Living through a terrorist event or under threat of attack affects both mental and physical health. A nation's primary care system plays a critical role under such circumstances. This article reviews the American experience after September 11, 2001 and advocates for integration of mental and physical health services in primary care settings as a key counter-terrorism strategy. Americans put their trust in primary care providers. The nation's healthcare system must develop and implement a strategy that informs and supports primary care providers in meeting the mental health needs of a nation confronted by terrorism. [Author Abstract] KEY WORDS: terrorism, mental healh, primary care, collaborative care, mind-body interactions

The current situation in Israel of continuous terrorist attacks poses unique challenges to the treatment of PTSD. This article addresses issues that arise when treating survivors of ongoing terrorism. These include: (a) Is PTSD treatable during ongoing adversity? (b) When should treatment be offered? (c) Is avoidance maladaptive or adaptive? (d) How does one deal with re-exposure? (e) How to define the end of treatment? and (f) What are the effects on the therapist when conducting treatment during ongoing adversity? Case studies are provided to illustrate these issues when treating clients with PTSD during ongoing terror. [Author Abstract] KEY WORDS: trauma, terror, cognitive behavior treatment, re-exposure, avoidance, coping

How to constitute a discussion group with women victims of terrorism when speaking has always been forbidden by the tradition and the terrorists "law"? The author tries to relate the story and the evolution of a group of traumatised women torn between the traumatism and the danger that can occur when someone speaks. [Author Abstract] KEY WORDS: Algeria, terrorism, group, word, traumatism

Terrorism directed against the United States abroad and at home during the 1990s, in conjunction with the ongoing terrorist threat and use of weapons of mass destruction, and mass casualty disasters demanded a reexamination of national security and disaster response. Strategies to confront current threats and meet population needs include increasing collaboration and cooperation among federal, state, and county agencies and voluntary organizations. The American Red Cross has implemented training to familiarize participants with terrorist threats and the characteristics of chemical, biological, radiological, nuclear, and explosive weapons and has introduced technological changes to speed up service delivery at disasters. [Author Abstract] KEY WORDS: American Red Cross, disaster response, terrorism, volunteer

This article presents a terrorist grief and recovery process model of 3 stages: Stage I: Disequilibrium -- the Immediate Aftermath; Stage II: Denial -- Outward Adjustment; and Stage III: Integration -- Coming to Terms. Protective factors, such as stress buffers and resiliency, are focused on, and personal factors, which include but are not limited to age, gender, and ethnicity, are also discussed. Predisposing factors (e.g., psychiatric histories, previous trauma, and educational disadvantages), peridisposing factors (e.g., proximity and duration of exposure to the terrorist attack), and postdisposing factors (e.g., family and other support systems) are also described. All these factors are believed to influence the grief and recovery process. After a terrorist attack such as that on the World Trade Center on September 11, 2001, people's beliefs are often impacted, specifically beliefs held about (a) the world as they knew it, (b) human nature, (c) spirituality, and (d) themselves, because their inner world cannot continue in the same way as before the attack, so they must go through some transformation in order for them to "find their place" and reintegrate themselves into the world. For many, this requires a grief and recovery process. Although many will need to assimilate or accommodate new values, some will be able to return to their old values and beliefs. Others might "get stuck", unable to deal effectively with the terrorist attack and its impact. [Author Abstract] KEY WORDS: terrorism, 9/11, grief, recovery process, trauma, PTSD, traumatology, World Trade Center

The threat from chemical warfare agents such as nerve agents against civilians has traditionally been considered irrelevant. Following the recent terrorist attacks in the US on 11 September 2001 and in Madrid, Spain on 11 March 2004, the threat from such weapons is taken seriously. Hospitals must therefore be prepared to take care of civilian victims. Emergency preparedness implies education and training of healthcare professionals, stocking of antidotes, and training of personnel. This involves decontamination of patients, establishment of routines to avoid contamination of hospitals, and the ability to determine if patients and first responders are contaminated with chemicals and to avoid such contamination. Treatment against nerve agents includes atropine, acetylcholinesterase reactivators (obidoxime or pralidoxime) and benzodiazepines (diazepam). Because these drugs are not sufficiently effective in protecting the brain, new and more effective countermeasures must be developed.

