disaster has been associated with increased risk of behavioral disturbances when compared to a natural disaster. 3 Kidnappings and torture are associated with the highest rates of PTSD, flooding with the lowest. 18 Severe behavioral effects are also seen where there is extreme and intensive property damage, serious and ongoing financial problems, or a high prevalence of trauma and death.3 In New York City after the September 11, 2001 terrorist attacks, those who lived closest to the World Trade Center area had a 3 times greater risk of developing PTSD. 9 That 43% of residents near the Exxon Valdez disaster had psychiatric impairments indicates that deaths are not necessary for there to be behavioral health effects. 12
Loss of psycho-social resources, such as family, friends and jobs as well as relocation and disruption of neighborhood patterns may be key mediators of post-terrorism behavioral disturbances, and pre-existing psychiatric conditions predispose individuals to post-disaster PTSD. 12 While associations with media exposure have been reported many of these studies are cross-sectional and the direction of the association is unclear.
Risk for developing post-terrorism PTSD varies by age with an increase during school age, followed by a second more prominent increase during middle age. 12 In a study of PTSD among 7,000 children 7 weeks after the bombing in Oklahoma City, physical, interpersonal and TV exposure together accounted for 12% of variance while peri-traumatic response alone accounted for 25%. The authors concluded that a child’s subjective response to trauma is a key predictor of PTSD, and should be included in the diagnostic criteria for PTSD in children.28
Studies of children most often report symptoms rather than diagnoses which may account, in part, for such high rates as the reported 95% of children who had symptoms of PTSD after the Armenian earthquakes.11 In one study of the psychological sequelae of the September 11,2001, terrorist attacks there was a 46% increase in the diagnosis of PTSD in children in the following months compared to the previous months. The increase for adults was 12%. Notably, there was no increase in the diagnosis of depression or substance abuse.29
Violence, such as terrorism, is associated with the highest level of mental health disturbances in children,8 but the relative impact of different kinds of exposures varies. Kuwaiti children were relatively unaffected by interpersonal exposure during the Gulf War, but those whose friends were killed in a non-war related bus crash were. 28 Fifty one percent of children exposed to Hurricane Andrew were reported to have a new onset behavioral disorder; 33% had PTDS and 56% of children in high impact areas remained impaired 2 months after the event. 12
Other Post-Disaster Behavior
Other post-terrorism behavioral disturbances are reported to varying degrees. There were a reported 99 hate crimes against middle easterners in the US in the month following the September 11, 2001 terrorist attacks compared to 93 such crimes in all of 2001 and 12 in 2000.30 Some of this increase may be attributed to increased surveillance. There was no increase in divorces following the Oklahoma City Bombing.31 Post-terrorism alcohol use among military veterans with a pre-existing diagnosis of PTSD hare been shown to increase, but has not been demonstrated among civilians.32
There are reports from war zones that patients with depressive disorders, obsessive compulsive disorders and phobias may show symptomatic improvement as a result of a traumatic experience. 7 According to one researcher, citing the British experience during the Long Blitzkrieg of World War II and the US experience during the race riots of the 1960’s, “Civil disorder can paradoxically have a beneficial psychological effect possibly through collective forces including increasing social cohesion”. 7 Another researcher has noted a 50% decline in the suicide rate as well as a decrease in stress-related lichen planus in Northern Ireland Between 1969 and 1975 as evidence of resiliency. 2 and yet another cites the U.S. nationwide decline in chronic fatigue syndrome following the September 11, 2001 terrorist attacks. 33 According to this line of reasoning, some individuals will invariably develop psychiatric illness after being subjected to or witnessing trauma, but many in the general population may actually improve psychologically: “…the general population (of Northern Ireland) …is largely unaffected from the psychiatric point of view…whilst the victims of violence do suffer emotional reactions…those reactions are often comparatively short-lived.”7
