Ebook: Risk Management of Terrorism Induced Stress

Professor Sir Simon WESSELY

King’s College London, UK

King’s Centre for Military Health Research, London, UK

Royal Society of Medicine, London, UK

(Corresponding Author: Professor Sir Simon Wessely, Institute of Psychiatry, King’s College London, Strand, London WC2R 2LS, United Kingdom; E-mail: simon.wessely@kcl.ac.uk.)

Terrorism is a psychological weapon, or it is nothing. By definition the purpose of terrorism is to spread an emotion – namely terror, or at least fear, in order to achieve goals that could not be gained by more conventional political or military means. It is par excellence a weapon of asymmetric warfare, but one where success or failure is entirely dependent on the psychological reactions of those who are the targets. In conventional military strategy victory is obtained when the enemy is unable to give battle, as happened with the German Army at the end of the First World War, but this objective is beyond the reach of those who chose to perpetrate a campaign of terror. Victory there comes when the targets of the campaign no longer wish to “give battle”, even though they could, because the political, rather than the military, wish to do has been lost. Terrorism is psychological warfare in its purest sense.

Perhaps surprisingly, although historians and political scientists(Anyone wishing to learn more could do worse than read anything written by the late Walter Laqueur on this topic.) have long been concerned with terrorism and its consequences, interest from the behavioural and psychological sciences has been relatively recent. It was on the rise in the 1990s, but given a dramatic boost by the iconic events of Sept 11th 2001.

This volume is concerned with the most immediate psychological consequences of being exposed to a terrorist incident. It uses the concept well known to those in surgery, military or emergency medicine known as the “Golden Hour”, where it has been well established that immediate interventions during that critical period immediately after injury make a major contribution to a person’s chance of survival. It provides a useful starting point for this volume, although one must be careful not to take analogies between physical and psychological medicine too closely, and indeed none of the contributors to this volume interpret an hour quite so literally.

So this volume is really about hours, days and even weeks rather than a single hour. And we are talking about mental health interventions, loosely defined. Now I can hear some readers already saying “surely, they are not going to be suggesting that everyone who has been caught up in a seriously traumatic event needs to see a psychiatrist straight away?” Rest assured we are not – it is clearly unfeasible, but fortunately it is also not just unnecessary, it is probably undesirable. Mental health interventions can and do happen without any mental health professional being audible or visible, except perhaps in the background giving advice, or even further in the background helping with planning and policy. We, and I include myself in this, do not need to see most, and perhaps even none, of those swept up in these events in this “Golden Hour”.

Instead most of the contributions to the book emphasise that in those early hours what matters most is our existing social networks of friends, families and colleagues. There is little point in listing the studies that show that first instinct that people have when confronted by large scale psychological trauma is to contact their family and friends – I am unaware of any evidence to the contrary. It was no surprise when our group showed that failure to make that contact led to a rise in anxiety following the 2005 London bombs – again, no surprises there [1]. But what was a surprise when we showed that this effect was still detectable six months later [2]. So, the first task of professional, planners and policy makers is to do what they can to facilitate doing what comes naturally. Perhaps the most useful thing that we can bring to the scene of the crime or emergency room is a large box of working mobiles and chargers. Mobile phones and chargers meant little to the civil defence authorities in the United Kingdom during the Second World War, responding to the impact of strategic bombing of our cities, but they knew what mattered when it came to immediate measures to support morale. Translate morale into “well being” and this could be written today, not 1941 [3].

“The morale of the bombed largely depends on the care they get in the first 36 hours…rest centres, facilities for children, information, health care and provision of food”.

Nor should we forget the literature on the failure of immediate single session psychological debriefing to reduce distress – indeed, in some studies it was shown to increase the rate of distress, rather than the opposite. There are a number of possible explanations for these findings, one being that it calls to attention disturbing and distressing traumatic imagery, but without the time or place to teach techniques to reduce such imagery. There is a time and a place for counselling or cognitive behavioural therapies, but a few hours after witnessing a ghastly event may not be it.

Of course, many people will already be experiencing distressing traumatic imagery anyway. The chapter by Emily Holmes and colleagues (Chapter 3.3) introduces the reader to a very novel approach, the concept of a “cognitive therapeutic vaccine”, again making an analogy to physical medicine, which if given early may prevent the reoccurrence of intrusive trauma memories that are at the relatively modern concept of post traumatic stress disorder, but not by a single session of individual counselling, but by setting out to do the opposite, by in their words.

“Engaging in a visuospatial task (i.e. one thought to require mental imagery) during memory consolidation (e.g. first hours post-trauma) competes for working memory resources with mental imagery and thereby interferes with the formation of intrusive memories of the trauma”.

They suggest that by getting the person to concentrate on non traumatic mental imagery it actively blocks the formation of traumatic mental imagery. If this is confirmed, and the authors are right to say that this is in its infancy, it could indeed represent a very significant step forward. This is not the only such approach – the contributions from Rachel Yehuda, Dominqiue de Quervain and colleagues (Chapters 2.3, 3.1) also explore equally radical pharmacological approaches, but are equally cautious in their conclusions. This is very much a space to watch.