This article examines the evolution of psychological and behavioral reactions following the September 2001 terrorist attacks in a nationally representative sample, and describes where people turned for support, information, and counseling. From November 9 to November 28, 2001, we resurveyed 395 (71%) of the original 560 adults 19 years or older within the United States who participated in our national random-digit-dialing telephone survey conducted on September 14 to September 16, 2001, about their terrorism-related psychological distress and behavior. 16% of adults had persistent distress, reporting one or more substantial distress symptoms in both September and November. Adults with persistent distress reported accomplishing less at work (65%); avoiding public gathering places (24%); and using alcohol, medications, or other drugs to relax, sleep, or feel better because of worries about terrorism (38%). 75% talked with family and friends; however, 43% reported sometimes feeling unable to share their terrorism-related thoughts and feelings with others because it made others uncomfortable. Few reported receiving counseling or information about psychological distress from general medical providers (11%). These findings suggest that a significant number of adults across the country were continuing to experience terrorism-related distress and disruption of their daily lives approximately 2 months after September 11; many turned to family and friends for support, but at times many felt uncomfortable doing so, and few used clinicians as a source of information or support. Clinicians and policymakers should consider how the healthcare system and other community organizations might provide a coordinated community-wide response for individuals needing information and counseling following terrorist events. [Author Abstract]

On the morning of March 11 of 2004, Madrid city suffered the most violent terrorist attack occurred in the modern European history. Ten bombs exploded in four commuter trains at morning rush hour, when many people went to Madrid downtown, resulted in 191 deaths and 1800 persons injured. After terrorist attacks, we started out three longitudinal studies with the aim of assessing the psychological impact of this event in the Madrid city population, and focused on: (1) general population, (2) victims and relatives, and (3) emergency personnel and rescue workers. Among other variables, it is explored the onset and evolution of different psychological pathologies such as panic attack, PTSD, and depression. In this study a representative sample of Madrid city residents of 1,589 subjects (1,265 residents of the 21 Madrid city districts plus an over-sampling of 324 residents in the affected areas) is addressed. Research design and telephone interview used in this study are similar to those employed by Galea et al. (2002) in the study of September 11, 2001, terrorist attacks in NYC. Among psychopathological prevalence rates, there are remarkable data regarding the 10,9% of panic attack, the 8% of major depression, and the 4% of PTSD after March 11, and the 2,3% of PTSD directed attributable to terrorist attacks. [Author Abstract] KEY WORDS: panic attack; PTSD; depression; trauma; terrorist attack

This paper is concerned with psychological aftermath in victims directly exposed to the March 11, 2004, terrorist attack in Madrid and their relatives. Sample was formed by 117 individuals with a mean age of 39.8 years, being the 59.5% females. The 66.1% of the overall sample had al least one relative killed, and the 87.9% at least one friend killed during the train bombings. This study followed a similar methodology than other three papers of out research group published in this volume by using for data collection a structured phone interview, carried out between 1 and 3 month after the terrorist attack. Results show that this group presents the highest psychopathological prevalence in comparison with the general population, affected zones and emergency personnel groups, due to the impact severity of the traumatic stressor. The 45.53% of the sample suffered panic attack during or soon after the terrorist attacks, especially when they heard bad news; the 31.3% presented major depression, and the 35.9% posttraumatic stress disorder (28.2% directed attributable to terrorism attacks); furthermore, there were other psychological sequelae such as increased tobacco, alcohol and drugs consumption. [Author Abstract] KEY WORDS: terrorism victims; panic attack; PTSD; depression; drugs consumption

Early analyses following the September 11 terrorist attacks on New York City showed an increase in cigarette, alcohol, and marijuana use, but it was unknown whether these increases would persist. A random-digit dial phone survey was conducted to estimate the prevalence of increased substance use among residents of New York City six to nine months after the attacks. Among 1570 adults, 9.9% reported an increase in smoking, 17.5% an increase in alcohol use, and 2.7% an increase in marijuana use compared to the month before September 11. These increases were comparable to increases reported in the first one to two months after September 11. Persons who increased use of cigarettes were more likely than those who did not to report symptoms consistent with PTSD in the past month (4.3% and 1.2% respectively). Depression was more common among those who increased use of cigarettes (14.6% and 5.2% respectively), alcohol (11.8% vs. 5.2%), and marijuana (34.1% vs. 5.3%). Among residents living in Manhattan below 110th Street, the prevalence of PTSD and depression declined by more than half in the first six months after September 11, while the increase in substance use did not decline substantially. These results suggest that the increase in substance use after a disaster may be a cause for public health concern in the long-term. [Author Abstract] KEY WORDS: cigarette smoking; alcohol, marijuana; substance use; disaster; PTSD