Ebook: The Integration and Management of Traumatized People After Terrorist Attacks

This book has been prepared to publicize the results of the “Integration of People Experience Trauma after Terrorist Attacks into Modern Society” workshop which was held on April 27–28, 2006 in Ankara, Turkey, under the sponsorship of NATO within the framework of 2006 Annual Education and Training Activities of the Center of Excellence Defence Against Terrorism (COE-DAT).

The international workshop aimed to bring together academics and experts to develop a concept on the treatment of traumas and depression caused by terrorist attacks and the integration of the victims into society.

Even though the topic of the workshop is closely related to psychology, at the same time it has strong links with social and economic matters. Therefore, the psychological impact of trauma together with sociological and economic impacts are analyzed in the workshop and these analyses are reflected in this book.

Seventeen key speakers from 10 different countries (Bulgaria, Croatia, France, Israel, Netherlands, Russia, Spain, Turkey, UK, USA) and 12 participants from 8 different countries (Albania, Azerbaijan, Georgia, Jordan, Kazakhstan, Kyrgyz Republic, Macedonia, Turkey) attended the workshop. The workshop attracted very much attention, not only from Turkish academics, but also from the international academics who participated. After the workshop, all participants had the opportunity to visit the Turkish General Staff (TGS) Rehabilitation Center to see the victims of terror in Turkey.

This book is composed of the articles of the academicians who participated in the workshop. The presentations of these academicians were about overcoming the harmful effects of trauma caused by terrorist attacks and sustaining the integration of traumatized people into society. The book has 4 main sections: general framework, psychological impacts, sociological impacts and economic impacts.

In the general framework section, Dr. Suat BEGEÇ, who is co-director of the workshop, explains how to prevent the causes of terrorism and to decrease the impact of terrorism and also the rights of terror victims which are provided by Turkish Army.

In the section concerning psychological impacts, readers will find 11 articles. In the first article, Prof. Dragica KOZARIC-KOVACIC from Croatia defines Post Traumatic Stress Disorder (PTSD) after terrorist attacks. She also puts forward the diagnosis of PTSD and presents the results of research on Croatian war veterans.

The second academician from Croatia, Dr. Nela PIVAC, touches on the symptoms of PTSD and tries to answer the question if the neurobiology of PTSD might improve the understanding and treatment of PTSD or not. Lastly, she shares her review of results related to biomarkers in Croatian war veterans with combat related PTSD.

In the third article, Dr. Louis JEHEL examines the predictive factors of a pathological evolution and useful questionnaires and clinical characteristics to identify subjects with a higher risk of PTSD and determines a health care strategy according to these criteria.

Dr. Elke GERAERTS brings up the common argument according to the results of the study made on 121 Croatian war veterans if traumatic experiences are processed and remembered in a qualitatively different way from neutral events or not.

Psychological responses to disasters such as terrorist attacks and some biological parameters in PTSD are examined by Asst Prof. Ali BOZKURT in his paper.

Prof. Vassily YASTREBOV, in his article, tries to classify of the consequences of PTSD of terrorism victims at individual and social levels and from an economic point of view. He presents a study on various terrorist acts committed in Russia from 1994 till 2005.

Prof. ECHEBURUA from Spain outlines ways (treatment guidelines) to effectively deal with the survivors of terrorism and with the family members of those injured or killed in terrorist attacks.

Prof. Richard McNALLY, in his article, defines what the psychological debriefing is. He tries to provide a review of the evidence bearing on the efficacy of debriefing and a survey on emerging alternatives to this widely used method of crisis intervention.

Israeli Dr. Irit MERETYK's paper is about what the therapeutic interventions in acute stress reactions after terrorist attacks are and she shares the Israeli experience based on observations in Rambam Medical Center.

Michael ROY's paper addresses the lessons learned from the 9/11 attacks in order to be better prepared for future terrorist acts and the psychological effects and physical consequences of them.

The Bulgarian academician, Dr. PARASHKEVOV refers to his personnel observations from Bulgarian missions in Iraq (6 months) and Afghanistan (1 year) and the results of a study of a group of 110 member of the peacekeeping contingent in Iraq who experienced a terrorist attack. He also lists the factors which affect the behavior and the psychological health of the servicemen in the missions.

Reader will find three papers in the sociological impacts section. Dr. James FOREST examines the findings of several studies on the economic and psychological impact of the 9/11 attacks on New York and Washington, DC. He analyses common themes and important similarities and differences among societies in preparing their communities for future terrorist attacks.