We must also acknowledge that no matter what we think we can and cannot, should and should not, do in the immediate aftermath of disaster as mental health professionals (who make up most of the contributors and probably most of the readership of this book), we are dwarfed by the impact, for good or ill, of something far larger, and far less manageable, if it is manageable at all. Küey (Chapter 6.2) quotes to good effect several sources to point out that.

Today, in terms of news, we are continuously, “reading, watching, viewing, listening, checking, snacking, monitoring, scanning, searching, clicking, linking, sharing, liking, recommending, commenting and voting,” and thus, “journalism today is interactive, interconnected, participatory, more open, more global, multi-platform, multi-linear, producing a constant stream of data, analysis, and comment”.

He is of course talking about the world of social media, and whilst there is no denying the impact of social media on how we think, experience, react to and organise our responses to terrorism in particular and disasters in general, what we do about it is another matter entirely. The lesson of King Canute comes to mind. (Canute, or Cnut as he should be better called, is probably best remembered for his probably mythical demonstration of the limits of kingship when he showed that all powerful though he was, he could not stop the flow of the tides. However, it is worth remembering that he was himself no stranger to use of terror- see for example his mutilation of Saxon hostages at Sandwich to create terror in his enemies.)

By now I hope the reader is champing at bit, anxious to get on with the real business of reading the book. But please, bear with me just for a moment longer, for a word of caution. Not about the contributions, but about the context in which we should view mental health reactions to terrorism, whether early or late.

Because what is unusual about terrorism is not how successful it has been, but how unsuccessful, unless one measures success by time spent queuing in airports. Does it create panic on the streets? Rarely. Not discussed, because there was no need, the considerable body of literature that shows that when exposed to the kind of acute incidents generated by terrorism, panic is the exception, not the rule. A fire in a crowded nightclub with obscured exits is a far more potent generator of panic than most terrorist incidents. The evacuation of the World Trade Centres, carried out by and large without any assistance from the emergency services, is often and correctly quoted as an example of an orderly self-directed evacuation. Images of people fleeing from Brussels Airport or the immediate vicinity of the Palace of Westminster need to be examined carefully before the actual reasons for large numbers of people seemingly fleeing “in panic” can be discerned. In fact, more often than not people will move towards the incident to offer assistance if left to themselves. When we talk about “first responders”, we should remember that the people already on the scene have started to respond themselves before the “blue light” services appear. All of this was the subject of a previous NATO workshop looking at the psychological consequences of terrorism in the immediate aftermath of 9/11 [4].

But what about the longer-term impacts? Just how effective is terrorism there? The political and psychological impact of man-made accidents, such as Chernobyl or Bhopal, are more long-lasting and pernicious than those of terrorism. Deliberate attempts by modern states at war to provoke terror, panic, demoralisation and ultimately defeat, such as the use of strategic bombing in the Second World War first against the United Kingdom and then against Germany, were not just ineffective, but counter productive [5].

So this book is by and large about how to prevent or manage adverse mental health consequences than might happen to people caught up in an act of terrorism. And it is right and proper that you do this, since it seems that terrorism is going to remain an unwelcome visitor to many of our shores for the foreseeable future (Although it is worth looking at the list of countries that currently account for most of the deaths from terrorism at the moment, as listed in the Duckers, Ursano, Vermetten chapter (Chapter 1.2), to realise that the burden falls almost entirely on Africa, the Middle East and Afghanistan, rather than the high income countries that seem to generate most of the research on the topic.), generating not just physical but also mental casualties. But just as not everyone involved in an act of terrorism needs surgery, whether in the Golden Hour or beyond, nor does everyone need mental health interventions either.

So, planners, policy makers, or just us as citizens, let us be careful not to do the job of the terrorist for them. Instead we must never lose sight of the simple fact that the commonest reaction to terrorism, whether it be by individuals, populations and societies, is fortitude and resolution [6]. Not for nothing does the first chapter that you can now open begin with an essential truth (Ursano and colleagues, Chapter 1.1).

“Most research has shown the majority of people will be resilient following a terrorist attack and return to full function; some may even feel increased ability to manage stressors in the future”.

We should be asking ourselves not why is terrorism so successful, but why it is so unsuccessful. Unless of course you measure success in time spent queuing in airports.

References

[1] G.J. Rubin, C. Brewin, N. Greenberg, J. Simpson, S. Wessely, Psychological and behavioural reactions to the bombings in London on 7 July 2005: cross sectional survey of a representative sample of Londoners, British Medical Journal 311 (2005), 606–610.

[2] G. Rubin, C. Brewin, N. Greenberg, J. Hacker Hughes, J. Simpson, S. Wessely, Predictors of persistent distress following terrorism: a seven month follow up survey of reactions to the bombings in London on 7 July 2005, Br J Psychiatry 190 (2007), 350–356.

