Terrorism and Bio-Terrorism

Community disasters (including terrorism) have a particularly devastating impact on people who have previously experienced trauma, increasing the length and severity of Posttraumatic Stress Disorder (PTSD), interrupting recovery, and leading to high rates of hospitalization. In the event of continued terrorism or disasters, the mental health system is ill-prepared to offer effective help to victims. Many mental health professionals have received little or no training in trauma.

Facts and Discussion Points:

* The majority of people recover from grief and shock after a few months. However, 25% to 30% of people directly affected by terrorist attacks or other disasters may eventually develop full-blown PTSD or other debilitating psychological conditions such as major depression.1, 2, 3, 4, 5

* Five to eight weeks following the 9-11-01 terrorist attacks, almost 10% of adults living below 110th Street in Manhattan reported symptoms of PTSD or clinical depression, and 3.7% met criteria for both diagnoses. These rates are 2 to 3 times higher than those normally reported in any given year.6

* Some traumatized individuals may take months or years to notice troubling symptoms or to seek help. Using formulas derived by the federal government following disasters such as the 1995 Oklahoma City bombing, the New York OMH estimates that as many as 1.5 million New Yorkers may eventually need some kind of mental health help as a result of 9-11-01.7, 8

* Almost 6% of Americans across the country, including children, had substantial symptoms of stress following the 9-11-01 terrorist attacks.9, 10

* Nearly 90% of the 710,000 New York City schoolchildren in grades 4 through 12 showed at least one symptom of posttraumatic stress six months after 9-11-01. An estimated 10%, or 75,000 children, are suffering six or more symptoms of post-traumatic stress.11

There are also some groups who are at higher risk for developing severe, lasting, and pervasive psychological effects after a disaster.

1--New York City schoolchildren with PTSD, at least two-thirds of whom have not received mental health services, are at high risk of suicide and substance abuse and may find their symptoms worsen if ignored.11, 12

2--Survivors of previous traumatic experiences who have not successfully resolved their trauma are at particular risk for developing symptoms severe enough to interfere with normal life. They may re-experience thoughts, emotions, symptoms, and arousal levels associated with their original experiences, and are at high risk for developing chronic PTSD.13, 14, 15

3--Abuse survivors with prior exposure to interpersonal violence (physical, sexual abuse or neglect) in childhood or adulthood, have significantly heightened susceptibility to severe and chronic PTSD, anxiety, and clinical depression following exposure to any type of traumatic event.6, 16, 17, 18, 19

4--Women or girls in 42 of 45 studies (93%) were affected more adversely by disasters than were men or boys; the effects lasted longer, and the strongest adverse effects were noted in cases of PTSD for which women’s rates often exceeded men’s by a ratio of 2:1.6, 21, 22

5--The number of women victimized by domestic violence increases significantly (46% in one study) following major disasters. Thirty-nine percent of abused women develop post-disaster PTSD compared to 17% of other women, and 57% of abused women develop post-disaster depression, compared to 28% of other women.23

6--People diagnosed with severe mental illness (SMI) may have an increased risk for distress, especially posttraumatic stress symptoms, after a disaster. More than 90% of people with SMI report exposure to previous trauma. Most experienced multiple traumatic events of an interpersonal nature including sexual and physical assault in childhood and adulthood. Approximately 30% to 40% of these people currently have PTSD. This rate is 20 to 30 times greater than that of people without SMI. Events such as a terrorist attack can exacerbate pre-existing PTSD symptoms and may cause people with SMI to be at increased risk for developing PTSD over time.22, 24

7--Children and adults with prior psychiatric disorders or with family histories (especially parental) of psychiatric or addictive disorders are at high risk for psychosocial impairment when exposed to trauma (including disasters and community or domestic violence).18, 22

8--Individuals whose parents have been previously traumatized are at risk of experiencing increased symptoms when exposed to a violent event.25

9--Significantly higher rates of both PTSD and clinical depression following the 9-11-01 terrorist attacks were found among people who lived close to ground zero, who suffered personal losses as a result of the attacks, who had endured other stressful events, who experienced extreme panic during or shortly after the attacks, or who had disengaged from coping efforts early on (e.g., giving up, denial, self distraction).6, 10, 22