In his paper, Mr. James DINGLEY explains socio-economic affects of terrorist attacks, and presents examinations on individual and society. He also lays out economic-political costs of terrorism to understand terrorist tactics and strategy.

Professor in Physical Medicine and Rehabilitation, Kamil YAZICIOĞLU, defines what rehabilitation is, methods of reintegration of handicapped and physical rehabilitation of the traumatized people. He also shares the results of research on the differential effects of socio-demographic characteristics, illness process and type of social support on the quality of life levels on 79 veterans.

In the section dealing with economic impacts of trauma there are two papers. One of them is the paper of Prof. MURSHED from UK which explains transnational terrorism, rational choice approaches and tries to develop solution proposals.

Lastly, Prof. Rafi ELDOR analyzes the impact of 473 terror attacks on various economic sectors in Israel. He tries to answer the question whether the economic impact of terrorism is purely a macroeconomic phenomenon affecting the entire economy or if its impact is concentrated in certain industries, leaving some sectors unaffected and perhaps even benefiting others.

Since how to counter or combat terrorism is still disputed, the world has to learn how to live with terrorism, and how to diminish its harmful effects on both individuals and society. No matter how important it is to prevent the causes of terrorism, in the struggle against it, it is also important to decrease its impact. In this book, what we focus on is how to deal with the impact of terrorism. Holding the workshop in a country like Turkey, which has suffered from terrorism for approximately 30 years, was meaningful, but I hope it was also fruitful. In this respect I hope this book will be an international guide to facilitate the integration of terror victims into society and may be beneficial for academicians, government officials and anyone interested in this area.

Dr. Suat BEGEÇ, COE-DAT, Ankara

The impacts of terrorism may diminish both by preventing the causes of terrorism and decreasing the impact of terrorism. The cost of causes has been reduced by the development and adoptation standarts and codes of good practice at the national level similar to international level. The primary impacts of terrorism concern health, social and economical issues. Despite living with the fear of the terrorism, leaders should try to both prevent the causes of terrorism and decrease the impact of terrorism.

Posttraumatic stress disorder (PTSD) was officially proposed as separate diagnosis in DSM-III, although the clinical consequences of trauma were recognized since ancient times. After its identification in DSM-III, the neurobiology of chronic PTSD has been area of increasing investigation. Earlier the psychoanalytic model of explanation and treatment mostly prevailed. Epidemiological studies show high prevalence of PTSD in general population and specific groups exposed to the traumatic events (survivors of war trauma, natural disasters, terrorist attacks, etc.). Trauma and its consequences affect significantly individual health and functioning, and whole society. The diagnosis of PTSD may have several subtypes, including psychotic symptoms, depending upon pre-existing psychiatric disorder, trauma severity and duration, comorbidity, post-trauma social environment, etc. The role of trauma as an etiological factor in other psychiatric disorders and symptoms remains to be clarified. This paper presents the diagnostic and therapeutic issues in relation to the stress-related disorders with the emphasis on our own experiences in the diagnostic assessment and treatment of psychotraumatized persons (establishing more precious diagnosis of PTSD and comorbid diagnoses, differential diagnoses, different models of treatment in the community and institutions after massive traumatization, including “Croatian model”, treatment of PTSD with psychotic features with novel antipsychotics, etc.).

Posttraumatic stress disorder (PTSD) is a serious and devastating psychiatric illness that develops after an exposure to a terrifying event. PTSD is associated with a diminished quality of life and considerable emotional suffering in patients and their families, and can be a financial burden to the whole society. PTSD symptoms include preoccupation and re-experiencing of the traumatic event, fear, anxiety, arousal, sleep disturbances, nightmares, emotional numbness, withdrawal, terror, helplessness, horror, irritability and aggression, and the loss of the sense of basic safety. However, not all subjects exposed to a traumatic event will develop PTSD. Brain regions mediate the stress response via specific neurochemical circuitry, but in PTSD the copping mechanisms change from normal reactions to stress into maladaptive responses. The studies of the neurobiology of PTSD, which primarily involves the neuroendocrine dysregulation (of the activity of the hypothalamic-pituitary adrenal axis), dysfunction of the noradrenergic, serotonergic, dopaminergic, GABA-ergic, glutamatergic, and opioidergic neurotransmitter systems, and genetic polymorphisms, might improve the understanding and treatment of PTSD. A complex interaction between trauma and genetic and environmental factors, and early experiences, underlies the development of PTSD. The authors present a review of their own results related to biomarkers in Croatian war veterans with combat related PTSD.