[3] Public Record Office, HO 199/442 “Report on Liverpool and Manchester 10th Jan 1941”

[4] S. Wessely, V. Krasnov (eds), Psychological Reactions to the New Terrorism: A NATO Russia Dialogue, IOS Press, 2005.

[5] E. Jones, R. Woolven, W. Durodie, S. Wessely, Public Panic and Morale: Second World War Civilian Responses Reexamined in the Light of the Current Antiterrorist Campaign, Journal of Risk Research 9 (2006), 57–73.

[6] W. Durodie, D. Wainwright, Terrorism and post traumatic stress disorder: A historical review, Lancet Psychiatry 6 (2019), 61–71.

The broad goals of terrorism are to 1) erode the sense of national security; 2) disrupt the continuity of society and destroy social capital (i.e. morale, cohesion and shared values). Terrorism opens the fault lines, the potential cracks, in our society and organizations. These include economic, racial/ethnic and religious. Terrorism is not a new form of war or human interaction. In the United States terrorism has a history that spans across the Klu Klux Klan, to drug gangs, shootings and hostages in organizations and schools and to the bully in the school yard. Most countries have had similar elements. Nation state terrorism is also not new and has a long history. What is perhaps new is the threat of terrorism to national security, because of the ability to span space, time and inflict greater damage. A Nation’s security is built on its military power, economic power, information systems and health. Note that health is part of this national security plan. “Without health there is no happiness” (Thomas Jefferson, third president of USA). And one can add, without happiness there also is no hope. And without hope there cannot be a nation or an organization, large scale or small. The continuity of these national security elements is critical to national security and the continuity of government. Protecting national security requires fostering, protecting and restoring resilience in the face of attacks on these infrastructure elements. Continuity of nations and organizations requires “the three R’s”: redundancy (expensive); reliability (usually machines better than people) and resilience (people are generally more so than organizations). Frequently organizations will focus on protecting building, records and funds. Yet continuity of people (i.e. Site R); functions; community/environment/culture and communications particularly to/from family may be the most critical elements. These components can inform our targets for preparing for, responding to and recovering from a terrorist attack whether we are speaking of a nation, a city, or a group-including a military unit, company, platoon, squad or special operations units (including traditional special operations, intelligence and UAV “drone” operations- the three present “special operation” which are bearing the present brunt of the ongoing Iraq/Afghanistan war in US military). There are 50 armed conflicts in the world, 18 had more than 1000 deaths in the past year. Of these, nearly all are INTRAstate conflicts usually characterized by terrorism. And how does one understand the responses to terrorism. They are best considered at multiple levels (Population (Nation), Organization (City, Family, Corporation, Division, Unit) and Individual (Servicemember, first responder, citizen). There are similarities and differences across these domains. In general consideration of continuity of operations, leadership, communications, and individual responses (resilience, distress, altered health risk behaviors; disorder) map in a 3x4 grid across the levels. In addition there is moving this grid across a timeline of an event (as well as prior to include preparation). This approach is similar to the Haddon Matrix used in understand risk of and recovery from injuries and adapted to understanding psychological responses to terrorism by the Institute of Medicine of the National Academy of Science (USA) to recognize the specific elements associated with various weapons (explosive, shootings, chemical, biological, nuclear).

This chapter explores the association between terrorism, mental health and the capacity to provide evidence-based mass casualty intervention from a global perspective. The main message is there are vast differences in these three areas across countries and that, especially the last of the three, variation in service capacity and supportive conditions, influences the chances of implementing evidence-based guidelines. Consequently, it will be easier to provide evidence-based cost-intensive therapy and treatment to affected populations in less vulnerable countries with well-developed healthcare systems than in resource-poor environments. It is important to better understand alternative interventions and mechanisms and societal options for care delivery in more vulnerable countries, and to develop strategies to utilize them effectively. Systematic enquiries can strengthen the evidence base of guideline implementation across different local contexts of terror-focused aftercare. Importantly, the future development of new lower intensity interventions, guidance and the potential to anticipate vulnerabilities can particularly benefit low resource countries.

Individuals exposed to traumatic events might develop a condition known as posttraumatic stress disorder (PTSD). PTSD affects memory and sleep, has long-lasting effect on hypothalamic-pituitary-adrenal (HPA)-axis, and has an impact on social and occupational functioning. Although, the original conceptualization in models of stress sensitization, fear conditioning and failure of extinction, has led to empirical data in support of the psychobiological notions, there is still no cure for PTSD. To achieve this, we need to have more insight in the relation between the biological alterations and the psychopathology of PTSD. But valid biomarkers for PTSD, linked to the underlying mechanism, are not available. These biological biomarkers are needed to facilitate the research towards the understanding of the underlying mechanism and the development of efficacious medicines to treat PTSD. Still then, retrospective studies in humans are difficult to perform and most studies fail to control for the effect of trauma itself, limiting the results of the studies. Therefore, a firm basis is needed on controlled animal research that optimally uses cross-species characteristics by integration of the mechanistic disturbance with symptoms, which can be applied to animals and humans alike. Knowledge achieved from translational research, using markers with an open eye towards human validity, will finally lead to novel therapeutic approaches.