However, much of the evidence about the behavioral consequences of terrorism and mass violence is unclear, such as the conflicting reports on the effect of the September 11th terrorist attacks on suicide rates,34, 35 and resilience in the face of terror must be balanced against the growing literature on medically unexplained symptoms and physical diagnoses following terrorism and disasters.
Medically unexplained symptoms are “physical symptoms that provoke care seeking but have no clinically determined pathogenesis”. 36 Research suggests that at least one third of symptoms in both clinical and population-based studies are medically unexplained. 36 At times these constellations of symptoms are characterized as physical, at other times as primarily physical. This may have more to do with the background, training and prior assumptions of the investigators than with the illness itself. 36 It is rare, though to have a truly new disease; similar constellations of symptoms are given new names based on the event from which they arose. 36 Such syndromes have followed vaccination programs for US and UK military personnel, and have been a prominent feature of Gulf War syndrome among US troops. Other instances include Canadian troops concerned about exposure to “red soil” in Croatia; a so-called “Balkan War Syndrome” attributed to exposure to depleted uranium; a “mystery syndrome” after a jetliner crashed into a populated area of Amsterdam, and “jungle fever” among Dutch peace keepers in Cambodia in the 1980’s. 37
Non-injury physical diagnoses reported following disasters have often been cardiac in nature. There was a greater than three-fold increase in myocardial infarctions in Japan following the Honshin Awerjuu earthquake38. This was attributed to increased hematocrit, fibrinogen and other coagulation factors, with the elderly perhaps most at risk. 38 In animal models, acute stress decreases the arrhythmia threshold by up to 40%. This effect has been shown to be interrupted by the administration of beta blockers. 38
Methodological and Research Issues:
Although the field of post-disaster research is burgeoning, there remain many questions, as suggested by the review above, and substantial methodological challenges that need to be overcome in future research. Approximately two thirds of disaster-related behavioral studies are cross-sectional. 12 Such studies are likely to pick up more long-standing cases of disease and may explain, at least in part, reports of extended chronicity,39 Those studies that have attempted a longitudinal approach, though often based on two data points, have demonstrated rapid declines in PTSD prevalence over time. 12 .Most of these latter studies are prospective, although retrospective approaches, such as interrupted time series analyses, may yield informative results. 31
The majority of post-disaster studies are individual level rather than ecologic. The observations of cross-community differences in responses to terrorist events such as the September 11, 2001 terrorist attacks suggest that ecologic studies may play an important role in assessing the determinants of population mental and behavioral heath after disasters and terrorism.40
Post-terrorism studies are likely to detect other non-disaster related chronic conditions. For example, approximately half of the Oklahoma City firefighters in one sample met lifetime criteria for alcohol abuse or dependency.41 Ninety percent of one sample of children studied after the 1998 US Embassy Bombing in Kenya were deemed exposed to other crimes or human-caused violence.42 This complicates the task of assessing the health problems that were caused by exposure to the disaster or terrorist attack. The exposure under study may also be confounded by other events that occurred during the same time period. For example, the 2001 attacks on New York’s World Trade Center were quickly followed by both anthrax-laced mail attacks and a passenger jet crash.
Resource utilization may be particularly difficult to measure during times of crisis. Fear of violence may cause people to stay home decreasing hospitalization numbers.2 Psychiatric admission rates may not capture successful outpatient treatments, and there may be changes in available services over time. Some psychiatric conditions may be overshadowed by physical complaints.7
PTSD continues to be a focus of research attention after disasters and terrorism, perhaps to the detriment of empiric development about other behavioral pathology. In one review of all post-disaster behavioral research, 68% of studies addressed PTSD, 36% included major depressive disorder and 20% generalized anxiety.12 Behavioral diagnoses such as alcohol abuse and somatic disorders are not commonly studied. 12 But, changes in diagnostic and screening instruments for PTSD over time 13 14 15 and the myriad available screening instruments available for assessing PTSD43 44, 45 46, 47make comparisons difficult even within the same geographic region. The number of studies conducted worldwide bear little resemblance to the overall risk of disaster and terrorism. Figure 2 represents the number of post-terrorism behavioral health studies conducted since 1980 compared to the number of reported terrorist incidents in the region.48
