Psychological trauma is defined as psychological injury caused by extreme emotional and/or physical assault. Key elements of psychological trauma include a sense of abject powerlessness in the face of the terroristic experience and a related disruption of normal routine for some time thereafter (6). For most survivors of terrorism, however, there is hope; fully two thirds of survivors of a terroristic experience display only minimal, normal-range symptomatology that remits within days to weeks of the initial trauma (7,8).

A variety of acute psychobiological response patterns are regarded as “normal” during and immediately after traumatic experience, including (a) cognitive problems such as confusion, poor concentration, memory lapses, diminished attentional focus; (b) physical problems such as fatigue, insomnia, gastrointestinal problems, muscle tension, heightened autonomic activity; (c) emotional problems including anxiety, depression, guilt, anger, and denial; and (d) behavioral problems including social withdrawal, listlessness, substance abuse, aggressive behaviors. Among those individuals terrorized most severely, a host of trauma-induced syndromes may manifest either singly or in combination in the weeks after the event.

The most widely researched emotional aftershock is posttraumatic stress disorder (PTSD) and its subclinical forms involving traumatic stress-related (TSR) symptoms. Terrorist attacks clearly meet the definition of a “traumatic event,” a core requirement for the development of PTSD (9). This syndrome involves a specific cluster of psychophysiological responses to the experience, frequently characterized by moments of apparent reexperiencing or intrusive memories/nightmares of the event coupled with attempts to avoid stimuli that might elicit these unbidden memories or dreams for weeks and perhaps even months and years after the critical incident. In full-blown PTSD, these clinical phenomena co-occur with evidence of sympathetic nervous system hyperarousal such as insomnia, elevated startle, hypervigilance, restlessness, irritability, and concentration difficulties (9).

Based on a review done by Gidron, the prevalence of PTSD after terrorist attacks worldwide is estimated to be 28%. The general public appears to have a considerably higher prevalence rate than trained security and emergency response professionals (10). Based on experience from the September 11, 2001, terrorist attacks, both the social distance to the traumatized victim and the temporal distance to a traumatic event were key determinants of who developed PTSD (11). Among direct survivors of the Oklahoma City bombing, 41% reported seeking professional mental health treatment within 6 months (12), whereas only 8.5% of the general Oklahoma City population sought help within 3 months.

Similarly, in the months following September 11, those with exposure to daily images of the World Trade Center developed more than double the usual baseline prevalence of PTSD and major depressive disorder (5), and the prevalence of PTSD in the New York City metropolitan area where the attacks took place was substantially higher than elsewhere in the country (13). At 6 months after 9/11, over 5% of New York City residents had continued PTSD symptoms and impaired functioning (14). Other longitudinal studies suggest that 33% to 50% of individuals affected initially go on to develop chronic stress symptoms (7,8), and subclinical levels of hostility, anxiety, depression, paranoid ideation, hypochondria, and phobias may continue for years after an encounter with terrorism (15).

Beyond PTSD, individuals directly exposed to a traumatic event are also at increased risk for developing other psychiatric disorders, somatic symptoms, and physical illness. Trauma-induced depression is a second, albeit poorly-understood, syndrome that is even more widely endorsed than PTSD symptoms after traumatic experience. Clinicians have observed that depressive syndromes brought on by experiences of terror and horror often develop into major depressive disorder, even among victims with previous lifetime mood stability, and it may take years to remit or treat successfully.

Finally, panic attacks, panic disorder, increased alcohol or substance abuse, and/or trauma-induced grief are often part of the posttrauma sequelae. Posttrauma panic symptoms are frequently associated with agoraphobia and involve cognitions related to a loss of a sense of safety. The symptoms may or may not be a manifestation of trauma-induced depression but frequently require psychotherapeutic intervention as well as psychopharmacology to treat successfully. Trauma-induced grief processes are inevitably a complicated bereavement and may involve survivor’s guilt, outrage and horror, and difficulties in working through the grief issues because of the presence of hyperarousal, the risk of inducing flashbacks, and other painful memories and related symptomatology.

The impact of traumatic experience, including exposure to terrorism, is most severe immediately postevent for both direct and vicarious victims, and, in general, it decreases with time (5,16). Both demographic and event-exposure factors are associated with adverse psychological outcomes after terrorism (6,17,18). The mental health of the New York City community improved with time after the terrorist attacks of 2001, with the initial 59% of general residents having four or more emotional symptoms dropping to 17% at 5 months. Those in their 40s and 50s seemed to have had relatively higher emotional distress than both younger and older groups (11). Analyses done on survey responses by lower Manhattan residents 30 days after the September 11 bombing of the World Trade Center indicated that those exposed to two or more lifetime traumas and those who were female were three times as likely as males to have been newly medicated after the attack (14). In addition, those who experienced a panic attack within hours of the incident were most likely to have sought psychiatric help within 30 days of the trauma. Related studies have confirmed higher levels of postevent PTSD and major depressive disorder
(MDD) for females, those with less education, those who are single or unmarried, those who have a prior history of mental health problems or psychological trauma (19), and those who use alcohol and cigarettes as coping mechanisms (20) (Table 40-1).

Converging evidence suggests that more than acute trauma exposure, early anxiety reactions may also serve as important predictors of subsequent maladjustment (14,21,22). Peritrauma dissociation, defined as disruption in the usually integrated functions of consciousness, memory, identity or perception of the environment, may also be predictive of subsequent psychiatric difficulties. Dissociative defenses highlight this risk and may include numbing (i.e., detachment from expected emotional reactions), reduced awareness of surroundings, memory impairment, depersonalization (i.e., a sense that one is seeing oneself from another’s perspective), and derealization (i.e., perception that one’s environment is unreal, dreamlike, or occurring in a distorted time frame).

Beyond time and space, the protective factors that insulate exposed individuals from later symptom development are not well understood. In an Israeli study in which the survey respondents appeared to be functioning unusually well given the scope of terrorism they endured, the most prevalent coping mechanisms were active information search about loved ones and social support (20). Among families of kidnapped victims held for ransom in Colombia, the quality of family system was positively correlated with outcome. Individuals from cohesive family systems who showed interest in each other’s concerns and let members share feelings presented less PTSD and psychological distress after kidnapping. In addition, certain patterns of adapting to terrorism appear to be more constructive than others. Avoiding avoidance, for example, may be healthy for some individuals because, according to Horowitz (1992), “avoidance blocks the assimilation of the traumatic experience leaving it encapsulated in a traumatic memory that may cause PTSD or other symptoms” at a later time.

Researchers and clinicians alike now recognize that it is normal for people to experience psychophysiological changes following terrorism. However, certain emergency department (ED) protocols may still be warranted to treat the acute manifestations of terror (Table 40-2).

In general, patients who experience a natural recovery from trauma are likely to appraise their peritraumatic responses as normal reactions to an abnormal event and to believe they are strong enough to cope (25). Recovery is hastened with resumption of normal routine and deliberate efforts not to avoid reminders of the trauma. In contrast, some patients who go on to experience persistent PTSD view their trauma symptoms as evidence of permanent, negative emotional damage that will not be overcome. Many experts believe persistent PTSD is maintained by excessive avoidance (of trauma reminders), rumination (viewing images over and over and cannibalizing all news media), and excessive safety-seeking behaviors (staying home, hypervigilance to danger). However, one size does not fit all. In the wake of a terrorist experience, it is not always possible to normalize daily routine and generalize emotional responses. Thus the physician treating these victims must be versatile and ready to respond with situation-specific, person-specific interventions that are compassionate and appropriate to the circumstance.