The amygdala can be considered a ‘hub’ of emotional learning and memory. The amygdala, along with hippocampus and prefrontal cortex function have been consistently shown to be dysregulated in Posttraumatic Stress Disorder (PTSD). Furthermore, the neural plasticity that underlies associative learning, classical or Pavlovian conditioning, is relatively well understood, and the neural circuitry supporting threat or fear processing is among the most well-worked out circuits in behavioral neuroscience. This chapter highlights recent progress in the neurobiology of fear learning and memory, specifically related to neural and molecular underpinnings of fear memory consolidation with a goal of translating this information for the prevention of fear-related disorders in humans, such as PTSD. Promising advances are being translated from basic science to the clinic, including methods to interfere with fear development during memory consolidation after a trauma. It is hoped that this new knowledge will translate to more successful, scientifically informed and rationally designed neurobiologically-driven approaches to preventing disorders of fear regulation, including PTSD.

One of the pitfalls of biomarker research is that it is often difficult to distinguish between a potential biological marker present in association with a disorder (in this case post-traumatic stress disorder (PTSD)) and a biological alteration that is indicative of the pathophysiological process that results in disorder. The former may be useful in predicting or diagnosing PTSD, but may not necessarily be a viable treatment target. This presentation will discuss the evidence for glucocorticoid dysregulation in PTSD that has nominated the hypothalamic-pituitary-adrenal (HPA) axis as a potential target of intervention. To date, most studies of glucocorticoid dysregulation have focused on cross-sectional evaluation of persons with chronic PTSD, or have used prospective, longitudinal approaches following trauma-exposed persons in the immediate aftermath of trauma exposure or even, prior to their exposure to critical incidents. Persuasive data have also been obtained by evaluating the effects of a single dose of glucocorticoids on relevant PTSD behaviors and biology. Other approaches involve understanding how glucocorticoid-related alterations change in response to treatment. In studies of civilians and combat veterans, glucocorticoid-based markers such as urinary cortisol and cortisol-related metabolites predicted treatment outcomes, and some markers also associated with symptom improvement. In combat veterans, glucocorticoid receptor sensitivity, glucocorticoid genotype, and epigenetic alterations on the glucocorticoid receptor were predictors of treatment response and correlates of recovery. These findings have provided support for initial trials of hydrocortisone in PTSD prophylaxis during the golden hours, in the acute aftermath of trauma.

Glucocorticoids are of special interest for the prevention and treatment of post-traumatic stress disorder (PTSD) because they affect memory processes that are involved in the pathophysiology, symptomatology and treatment of this disorder. Administered soon after a traumatic event, high doses of glucocorticoids may have preventive effects with regard to the development of the disorder by interfering with initial consolidation of the trauma and/or by reducing aversive memory retrieval. Further, glucocorticoids could be used in existing PTSD to reduce the retrieval of aversive memories and thus to curtail the expression of fear, such as of flashbacks. Finally, moderate doses of glucocorticoids could be used to augment the consolidation of extinction memory in patients who undergo extinction-based psychotherapy. Below, we review clinical studies that used glucocorticoid signalling-based interventions to prevent or treat PTSD. Because of the rather small sample sizes of these studies, only weak recommendation for the use of glucocorticoids in the prevention or treatment of PTSD can be made so far.

Several psychological approaches have been evaluated in the immediate aftermath of trauma to prevent the onset of mental health problems, such as posttraumatic stress disorder (PTSD) and depression. Secondary prevention strategies include interventions offered to all individuals exposed to a traumatic event unselected for their levels of distress or for presence of a clinical diagnosis. For adults, psychological debriefing -or similar brief counseling interventions – were not effective in reducing the development of PTSD, depression or anxiety. Psychological First Aid (PFA) is a modular approach aimed at reducing initial distress and fostering short and long-term adaptive functioning. Although implemented worldwide, there have been no effectiveness studies thus far. Abbreviated versions of evidence-based treatments such as trauma-focused CBT or exposure therapy have been shown effective in reducing the onset or course of PTSD in people identified with acute stress disorder (ASD) or early symptoms of PTSD. Finally, collaborative care interventions, multidisciplinary interventions consisting of case management, and clinician involvement if needed, showed modest effects on PTSD symptoms and alcohol use in injured trauma surgery patients. In conclusion, there are still many important gaps in our knowledge about effectiveness of psychological approaches to prevent mental health problems following trauma. These gaps include a lack of studies on interventions for mental health outcomes other than PTSD (such as daily functioning, and social and community functioning), studies in children, and studies evaluating the cost-effectiveness of early interventions.