Prevention, Treatment and Resilience
Ascribing suicide terrorism to individual characteristics may be misattributing the primary causes of terrorism. 5 Psychopathology, poverty and lack of education also are not reliable indicators: "suicide terrorists have no appreciable psychopathology and are at least as educated and economically well off as their surrounding populations" of who may become a terrorist.5 In fact, there may be a slight positive correlation with education, and although relative economic loss may be a factor, there is no real association with poverty. The only distinguishing characteristics of suicide bombers are that they tend to be single, male, and religious. 5 This then suggests that pre-emptive screening and identification of persons who might become terrorists may be impossible. It has been argued that interventions are needed at the community (ecologic) level. An effective approach may be to target moderates within a community and address issues of discontent so as to encourage the communities themselves to abandon support for terrorist activities. 5 Although this is intuitively appealing, the scant data on the evolution of terrorism make it difficult to muster the empiric evidence to support such sweeping recommendations. Therefore, our relatively limited armamentarium of empirically validated measures to prevent terrorism suggest that it is incumbent on policy makers to consider ways to mitigate the potential consequences of terrorism and not simply focus on preventing terrorism.
Primary prevention of behavioral health effects among first responders may be feasible in the form of training as well as control of the post-terrorist environment. The mental health effects of disasters on recovery workers can be mitigated by training and experience.12 Training must be tailored to the type of likely exposure. Fire fighters and other first responders are exposed to personal risk; medical workers must confront death and horror; counselors risk vicarious trauma. 3 Rescuers with realistic expectations of what to expect may experience fewer behavioral breakdowns. 36 It has been shown that soldiers with higher rank and esprit de corps exhibit fewer behavioral problems during times of war and that isolated support troops sometimes have higher rates of illness than front-line forces. 36 Cultivating a culture of collegiality and common purpose may also control post-disaster pathology.
Individual pre-event screening among the civilian population may look for individuals at risk of developing behavioral symptoms and offer early treatment. Once identified, interventions may include cognitive-behavioral therapy. 36 However, studies about the predictive power of screening instruments and the cost-effectiveness of individual versus community level interventions are limited
Secondary prevention, in the form of early identification and quick intervention is also possible. The onset of PTSD is fairly early after an incident, so interventions should start early with triage to identify those most at risk due to pre-existing psychiatric disease18 and other risk factors such as proximity to the event. There is little evidence to endorse any particular treatment approach. While there have been no randomized clinical trials of post-disaster behavioral interventions 37, there is no evidence that critical stress debriefing is effective, 36 37 although identifying high-risk individuals and providing several sessions of cognitive-behavioral therapy can prevent PTSD. 36 There have been few studies of the effects of drug regiments. 3 Interventional trials with drugs that have an acceptable safety profile, such as beta blockers, may be warranted.
Since most individuals experiencing medically unexplained symptoms will get better spontaneously, 36 public health messages reminding people that most symptoms will resolve may be helpful. Efforts should be directed at symptom management and not establishing a hard diagnosis. 36 It is important, though, on both the individual and community level to avoid trivializing people’s concerns.
Perceptions of self-efficacy may be a key to resilience. “What matters, apparently, is not so much how people actually cope, but rather how they perceive their capacities to cope and control outcomes”. 12 Resilience may reside as much in the community as in the individual. Resource dynamics "undoubtedly account for the overall resilience many, if not most, people show in the face of-even quite serious stress".3 Collective interventions should replace valued resources as quickly as possible, emphasize self-empowerment and