People exposed to a violent event such as a terrorist attack present various reactions to stress that may need an emergency intervention and first some specific traumatic stress evaluation. The latter is crucial when it comes to determine those who will develop severe and disabling troubles likely to last several years. It is demonstrated that theses troubles are particularly severe when they are related to human designed traumatic events as terrorism. 5 to 20% will develop psychiatric post-traumatic symptoms. Of all those concerned, health care professionals have to determine those for whom a severe evolution is dreaded. It is crucial to make their taking care of a priority. We will indicate the best predictive factors of a pathological evolution hereafter. We will present the most useful questionnaires and clinical characteristics to identify subjects with the higher risk of PTSD. According to these criteria a health care strategy is going to be determined. Identifying the predictive factors concerns the individual peritraumatic reactions as well as the traumatic event itself. Thus it is necessary to take into account the previous health state of the person and the early help provided. Among the initial reaction characteristics several clinical studies suggest that measuring the heart beat is an indicator to emotional reaction. A heart beat superior to 92 per minute could predict a PTSD to come. This simple physiological indicator added to more specific psychological and peritraumatic dissociation ones could be the best actual PTSD predictive factors.

Several authors have argued that traumatic experiences are processed and remembered in a qualitatively different way from neutral events. To investigate this issue, we interviewed 121 Croatian war veterans diagnosed with posttraumatic stress disorder (PTSD) about amnesia, intrusions (i.e., flashbacks and nightmares), and the sensory qualities of their most horrific war memories. Additionally, they completed a self-report scale measuring dissociative experiences. In contrast to what one would expect on the basis of theories emphasizing the special status of traumatic memories, amnesia and high frequency intrusions were not particularly typical for our sample of traumatized individuals. Moreover, traumatic memories were not qualitatively different from neutral memories with respect to their stability and sensory qualities. The severity of PTSD symptoms was not significantly correlated with dissociative experiences. Our findings do not support the existence of special memory mechanisms that are unique to experiencing traumatic events.

Terrorism has psychological and social effects. The emotional and behavioral responses to disasters occur in four phases. Psychological responses to terrorism may include acute stress disorder, posttraumatic stress disorder, and other clinical diagnosis. Studies indicate that in the year following terrorist incidents, the prevalence of PTSD in directly affected populations varies between 12% and 16% but it may also decline 25% over the course of that year. There are several vulnerability factors for developing PTSD after a trauma. As known not all subject develop PTSD symptoms after trauma. Those factors are presence of childhood trauma, some personality disorders, inadequate family or peer support, being female, genetic vulnerability or psychiatric illness, recent stressful life changes, recent excessive alcohol intake and perception of an external locus of control. PTSD is usually accompanied with another axis 1 disorder. The most common comorbid disorders are; (a) alcohol abuse, (b) substance abuse (c) depression (d) anxiety disorders (especially phobia and panic disorder) (e) personality disorders (especially antisocial and borderline personality disorders). Some biological parameters are related with PTSD. Yetkin investigated 25 PTSD subjects at Gülhane Military Medical Academy Department of Psychiatry. PTSD patients had decreased sleep efficiency, decreased total sleep time, reduced stages 4 sleep, decreased REM latency, increased sleep latency and waking during sleep in comparison to the control subjects. Heart rate in sleep stages were significantly elevated In PTSD subjects and there were not any difference between stages. The number of brain imaging studies in PTSD has increased in the last years. Studies can be classified as structural, functional and receptor imaging studies. The structurel pathological main sites are hippocampus, parahipocampal gyrus, and amygdale. Functional imaging studies revealed that hyperactive or altered function of emotion response brain regions, such as amygdala and the insula, and hypofunction of emotion-regulatory structures, such as the medial prefrontral and cingulate cortex. Brain imaging neurochemical receptors have suggested that γ-aminobutyric acidergic and μ-opioid mechanisms may underlie brain activation patterns found in functional studies of PTSD. In a PTSD study in 1998 Doruk has investigated 48 PTSD subjects. 40 of those patients did have PTSD due terrorism. There were negative correlation between serum cortisol levels and intrusive-avoidance symptoms, between serum cortisol/noradrenalin and global severity, and between serum GH levels and avoidance-hyperarousal symptoms. However, between 24 hour urine cortisol/adrenaline and intrusive-hyperarousal symptoms had positive correlation.