Intrusive memories of a traumatic event are distressing, vivid mental images that spring to mind unbidden, and the core clinical symptom in PTSD (Posttraumatic Stress Disorder) and ASD (Acute Stress Disorder). We propose that a brief science-derived intervention can be delivered in the first few hours after a traumatic event as a so-called “cognitive therapeutic vaccine” to prevent the recurrence of intrusive memories of trauma. Our approach differs from traditional talking therapies in various ways including: a) focusing on one core clinical symptom as a treatment target, rather than a whole disorder; b) deriving a novel type of intervention technique informed by neuroscientific insights and experimental research, rather than adapting existing psychotherapy techniques; c) aiming for scalability from the onset, rather than an adaptation of face-to face therapy. The behavioural intervention technique was developed in the laboratory with a focus on perceptual intrusive memory. It uses cognitive task interference as a hypothesised blockade of sensory mental imagery during trauma memory consolidation to reduce the frequency of intrusive memories of trauma. In early tests of clinical translation from the laboratory to real-world single event trauma, the technique has involved a 25-minute, single-session procedure (including Tetris computer game play), delivered in a hospital within 6 hours of a traumatic event. Results of two proof-of-concept trials provide initial support for the efficacy of the intervention: there were fewer intrusive memories compared to control when delivered in hospital within 6 hours following both traumatic motor vehicle accidents (Iyadurai et al., 2018) and traumatic childbirth (Horsch et al., 2017). Both studies indicated that the intervention was met with acceptability. Future trials are warranted as well as mechanistic research with cultural adaptability in mind.

Sleep is a universal sensitive indicator of well-being, driven by its role in many critical processes including metabolic regulation, emotional processing, learning, and memory. Acute and prolonged stressors are inherent to the aftermath of terrorism and can significantly contribute to two distinct forms of sleep disruption: sleep deprivation and sleep disturbances. Sleep deprivation occurs when the safe opportunity to sleep in a consolidated episode in a 24-hour period becomes significantly reduced or eliminated. Even when sleep opportunities arise, sleep disturbances can further disrupt sleep. Common trauma-related sleep disturbances include insomnia, nightmares, and other disruptive nocturnal behaviors and cognitions (e.g., simple and complex vocal and motor behaviors, night sweats). Sleep disturbances further exacerbate one’s ability to cope. Thus, sleep-targeted interventions can optimize resilience and accelerate the recovery. Individuals with a history of sleep disturbances and insufficient sleep prior to trauma exposure represent a vulnerable group of individuals. Post-trauma, individuals who report poor sleep for more than one month after a critical event are at greater risk of developing stress-related psychiatric disorders. Increased levels of indirect exposure to terrorist attacks via traditional or digital social media can also contribute to the onset and maintenance of chronic sleep disturbances. Psychological sleep-focused treatment (including Cognitive Behavioural Therapy for Insomnia (CBTi) and Imagery Rehearsal Therapy (IRT) for nightmares) in patients with PTSD improves PTSD symptomatology as well as sleep disturbances, further suggesting a causal role of sleep in PTSD etiology. However, the extent to which sleep-focused interventions in the acute aftermath of trauma exposure may promote resilience and recovery remains unknown. While most individuals can cope with temporary sleep loss due to acute stressors, insufficient sleep and sleep disturbances often become chronic, which can result in a range of acute deleterious consequences and long-term physical and mental health conditions. Creating safe, sleep-promoting environments and healthy sleep behaviors that accelerate the return to homeostasis for sleep regulatory mechanisms and support resilience may prevent chronic maladaptive stress responses. The World Health Organization (WHO) guidelines strongly emphasizes the need to avoid the use of benzodiazepines for the treatment of sleep disturbances, and reinforce the use of non-pharmacological, healthy sleep practices in the acute period following trauma exposure. Guidance for the detection, mitigation and management of sleep loss in the aftermath of trauma exposure, including terrorist events is lacking. Nevertheless, the recommendations from WHO in combination with recommendations from other sources, including military publications (e.g., US Army Techniques Publication 6-22.5, A Leader’s Guide to Soldier Health and Fitness) and efficacy of psychological treatment for sleep in PTSD can provide evidence-based strategies to mitigate the adverse effects of extreme circumstances on sleep. Sleep in the immediate aftermath of a traumatic event has the added impact on memory consolidation of that event. Initial experimental data is mixed with total sleep deprivation on the first night after an analogue traumatic event preventing (in animal studies and 2 human studies) or contributing (2 human studies) to intrusive memoires and stress reactions. Further research is needed to investigate potential effect of sleep deprivation in the immediate aftermath of trauma exposure, the discrepancies between animal and human studies and the clinical significance of these findings.