reinforce indigenous networks. If relocation is necessary, people should be kept in natural groups and be encouraged to return to normal activities as soon as possible. 3

Community and neighborhood interventions such as public education, capacity building and a return to normalcy probably should receive higher priority than individual interventions.3 Disasters are characterized by a loss of community services just at the time they are most needed. 3 Social support can be defined as both the perceived support as well as the goods and services that are actually delivered. Interventions thought to be effective “improve community cohesion … provide appropriate direction and high quality leadership … and build a sense of individual responsibility and control”. 36

Terrorist-Related Physical Injury
Despite concern over chemical, radiological and biological attacks, the majority of direct terrorist-related physical injury to date has been the result of direct trauma. While many terror-related injuries tend to be of greater severity than non-terror related injuries and are characterized by penetrating wounds and the consequences of explosions, there are often a large proportion of persons with minor injuries.
An Israeli review of a pediatric population found that 54% of 138 children injured due to terrorist activity had the highest injury severity score (25+) compared to 3% of 8,363 non-terror injured children. The terrorist-related injuries were significantly more likely to require a higher degree of critical care, more likely to involve penetrating injuries to the torso or open head wounds, and more likely to involve internal injuries.49 In Bologna, Italy, in 1980 73 of 291 casualties died at the scene. Morbidity was characterized by primary blast injuries such as so-called ‘blast lung’ and flash burns as well as secondary injuries such as concussions, lacerations and factures.50
Terrorist-related injuries are more likely to involve gun-shot wounds and explosives than non-terrorist related injuries. In a one-year period between 1993 and 1994, one Israeli hospital reported treating 220 terrorist-related injuries. While, more than half the patients (54%) were injured by thrown projectiles and stones, a quarter (25%) had been shot and 10 patients (4.5%) were injured by explosives.51
These kinds of injuries are labor and resource intensive and exact a great toll on healthcare systems. During a 15 month period between 2000 and 2001, 2.4% (561) of all trauma admissions to 9 acute-care Israeli hospitals were for terrorist-related injuries. Three quarters of patients were in their twenties and male. Forty eight percent of injuries were due to explosions, 47% due to gunshot wounds. The authors concluded that the severity of injuries required a greater level of critical care from that seen in non-terrorist-related injuries and imposed a significant burden on the Israeli healthcare system.52
Researchers have attempted to pool terrorist-related injuries to describe overall patterns. One such study combined 3,357 casualties from 220 world-wide terrorist incidents and found an immediate fatality rate of 13%. Thirty percent of survivors were hospitalized of whom 1.4% died. The authors concluded that discriminating triage could decrease overall survival.53 A meta-analysis of 29 terrorist bombings concluded that most of the 903 deaths among the 8,634 casualties were immediate and untreatable. Penetrating soft-tissue injuries (41-86%) predominated followed by pulmonary injuries (1-21% of survivors) depending on the environment (closed or open space) in which the bombing occurred. 54
While many injuries are immediately fatal, the majority of survivors will suffer less significant trauma. During a 4 ½ year period from 1975 to 1979, one Jerusalem hospital reported 272 terrorist-related hospital admissions, the majority of which (87%) were graded as ‘light’ according to a commonly used “Injury Severity Score”. Ten percent of injuries were considered ‘severe.’ 55 A 1978 British study of 1532 consecutive terrorist bombing victims found only 9 deaths in hospital.56
More recent events have born out this experience. Seven hundred fifty nine persons sustained injuries after the 1995 Oklahoma City bombing: 167 persons died, 83 survivors were hospitalized. Survivors’ injuries were characterized by soft-tissue trauma such as lacerations and sprains.57 Following the events of September 11th in New York City, two nearby hospitals treated approximately 900 patients, of whom 85% were ‘walking wounded’ sustaining ocular injuries and lacerations. One hundred thirty five patients were admitted to hospital, of whom 18 required surgery. 58 Of 970 recorded injuries to rescue and non-rescue workers on that day in New York, 49% involved inhalation injuries followed by ocular injuries (26%) and minor soft-tissue trauma such as sprains and contusions (14%) and lacerations (14%). 59
Injury research and control in general deserves greater attention and resources. Although injury is the number one killer of 1 to 34 year-olds in the United States60 and results in more potential years of life lost than cancer and cardiovascular disease combined,61 for every dollar spent on cancer research, the federal government spends about 11 cents for injury research.62 Despite its seemingly random nature, injuries, including those due to terrorism, are far from chance events and can be fitted to predictive models. Once adequately described, there is every reason to expect that terrorist-related injuries are at the very least amenable to secondary and tertiary public health interventions.
Many questions remain to be answered.63 What are the types, prevalence and incidence of fatal and non-fatal injuries? What are the demographic characteristics, including race, ethnicity and socio-economic status, of affected individuals? What are the best means of transport and what are the most effective treatments? What resources will be needed and how will they effect surge response? This kind of information is crucial for medical and public health professionals and community planners and policy makers to prepare for the possibility of terrorist incidents.