Aim of this report is to determine the main kinds of consequences of PTSD of terrorism victims on individual, social levels and from economic point of view. The most dimensioned terrorist acts which have been committed in Russia from 1994 till 2005 were included in this study. PTSD of terrorists attack victims are defined as the grave medico-social problem. It's noted that different specialists (clinicians, psychologists, sociologists and economists) have to take part in investigation of this problem. The main levels of consequences of PTSD are picked out. Author gives main recommendations for elaboration of special complex program for reduction of these kinds of consequences. It is stressed, that determination of the main kinds of after-effects of terrorism victims PTSD, working out of approaches to assess of the scale of burden in these cases, can give an opportunity to elaborate of special complex program for reduction of these grave consequences.

Victims of terrorism are subject to severe stress and disruption and may manifest a pattern of dissociative and anxiety/depression symptoms. The trauma may impair the person's quality of life and disrupt social and other functioning. If symptoms last beyond a month following the traumatic event, PTSD may ensue. These adverse effects do not always disappear with time. Crisis intervention is focused on ensuring safety and providing support, including assessment of coping resources and support networks. The role of early psychological debriefing to prevent psychopathology following a traumatic event is to detect individuals who require more complex intervention. The issues addressed in therapy include the need to correct unrealistic expectations, to deal with guilt and phobic reactions as well as family and network reorganization. Cognitive-behavioral treatments, such as exposure techniques or cognitive restructuring approaches, have been shown to work. At times, work with the family members may be necessary too. Considerable attention has been given to the development and delivery of support and treatment interventions but this has not been matched by a corresponding effort on evaluation. Many terrorists attacks cannot be prevented but the magnitude of their psychosocial impact can be reduced by better community preparedness and response.

Psychological debriefing is a popular crisis intervention designed to attenuate acute distress and prevent posttraumatic psychopathology following exposure to traumatic events, including terrorist attacks. Despite a flourishing “debriefing industry,” there is no convincing evidence that it diminishes the incidence of posttraumatic psychopathology. Most studies indicate that trauma-exposed persons who receive debriefing fare no better than those who do not. More ominously, other studies reveal that debriefing actually impedes natural recovery from the effects of trauma. These disappointing have prompted the development of screening methods to identify those most at risk for posttraumatic psychopathology, and the development of alternative early treatment methods. These new approaches are discussed.

Israeli society has had a longstanding need to cope with the terror attacks that have brought us many physically and mentally wounded victims and wide exposure to traumatic, stressful events. Terror has delivered the dread of war to our doorsteps, and combat reactions no longer belong to soldiers on the battlefield alone. The concrete possibility of so many simultaneously injured people, the uncertainty, and contagious anxiety affect the masses, enhance the traumatic potential, and place complex challenges on health systems (Bleich et al., 2003). The immediate and early phases of the post-traumatic period are the most intriguing. A large variety of elements influence mental responses, coping mechanisms and future mental processes. The traumatic cause, the internal and external resources, the surroundings and treatment accessibility are among these elements.

On September 11, 2001, thousands perished when terrorists hijacked commercial airliners and crashed them into the World Trade Center in New York City and the Pentagon in Washington, DC. The following month, anthrax was disseminated through the U.S. mail to the Capitol in Washington, and a news studio in New York, resulting in 11 cases each of cutaneous and inhalational anthrax, with 6 of the latter fatal. This paper will address the lessons learned from the aftermath of these incidents, so that we may be better prepared for future terrorist acts. Among the most salient lessons from 9/11 is that it is critical to establish clear lines of communication (since phone service may be unreliable), avenues of evacuation to medical facilities (since gridlock rapidly ensues), and command structure (since jurisdiction may be ambiguous). The many lessons from the anthrax attacks include the clinical signs distinguishing anthrax from influenza and other viral illnesses, and the survival benefits from prompt treatment with multiple antibiotics. Most notable of all, the psychological effects of each incident proved to be more durable and widespread than the immediate physical consequences. In addition to delineating lessons learned from the immediate aftermath of the incidents, we also address the most significant ways to enhance the education of health care providers so they can more effectively diagnose and treat patients exposed to terrorist attacks.

