Seven years after the bombing of the Murrah Federal Building in Oklahoma City, 34 individuals affiliated with various organizations were interviewed about their experiences in providing disaster mental health services to victims and the community. Their perspectives elucidated the importance of preparedness, training and education, local control, interagency cooperation, and psychosocial support for providers. Significant conflicts emerged among providers about credentials, referrals, the quality of services provided, and the appropriateness, in this context, of basing services solely on a crisis counseling model. The lack of ongoing needs assessment or evaluation data further fueled the debates. On the basis of the findings, the authors outline several recommendations for planning mental health responses to future terrorist attacks. [Author Abstract] KEY WORDS: disaster, terrorism, mental health services, Oklahoma City bombing

BACKGROUND: All physicians would need to address the psychosocial consequences of a mass casualty terrorist attack should it occur. METHOD: A review of evidence and expert opinion regarding psychosocial response to mass casualty incidents was performed. Data were obtained via the PubMed database in an English-language search using the terms PTSD secondary prevention, psychological first aid, and disaster psychiatry and the dates 1995 through 2004. RESULTS: There is a National Institute of Mental Health consensus statement on the psychiatric response to mass violence, but sparse psychopharmacologic literature. Psychotherapeutic interventions are well studied in posttraumatic settings. CONCLUSIONS: The physician's response to mass casualty terrorism must address the high volume of patients with anxiety reactions and somatic symptoms likely to present for care. Supportive interventions include fostering a sense of safety and efficacy, connecting patients with communities and services, and helping parents talk about the trauma with their children. In the future, early pharmacologic interventions may be proven effective. [Author Abstract]

OBJECTIVE: This study evaluated the prevalence of PTSD and the longitudinal course of early PTSD symptoms in survivors of terrorist attacks. It additionally assessed the effect of continuous terrorism on the course of early symptoms of PTSD. METHOD: 39 survivors of terrorist attacks and 354 survivors of motor vehicle accidents were evaluated upon admission to a general hospital emergency room and 1 week and 4 months later. Heart rate was measured upon admission to the emergency room. Peritraumatic dissociation was assessed at 1 week. PTSD symptoms, anxiety, and depression were measured at 1 week and 4 months. The Clinician-Administered PTSD Scale conferred a diagnosis of PTSD at 4 months. Additionally, the course of early PTSD symptoms during an era of frequent terrorist attacks (N = 137) was compared with that seen during years of relative calm (N = 256). RESULTS: Survivors of terrorist attacks had higher rates of PTSD than motor vehicle accident survivors (37.8% versus 18.7%). The type of traumatic event, however, did not add to the prediction of PTSD from the emergency room heart rate, peritraumatic dissociation symptoms, and early PTSD symptoms. The longitudinal course of early PTSD symptoms was not affected by the greater frequency of terrorist attacks. CONCLUSIONS: Early symptoms are reliable risk indicators of PTSD across events and circumstances. Converging effects of terror-induced fear, adjustment, and resiliency might explain the lack of effect of intense terrorism on the course of PTSD symptoms. [Author Abstract]

In this article, career firefighters from Oklahoma City, New York City, and Arlington County, VA, and volunteer firefighters from Pennsylvania, share their on-site experiences and the emotional aftermath of responding to terrorism. The authors acted as facilitators, compilers, and organizers so that major themes firefighters have raised are presented to inform the work of first responders and others seeking to understand the experiences of firefighters during and after terrorist incidents. The authors conclude by presenting survey data indicating high levels of firefighter job satisfaction and the major sources of emotional support they use following exposure to terrorism. [Author Abstract] KEY WORDS: firefighters, first responders, emergency services, disasters, terrorism, trauma

The authors examined self-enhancing bias as a predictor of adjustment among individuals in or near the World Trade Center during the September 11, 2001, terrorist attacks. Resilience was defined from categorical and continuous analyses of both participant self-report and friend and relative ratings of adjustment. Self-enhancement was associated with a resilient outcome, ratings of better adjustment prior to September 11th, greater positive affect, and reduced perceptions of social constraints. Additional analyses indicated that self-enhancers' reduced symptom levels were fully mediated by their low perceived social constraints. However, consistent with previous evidence suggesting a social cost to self-enhancement, at 18 months post-September 11th, self-enhancers' friends and relatives also rated them as decreasing in social adjustment and as being less honest. [Author Abstract] KEY WORDS: self-enhancement; trauma; resilience; terrorism; PTSD