Effective post-terrorist public health interventions require the recognition that behavioral consequences are, in fact, the intent of terrorists. The behavioral consequences of terrorist incidents have received considerable recent attention, much of it driven by the Oklahoma City bombings and the attacks of September 11, 2001 in the United States. Post-traumatic stress disorder is the most commonly studied psychopathology after disasters. Survivors of terrorist incidents consistently suffering the highest rates of PTSD; rescuers first responders are at next highest risk. Prevalence estimates of disorders such as PTSD may mask great variability depending on who is being studied, who is conducting the study and where the event occurred.
It appears that terrorism-related behavioral diagnoses such as PTSD behave similarly to that seen after other incidents such as natural disasters. The accumulated evidence on interventions following natural disasters is likely to be appropriate for the post-terrorist environment. Prior psychiatric diagnoses are strongly associated with subsequent PTSD and may be a useful triage factor, particularly when taken with such factors as female gender and direct exposure to events as either a survivor or rescuer. These associations are consistent across study types and environments, and represent important variables to consider when developing triage, outreach and treatment programs.
Although most people in the general population can be expected to recover spontaneously within several months to a year, there are potential population-level interventions to perhaps facilitate and speed the process. These include recognition of honest appraisals of behavioral health effects in community health announcements, preserving as much as possible community, family and social networks and returning individuals to normal activities as soon as feasible. Finally, some individuals such as survivors, rescuers and those with a prior psychiatric history are at increased risk of conditions such as PTSD and may require individual interventions. These persons should be identified and referred for treatment.
The physical injuries associated with terrorism are characterized by immediately fatal and severe injuries in those most directly exposed to the event and a greater number of minor injuries for those more peripherally exposed. Many questions remain to be answered about how best to utilize health care resources in response to terrorism.

Figure 1: Relative proportion of persons affected by trauma of September 11th, 2001, New York City World Trade Center terrorist attacks.

Figure 2: Comparison of proportion of post-terrorism behavioral health studies (grey) to proportion of reported terrorist incidents (black) since 1980 by region of the world.

(Reprinted from: DiMaggio C and Galea S.22)

1. Alexander D. Psychological Aspects of Terrorism. Paper presented at: 14th World Congress on Disaster and Emergency Medicine; 18 May 2005, 2005; Edinburgh, Scotland.

2. Beare JM, Burrows D, Merrett JD. The effects of mental and physical stress on the incidence of skin disorders. British Journal of Dermatology. 1978;98(5):553-558.

3. Norris FH, Friedman MJ, Watson PJ. 60,000 disaster victims speak: Part II. Summary and implications of the disaster mental health research. Psychiatry. Fall 2002;65(3):240-260.

4. Butler AS, Panzer AM, Goldfrank LR, ebrary Inc. Preparing for the psychological consequences of terrorism

a public health strategy. xvi, 168 p. Available at: Online book

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