Personnel for taking medical care of the civilian populations in cases of natural disasters, technological accidents and supporting of military contingents for peacekeeping and peaceinforcing operations are preparing in the Military medical Detachment for emergency response at Military Medical Academy – Sofia. Psychic condition of the participants is very important for the efficiency of the processing of the all mission. A group of 110 male participants in the peacekeeping operation in Iraq are examined after six months mission. In this research are used questionnaire for posttraumatic stress disorders (PTSD) and card. The received results are base for prognosis and tracing of late impact of war stress and their minimizing in this specific contingent of the Bulgarian army.

This paper reviews the findings of several studies on the economic and psychological impact of the 9/11 attacks on New York and Washington, DC, and identifies common themes and important similarities (as well as key differences) from this research literature that inform our understanding of national resilience. The paper then examines some of the ways in which the U.S. has responded to 9/11 in terms of preparing our communities for future terrorist attacks. While federal, state and local authorities have held numerous preparatory exercises, this analysis argues that it is a mistake to rely solely on the government to deal with the immediate impact of terrorist attacks. Community education and empowerment must play a prominent role in any comprehensive homeland security strategy. Community Emergency Response Training (CERT) initiatives have been developed throughout the United States to do just that, and provide an important model for other countries who seek to build resilience in their communities. Further, in our efforts to do so, there is much the U.S. can learn from the experiences of other nations who have faced terrorist attacks for many years, including Colombia, Ireland, Israel, Spain, Sri Lanka, Russia, and Turkey. Finally, this analysis concludes that leadership, preparation, communication, education, and the development of social capital are vital elements of any strategy for building community resilience in an age of terrorism.

Responses to terrorist attacks have above all to be able to respond not only to the immediate consequences and aftermath of an attack but also to the long-term aims and objectives of an attack. The two must be carefully coordinated. In turn this also requires some appreciation of the aims and objectives of the attack. The immediate consequences are the injury (mental and physical) to individuals which require specific services and facilities to be readily available. But one also has to consider the affects on routine social order and society in general, which not only imply the immediate social disruption but potential social anomie and division, thus harming the long-term functioning of society. Further, one also has to recognise the economic impact not just in terms of economic disruption but also of the diversion of scarce resources and alienation of future investment. Thus whilst the immediate outcome of an attack may be quickly reparable the longer term may be less so and even less appreciated and the remit for this may lie outside of the normal security services who are delegated to respond.

The aim of rehabilitation is to make the disabled independent in all fields. Unfortunately, being physically independent is not enough for disabled for community reintegration. Social support and recreational therapy, especially disabled sports are very essential for the reintegration period, and social adaption.

Transnational terrorism can be characterised as an international spillover of domestic disputes, because an external power is seen to support the regime at home, which is also regarded as a client state of the foreign power. To this we may add a deep sense of humiliation, which can drive sufficiently motivated individuals to go to great lengths to further their cause, including even suicide. From that viewpoint, if suicide promotes the cause; it can be rational. Deterrence against such individuals could backfire, as it strengthens their resolve to resist, unless of course extremely destructive force is used, something that is intolerable in most Western democracies. In other situations, so-called terrorism constitutes violent acts against the state in the context of a purely domestic dispute without implications for international terrorism. The long-term solutions to terrorism are political and economic, and not military. In that sense, the solutions for terrorism, and the difficulties associated with self-sustaining peace agreements are similar. Concepts of ‘fair division’ can be applied to the post-conflict dispensation. But the greatest difficult arises in attempts to divide the indivisible; something that ultimately requires power-sharing, common access and other federative formulas. Culturalist explanations for terrorism are a means of disguising the root causes of a phenomenon that lie in political injustices, unfair post-colonial dispensations and economic discrimination. Ultimately, violence has a rational basis which is universal to all cultures.

This paper analyzes the impact of 473 terror attacks on various economic sectors in Israel between 27 September 2000 and 31 December 2003. Shares traded in the Tel Aviv stocks exchange (TASE) are classified into ten industries: Banking, Chemicals, Commerce & Services, Electrical & Electronics, Insurance, Investments & Holding, Manufacturing, Mortgage Banks, Oil Exploration and Real-Estate & Construction. The impact is the strongest for the Banking, Commerce & Services, Insurance, Investment & Holdings, Manufacturing and Real-Estate & Construction sectors. The Electrical & Electronics and Mortgage Bank sectors exhibited lower sensitivity to terrorist events.