The terrorist attacks of September 11, 2001, and the constant threat of imminent terrorist activity have brought into the forefront the urgent need to prepare for the consequences of such attacks. Such preparation entails utilization of existing knowledge, identification of crucial gaps in our scientific knowledge, and taking steps to acquire this knowledge. At present, there is little empirical knowledge about interventions following terrorism and absolutely no available empirical knowledge about interventions following bioterrorism. Therefore, this paper reviews knowledge about (1) reactions following the September 11 terrorist attacks in New York City and other places, (2) the practical experiences accumulated in recent years in countries (eg, Israel) that have had to cope with the threat of bioterrorism and the reality of terrorism, and (3) interventions for acute and chronic stress reactions following other types of traumatic events (e.g, rape, war, accidents). Our review found several treatments efficacious in treating individuals for acute and chronic PTSD related to other traumatic events that will likely be efficacious in treating PTSD related to terrorist attacks. However, there were significant gaps in our knowledge about how to prepare populations and individuals for the possibility of a terrorist attack and what interventions to apply in the immediate aftermath of such an attack. Accordingly, we conclude the paper with several questions designed to guide future research. [Author Abstract] KEY WORDS: trauma; PTSD; terrorism; prevention; trauma intervention

In October 2002, 800 plus hostages were held for three days in a Moscow theater by suicide terrorists armed with bombs. The stand-off ended when Russian Special Forces gassed and stormed the theater. 130 of the hostages died. The authors -- an American psychologist and colleagues from the Russian Academy of Sciences -- began to collaborate soon after the event. This article reports on interviews with 11 hostages regarding their psychological responses to captivity including their expressions of Stockholm syndrome. [Author Abstract] KEY WORDS: suicide terrorist, Stockholm Syndrome, hostages, hostage-taking, terrorism

A number of studies have considered whether background stress affects cardiovascular responses to acute stress tasks. The present study considers the effect of a potent background stressor with a clear onset, namely the terrorist attacks on September 11, 2001. Specifically, the authors investigated differences among 9.5-year-old children tested before (N = 30) and then following (N = 20) the 9/11 attacks. In addition, a majority of these children (N = 37) were retested approximately 1 year later (i.e., before and after 9/11/2002). Children tested directly following 9/11/2001 exhibited significantly greater stroke volume and cardiac output responses to acute stress tasks compared with their responses 1 year later, and this change in reactivity differed significantly from the change in reactivity exhibited by children tested before 9/11/2001 and again 1 year later. These results suggest that a potent background stressor can temporarily heighten some children's cardiovascular responses to subsequent acute stressors. [Author Abstract] KEY WORDS: terrorism; cardiovascular reactivity; acute stress

Clinicians should have a basic understanding of the physical and financial risk to mental health facilities related to external threat, such as (but not necessarily limited to) terrorism. Patient care and accessibility to mental health services rest not only on clinical skills, but on a place to practice them and an organized system supported by staff, physical facilities and funding. Clinicians who have some familiarity with the non-clinical requirements for care are in a position to support non-clinical staff in preventing care from being interrupted by external threats or events such as terrorist activity, and/or serving at the interface of facility operations and direct clinical care. Readers should note that this article is an introduction to the topic and cannot address all local, state, and national standards for hospital safety, or insurance providers' individual facility requirements.

Traumatic experiences are relatively common. More than two thirds of persons in the general population may experience a significant traumatic event at some point in their lives, and up to one fifth of people in the United States may experience such an event in any given year. Although comparable international data are limited, large proportions of populations in many countries have been exposed to terrorism, forced relocation, and violence, which suggests that the overall prevalence of exposure to traumatic events worldwide may be even higher than that in the United States. Disasters (e.g., floods, transportation accidents) are traumatic events that are experienced by many people and may result in a wide range of mental and physical health consequences. In the National Comorbidity Survey, 18.9% of men and 15.2% of women reported a lifetime experience of a natural disaster. This article will assess the epidemiologic evidence about PTSD after disasters. [Adapted from Text]