10--Rates of PTSD and clinical depression were higher among New York City Hispanic respondents than among Whites, Blacks or Asians. Hispanics were 2.6 times more likely to have experienced posttraumatic stress and 3.2 times more likely to experience depression than were Whites.6

11--Refugee clients who had been previously traumatized in their native war-torn countries and who were diagnosed with PTSD reacted intensely to televised images of 9-11-01. Cross–cultural reactivation of trauma has a significant clinical impact. It is essential that clinicians anticipate PTSD symptom reactivation among refugees when they are re-exposed to significant traumatic stimuli.26

12--As more time elapses after a trauma, PTSD symptoms and co-morbidity increase. This finding implies that PTSD is a chronic disorder with a downward course, and suggests the necessity for early recognition and intervention.27

13--Before severe, lasting, and pervasive psychological effects appear, professional help from providers trained in the early identification, recognition, and treatment of stress disorders is recommended.28

A shortage of mental health workers with knowledge of trauma is widely reported.

* Existing mental health systems are not designed for the scope and the nature of the needs created by terrorism acts such as those seen on 9-11-01.13

* Few New York-based mental health clinicians were trained to treat the level of trauma or the profound psychological impact incurred by the World Trade Center attack. Left untreated, the most serious mental health disorders brought on by trauma can lead to suicide.29, 30

* Across the country, few universities offer comprehensive trauma programs that prepare their graduates to address trauma. As a result, mental health clinicians are often scared, uncomfortable and uncertain about whether they have the skills they need to help victims of traumatic events.29, 30

* Without sufficient training in techniques to treat trauma, clinicians may: 1) offer untested therapies; 2) fail to recognize and treat symptoms ranging from flashbacks to anxiety to physical effects; or 3) provide treatment that is harmful.13, 29

* Individuals who have successfully resolved previous traumatic reactions have been shown to be more resilient to disasters, and should be viewed as a resource for disaster-stricken communities.14

* A program in Hawaii successfully identified and treated children with posttraumatic stress symptoms following a 1977 disaster and noted a gulf between children who had received counseling for PTSD and those who had not. Children who were treated reported fewer trauma-related symptoms, and the positive effects were maintained a year later.8, 31

* The development of a meaningful narrative of trauma experience is an important factor in recovery. Religious beliefs may provide meaning for trauma survivors and may be a useful focus for intervention with trauma survivors.32, 33


1---Invest in training to enable the mental health system to address trauma specifically. Collaborate with academia, professional organizations and policy makers to develop comprehensive trauma programs and curricula that teach best practices in the treatment of trauma.30

2---Develop mental health system capacity to provide early diagnosis, trauma assessment and intervention. Evaluate trauma history to aid in early intervention efforts. Interventions addressing initial reactions to a disaster, such as panic attacks, may help prevent the development of long-lasting psychological sequelae.6, 27, 28

3---Mental health providers should make additional support and services available including routine assessment for PTSD and consultation with trauma specialists when a client experiences symptom exacerbation following recent trauma.3, 24, 27

4---Mental health workers should collaborate with primary care physicians, family practice physicians and health care personnel to ensure prompt recognition of signs of PTSD and early intervention.

5---Health care workers can prepare for the effects of disaster and terrorism by establishing tertiary prevention initiatives to reduce the impact of retraumatization on vulnerable groups.

6---A national volunteer agency has been created called Citizen Corps, which among other activities will aid in recruiting and training retired doctors and health care workers for emergencies, and increase training for disaster preparedness in local communities. As part of the new USA Freedom Corps (which includes Peace Corps, Senior Corps and AmeriCorps), Citizen Corps will include trauma experts, training, and educational materials on how to respond to people who are most at risk of developing PTSD following a catastrophe. This educational initiative should also be included in ongoing disaster preparedness work in local communities.

7---Collaborate with the National Disaster Team program to address 9-11-01 and other community disasters and the continuing impacts of terrorism. Create basic, easy-to-read educational material on: 1) how prior trauma (childhood abuse or other events) can put people at risk for developing chronic or severe PTSD symptoms when exposed to subsequent trauma; and 2) how to recognize and respond to those who are at-risk.