Terrorism generates a wider range of responses in children and adolescents than in adults. Although most children are not affected beyond temporary distress, some experience adjustment problems post terrorism that reach clinically significant levels. Given the need and desire to help diverse youth post mass events, intervention developers have created early intervention treatment packages in response to correlates or risk factors, specific problems and general children’s stress reactions. Interventionists must ethically balance the desire to provide help youth after terrorism with any potential costs of interfering with natural recovery or creating iatrogenic harm. In general, four overall approaches are used in immediate and early interventions: psychological first aid (PFA), triage/screening interventions, general therapeutic approaches, and trauma-focused interventions. Interventions vary considerably with respect to whether they are conducted for all exposed youth, or only to youth with particular risks or symptom levels. The database to make evidence-based recommendations on the best early interventions for youth after terrorism is quite limited. PFA and early triage/screening interventions appear promising and feasible for the immediate period but have not been assessed. General therapeutic approaches, and trauma-focused interventions all have initial promising results in the few existing studies but the field requires far more information to indicate which interventions are best for what children at what time. The most salient point is that all early interventions with youth require evaluation, preferably well designed randomized control studies, but any formal evaluation is needed at this point to inform policy. Further, the need to enhance the quality and feasibility of evaluation of post terrorism studies of youth especially those delivered in the immediate post-event period is striking. Efforts may include grant funding, early planning, computer assisted applications, innovative methodology, and human ethics considerations. In the meantime, available evidence, strategies, and expert consensus should guide early intervention delivery and development for youth. The needs of children must be addressed with a clear understanding that youth of different ages may require different approaches at different time intervals. In the immediate response phase, interventions that address 5 empirically based principles to promote safety, calming, self and community efficacy, connectedness and hope appear reasonable. Thereafter, early interventions should carefully consider and match youth age with targeted goals and document the effect of the interventions, closely monitoring and documenting obstacles, successes, and failures. In addition to creating and evaluating a wide range of interventions for children that are developmentally appropriate, the way we approach adult immediate interventions post terrorism must become child-focused – immediate and early adult interventions should include components targeting ways to help youth. Relatedly, it may be useful to evaluate children of adults enrolled in early interventions to determine if helping parents cope with their own distress improves outcomes among their children.

Survivors and first responders may suffer from psychological trauma in times of terror. In the first moments after a terror attack, fire, police and Emergency Medical Services (EMS) personnel are exposed to horrific scenes which are only familiar to military personnel with combat related experiences. According to the European Association of Fire & Rescue Psychology (AEPSP), between 8–10% of fire and EMS personnel suffer from Post-Traumatic Stress Disorder (PTSD). The prevalence rates of probable PTSD may range from 1.3% to 22.0% in situations of man-made mass violence. In this chapter, the experiences of survivors and first responders, during the terror attacks on Brussels (2016 March 22nd), will be used to introduce the concept of Advanced Psychological Support by the ResQ Squirrel method. This method has been developed in analogy with Advanced Trauma Life Support (which aims to prevent early death of survivable victims by providing advanced medical support) and aims to prevent early development of psychological trauma. The terror attacks on Brussels confronted first responders and psychosocial caregivers with a series of new challenges which have not been fully documented in scientific research till today: the need for acute psychophysiological stabilization during and immediately after (multisite) terror attacks, in a context of horror and gruesome images, the common skills deviation issues (i.e. some first aid techniques are only used by military personnel in wartime deployment), operating in a multidisciplinary context with experienced military personnel, etc. This chapter will list the predictors and determinants for the early development of chronic trauma, based on trauma exposure, dissociative responses, negative emotions, etc. in order to draw a set of practice-based interventions for acute trauma support which are used in daily practice by fire and rescue services personnel in Belgium and France. These interventions may provide the feeling of usefulness and perceived self-efficacy which appear to hamper the development of posttraumatic symptomatology in first responders involved in technological and man-made disaster.

There is little empirical research looking at service members who are exposed to acts of terrorism as opposed to other service connected stressors. When discussing terrorism induced stress among service members, one can conceive of potentially unique stressors as well as opportunities to mitigate negative outcomes. There has been much debate over the years in the field of psychotraumatology regarding soldiers and veterans. Despite PTSD’s origins to, in part, explain the plight of service members returning from conflicts such as the Vietnam War, there has been debate as to the how the language of traumatology captures the veteran experience. Like civilians, service members are potential targets of various terrorist groups pursuing a political aim. However, immediately following a terroristic act, unlike most civilians, service members don the role of first responders, and in most cases, defenders against the act of terrorism. The service member’s trauma may not be “being shot at”, but rather the witnessing of a severely wounded civilian. Some may have a classic PTSD picture with fear, anxiety and avoidance that may respond to the traditional desensitization and habituation that exposure therapy provides. Yet others may have overwhelming depression, guilt, and shame based on their inability to act or perceived failure. These complexities may necessitate a different approach and exposure may temporarily aggravate symptoms, but clinical awareness of these set of potentially unique issues is critical to ensuring the highest quality care.

Disclaimer: The views expressed are those of the authors and do not represent the views of the US Government, Department of Defense, the Uniformed Services University of the Health Sciences or any other agency either public or private.