8---Implement programs of self-care for volunteers, crisis workers, first responders, and clergy, etc. who are at increased risk of developing secondary stress reactions following a disaster.

9---Develop peer-professional alliances in support of a trauma-preparedness support system. One such example in Connecticut is a systematic, comprehensive, and relatively inexpensive statewide network of professionally guided, peer-conducted trauma education and support programs for people in recovery.

10---Develop partnerships between women in recovery and providers around the issue of community safety and preparedness, which could lead to consumer-driven support services linked with gender-specific treatment.

11---Educate teachers, school administrators, and parents about how to recognize children in distress. All schoolchildren impacted by a disaster should be screened, childcare professionals should be trained on handling traumatized children, and more funding should be directed toward treatment.

12---Develop collaborations with faith-based organizations. Combine spiritual support with a basic framework for understanding and responding to traumatized individuals (such as the Risking Connections curriculum).

13---Train clinicians to anticipate PTSD symptom reactivation among refugees when they are re-exposed to significant traumatic stimuli.26

Terrorism and Bio-Terrorism References

1. Marshall, S. (March 4, 2002). Mental health system failing 9/11 victims: Traumatized counselors lack skills, funds. Crains New York Business.

2. Eig, J. (October 23, 2001). Flood site holds key to trauma recovery. Dr. Honig Studies, Wall Street Journal.

3. North, C. S. (December 2001). The course of post traumatic stress disorder after the Oklahoma City bombing. Mil Med, 166(12 Suppl): 51-2.

4. Abenhaim, L., Dab, W., & Salmi, L. R. (February 1992). Study of civilian victims of terrorist attacks (France 1982-1987). Journal of Clinical Epidemiol, 45(2);103-9.

5. Jehel, L., Duchet, C., Paterniti, S., Consoli, S. M., Guelfi, J. D. (September-October 2001). Prospective study of post traumatic stress in victims of terrorist attacks. Encephale, 27(5):393-400.

6. Galea, S., Ahern, J., Resnick, H., Kilpatrik, D., Bucuvalas, M., Gold, J., & Vlahov, D. (March 28, 2002). Psychological sequelae of the September 11 terrorist attacks in New York City. New England Journal of Medicine, Vol. 346, No. 13, pp. 982-987.

7. Kluger, J., Dorfman., A., Gorman, C., Horowitz, J. M., Park, A., Ellin, H., & McDowell, J. (September 24, 2001). Attack on the spirit. Time Atlantic, Vol. 158 Issue 13, p. 90.

8. Sealey, G. (November 5, 2001). Fragile psyches: Mental health counselors gear up for potential crisis in NY. ABC News.com. New York, NY.

9. Schuster, M. A., Stein, B. D., Jaycox, L., Collins, R. L., Marshall, G. N., Elliott, M. H., Zhou, A. J., Kanouse, D. E., Morrison, J. L., & Berry, S. H. (November 15, 2001). A national survey of stress reactions after the September 11, 2001 terrorist attacks. New England Journal of Medicine, 345(20), pp.1507-12.

10. Silver, R. C., Holman, E. A., McIntosh, D. N., Poulin, M., & Gil-Rivas, V. (2002, September 11). Nationwide longitudinal study of psychological responses to September 11. JAMA: the Journal of the American Medical Association, 288(10), pp.1235-44.

11. Kugler, S. (June 10, 2002). Children affected by World Trade Center attack need better mental health care. Report on Congressional hearing in lower Manhattan to address children’s mental health needs. Associated Press.

12. Effects of the World Trade Center attack on NYC: Initial report to the New York City Board of Education. May 6, 2002.

13. Goode E. (November 20, 2001). Treatment can ease lingering trauma of September 11. Science Times, The New York Times.

14. Nader, K. (1998). Violence: Effects of a parents’ previous trauma on currently traumatized children. In Y. Danieli (Ed.), An international handbook of multigenerational legacies of trauma (pp. 571-583), New York, NY: Plenum Press.

15. Brewin, C. R., Andrews, B., Valentine, J. D. (2000). Meta-analysis of risk factors for Posttraumatic Stress Disorder in trauma-exposed adults. J of Consulting and Clinical Psychology, 68:748-766.

16. Chambers, S. (Oct 19, 2001). As tragedy begins to hit home, mental health providers worry. New Jersey Star-Ledger.

17. Widom, D. C. (1999). Childhood victimization and the development of personality disorders: Unanswered questions remain. Archives of General Psychiatry, 56(7), 607-608.

18. Breslau, N., Chilcoat, H. D., Kessler, R. C., Davis, G. C. (1999). Previous exposure to trauma and PTSD effects of subsequent trauma: Results from the Detroit Area Survey of Trauma. American Journal of Psychiatry, 156:902-907.

19. King et al. (1999). Stretch, Knudson, & Durand (1998). Bremner, Southwick, Brett, & Fontant (1992). Breslau et al. (1998). Green et al. (2000). Nishith, Mechanic, & Resnick (2000). In B. Litz, M. Gray, R. Bryant, & A. Adler. Early intervention for trauma: Current status and future directions. A National Center for PTSD Fact Sheet. See www.ncptsd.org/facts/disasters/fs_earlyint_disaster.html

20. Breslau, N. (January-February 2002). Gender differences in trauma and Posttraumatic Stress Disorder. Journal of Gender-specific Medicine, 5(1), pp.34-40.

21. Norris, F. H., Byrne, C. M., Diaz, E., & Kaniasty, K. (2002). Risk factors for adverse outcomes in natural and human-caused disasters: A review of the empirical literature. A National Center for PTSD Fact Sheet. See www.ncptsd.org

22. North, C., Nixon, S., Shariat, S., Mallonee, S., McMillen, J., Spitzanagel, E., & Smith, E. (1999). Psychiatric disorders among survivors of the Oklahoma City bombing. Journal of the American Medical Association, 282, 755-762.

23. Norris, F. H. Prevalence and impact of domestic violence in the wake of disasters. A National Center for PTSD Fact Sheet. See www.ncptsd.org/facts/disasters/fs_domestic.html

24. Mueser, K. T., Trumbetta, S. L., Rosenberg, S. D., Vidaver, R. M., Goodman, L. B., Osher, F. C., Auciello, P., Foy, D. W. (1998). Trauma and Posttraumatic Stress Disorder in severe mental illness. Journal of Consulting and Clinical Psychology, 66(3), 493-499.

25. Nader, K. (October 9, 2001). Terrorism: September 11, 2001: Trauma, grief, and recovery. Published by www.GiftFromWithin.com

26. Kinzie, J. D., Boehnlein, J. K., Riley, C., Sparr, L. (July 2002). The effects of September 11 on traumatized refugees: Reactivation of Post Traumatic Stress Disorder. J Nerv Ment Dis, 190(7):437-41.

27. Amir, M., & Kaplan, Z. (October 1996). Type of trauma, severity of Posttraumatic Stress Disorder core symptoms, and associated features. J of General Psychology, Vol.123, Issue 4, p. 341.

28. Norris, F. H., Byrne, C. M., Diaz, E., & Kaniasty, K. (September 2002). The range, magnitude, and duration of effects of natural and human-caused disasters: A review of the empirical literature. A National Center for PTSD Fact Sheet. See www.ncptsd.org/facts/disasters

29. Marshall, S. (March 4, 2002). Mental health system failing 9/11 victims: Traumatized counselors lack skills, funds. Crain’s New York Business.

30. Strom, S. (July 22, 2002). Mending the hearts broken on September 11 is as difficult as explaining the cost. The New York Times.

31. Chemtob, C. (2002). School based trauma program helps children cope. Archives of Pediatrics and Adolescent Medicine, 156:208, 211-216.

32. Ogden, C. J., Kaminer, D., Van Kradenburg, J., Seedat, S., Stein, D. J. (July 2000). Narrative themes in responses to trauma in a religious community. Central African Journal of Medicine, 46(7), pp.178-84.

33. Niles, D. P. (November 1991). War trauma and Post-Traumatic Stress Disorder. American Family Physician, 44(5), pp.1663-9.