Armed conflicts, persecution, human rights violations and related poverty and trauma have led to humanitarian disasters across the world: forced displacement of millions of people. The reasons of forced displacement are complex, including political, economic, legal and psycho-social factors. Masses of civilians flee from their homes and home countries, where they face severely traumatizing violent acts, with the hope of re-settling in a safe humane environment. Mental health problems related to armed conflicts and forced displacement constitute a serious public mental health problem. Forcibly displaced people flee their homes and home countries due to violence and threat to their lives and those of their families. People forced to leave their psychosocial support systems are under threat in all areas of attachment, mastery, and survival. Almost all attachments are left behind, degree of mastery is decreased; the nutrition of the self and the self-image are devastated. Basic needs for survival maintained mostly in the mercy of others. Refugees fleeing with few possessions leading to neighboring or more developed countries face various life-threatening risks before, during and after displacement, and they have nowhere to return. A refugee is a person who has lost the past for an unknown future. Experiences of loss and threat of loss are imprinted in their selves causing depressive and anxiety states, and triggering mental disorders including, but not limited to, Post-Traumatic Stress Disorder. There is increasing evidence that over half of refugees and asylum seekers suffer from mental disorders in the short/medium term, and specific groups (e.g., elderly, unaccompanied children, single mothering, and people with disabilities) are under higher risk. In the long term, mental disorders tend to be highly prevalent in war refugees even many years after resettlement. This may not only be a consequence of exposure to wartime trauma but is also influenced by post-displacement socio-economic factors and discrimination enforced by racism. Furthermore, evidence show that perceived racial discrimination is a significant risk factor for mental health problems. In fact, “we are seeing here the immense costs of not ending wars, of failing to resolve or prevent conflicts.” Forcibly displaced people are not the cradle of terrorism but the victims and survivors of violence itself. Albeit the widespread exercise of violence and discrimination, peoples of the world also have a long history of implementing more integrative means of solving conflicts between in-groups and out-groups, thus leading to a more non-violent, egalitarian and peaceful human existence. Psychiatry and mental health workers are facing the mental health consequences of forced displacement across the world. A challenge here is both consolidating the psychiatric / medical services and avoiding the medicalization of social phenomena at the same time.

Mass casualties’ events result in protracted psychopathology in a significant proportion of exposed individuals, which community-based resilience-promoting interventions may mitigate but not eliminate. Survivors with prolonged mental health sequelae remain, therefore, a major long-term burden on individuals, families and the society at large. Early cognitive behavioral interventions may reduce the proportion of affected survivors but are prohibitively costly and marginally efficient when provided unselectively. Consequently, an efficient prevention critically hinges on the capacity to reliably identify survivors at significant risk. Several risk indicators have been identified (e.g., female gender, prior trauma exposure, exposure type or severity, early symptoms’ configuration and severity). These group-level estimators, however, do not inform survivors’ personal outcome. Indeed, their underlying classification models explore parameters that differentiate cases (future PTSD) from non-cases (no future PTSD) – an impossible task given predictors diversity, interdependence, and the limited variance explained by each. Seeking an alternative to case prediction, the International Consortium to Predict PTSD (ICPP) pooled data from 16 acute-care-based longitudinal studies towards developing a risk estimate model, capable of quantifying prolonged PTSD likelihood for each survivors (i.e., “How likely is that survivor to develop PTSD”). Using survivors’ early PTSD symptoms, gender, lifetime trauma history and educational attainment to predict nine to fifteen months’ PTSD, the ICPP group developed a simple, web-based risk assessment tool that applies to every trauma survivor. Because it addresses a single traumatic events in civilians admitted to acute care services, the ICPP tool requires re-calibration and adjustments to inform mass casualty trauma. It nonetheless exemplifies the advantage of replacing case prediction by risk likelihood estimates, and provides a reliable assessment tool for acute care trauma survivors.

This chapter gives an overview of research into psychological and neurobiological factors involved in an individual’s resilience to traumatic stress. Resilience is a multifaceted construct and can be defined as (the capacity for) the dynamic process encompassing positive protection from, adaptation to or significant rapid recovery within the context of significant adversity. An extensive body of research in the psychological and psychosocial domain of resilience has identified a range of intra and interpersonal psychobiological factors, dimensions and constructs of various complexity, ranging from attentional control to optimism. Neurobiological research is still lagging behind, but studies in professionals implicate the stress-axis and various neurotransmitter systems and neuropeptides. Recent neuroimaging studies point at specific patterns of structural and functional connectivity in resilience, with a key role for the salience network.

For 200 years some all or some parts of Georgia have been occupied by Russia. The Russian aggression against Georgian civilians covered not only the regions of conflict during and after the wars of 1992 and 2008 but also the regions adjacent to the zones of military conflict. Since 2004 Georgian Armed Forces have participated in International Security Assistance Force in Afghanistan with approximately 14,000 troops. But the Military Mental Health department was established in the Ministry of Defense of Georgia in 2014. This is when the research was performed on the Georgian military personnel (N=2799) who participated in the peacekeeping international mission in Afghanistan in 2014–2015. The purpose of this study was to examine the mechanism of association between PTSD, depression, anxiety and somatic complaints. Based on the results we conclude that PTSD symptom severity appears to be positively associated with depression, anxiety and somatic complaints in a statistically significant sense. Namely, the significant indirect association between PTSD symptoms and somatic complaints is explained by depression and anxiety symptoms as a mediator, but depression symptoms is a slightly stronger mediator than anxiety symptoms in this respect. These findings lead us to formulate several recommendations for early management of trauma. The use of joint questionnaires for PTSD, depression, anxiety and somatic complaints in the early stage after trauma may increase the chance of getting a comprehensive picture of victims’ mental state after exposure. PCL-5 and PHQ show good properties to be used in such kind of situations. Taking into consideration the HPA axis theory of linkage between above mentioned comorbid states, cortisol usage during “golden hours” may also be beneficial for the prevention of depression and anxiety symptoms. Ketamine administration for PTSD management may be beneficial for depression prevention and treatment as well as suicide prevention. As a conclusion, we can state that if we take highly associated comorbid disorders of PTSD into consideration, early administration of trauma-stress related disorders may lead to more comprehensive results in trauma management.

Many European countries have seen an abrupt increase in terrorist threats over the last years. In 2017, according to the United Nations High Commission for Refugees (UNHCR) annual Global Trends report, 68.5 million people were uprooted worldwide from their homes by conflict and persecution. The demand for mental healthcare among people fleeing war and persecution can only grow, and the WHO recommends specific training for mental health care professionals. In 2017, an online cross-sectional survey was designed by the European Federation of Psychiatric Trainees (EFPT) Psychiatry Across Borders Working Group to survey psychiatric trainees regarding their current knowledge about acute trauma prevention and experience and knowledge of issues related to the mental health of forcibly displaced people (FDP), distributed via local trainee networks using e-mail. Respondents (n=408) from 33 European countries answered the survey, 64% female, mean age 30 years old (SD: 4.6); the mean duration of psychiatric training was 32 months (SD: 19.4). The majority (72%) of the trainees (n=294) had had contact with FDPs in the last 12 months as part of their clinical work. Three quarters (75%) expressed a strong interest in the issue of refugees’ mental health, but only 34.5% felt confident assessing and treating mental health disorders in this population. Concerningly, 39% of trainees recommended immediate debriefing following trauma (recognised to be harmful), and one quarter of respondents incorrectly agreed that benzodiazepines were effective in preventing PTSD when given during the “golden hours” immediately following trauma. This survey demonstrates a lack of knowledge by psychiatric trainees about evidence-based treatments in the golden hours, and a clear unmet need for specific training regarding intervention at this time.

In planning and implementing the 5 Principles for Mass Casualty Intervention it would be impossible to begin after a mass casualty event from an unprepared base. Promoting sense of safety, calming, self- and community-efficacy, connectedness and hope, the 5 principles demand attention to both complex psychological processes and messaging. They also have profound implications that affect realities on the ground that require coordination with government, emergency services, hospitals and clinics, major media, website formulation, and communications technology. Such complex programming must be developed with forethought and require time to build these bridges, achieve funding, and create “templates and policy” that are ready to be served up. Moreover, dissemination and information sharing (marketing) must occur prior to attacks or disasters, so that the public and those who must team together have foreknowledge on how to navigate during the golden hours. Since the 9–11 attack on the World Trade Center and other terrorist attacks in France, Great Britain, school shootings, and several monumental major disasters there has been increasing recognition of a need to create and form policy. Rather than being published in a formal sense, most of this work has occurred on an organizational level, especially by NGOs but often with government involvement. The WHO has also been instrumental in aiding policy formulation as well as participation in field implementation as has the International Red Cross and Red Crescent Societies. Hence, work in the “golden hours” need to be part of prepared plans that are ready for implementation, with the attendant cross-communication between government, first responders, mental health organizations, hospitals, and community organizations. A second important factor to consider in implementation is that under-resourced communities and individuals are both most vulnerable to attack or the devastating impact of disaster and the least able to engage with aid. This means that bridges need to be made ready for enabling them to profit from intervention. Interventions are only successful when individuals and communities have the means to engage them, and such means must not be assumed. Evacuation will not occur if people believe they will lose the rights to their homes or they must abandon their elderly. Even those who have not experienced prior disaster or mass casualty may have an impaired sense of safety and compromised trust in police and government. A third critical factor is the fundamental understanding that the “golden hour” is not the first “golden hour” for many individuals or communities. Terrorist attacks, refugee flight, war, and natural disasters are often repetitive, such that trust, safety, hope, social connections, sense of self and communal efficacy, and psychological calm have already been impaired or devastated. The poorest and least well-resourced in any community are those most likely to already been harmed through everyday events of violence and tragedy or prior mass casualty. Knowing that the “golden hour” of intervention occurs on an already weakened and damaged base is critical.