Molly J. Hall, Ann E. Norwood, Robert J. Ursano, Carol S. Fullerton


Biosecur Bioterror. 2003;1(2) 

In This Article

Terrorism and Distress

In the wake of terrorism most people will experience some level of psychological distress including an altered sense of safety, hypervigilance, sadness, anger, fear, decreased concentration, and difficulty sleeping. Others will be distressed and will alter their behavior, travel less, stay at home, keep children out of school, or increase smoking and alcohol use. Psychological effects are not limited to those experiencing the trauma directly; nationwide, millions of ordinary people will suffer as well.[11]

In the earliest study conducted after September 11, an interview of 560 adults nationwide, 90% reported at least one stress symptom and 44% had several symptoms of stress.[12] In another survey conducted days later, 71% reported feeling depressed, 49% had difficulty concentrating, and 33% were sleeping poorly.[13] Subsequent survey-based studies estimated that almost half a million people in New York State were experiencing symptoms that would meet criteria for acute post-traumatic stress disorder (PTSD), and in Manhattan the estimated prevalence of acute PTSD was 11.2%, increasing to 20% in people living close to the World Trade Center.[14,15] In a mental health needs assessment by the District of Columbia Department of Mental Health conducted between November 26 and December 14, 2001, 70% of 161 focus group participants reported an adverse health impact or psychological symptom, although less than 10% had sought care.[16] This included low-level depression, fear and anxiety, and heightened sensitivity to normal events such as a plane passing overhead. Alcohol and tobacco use increased as did incidents of domestic violence. The study noted that DC city youth, who already expressed fatalism about their future, now reported engaging in riskier behaviors and caring less. People altered normal day-to-day routines such as shopping or using the Metro, and 50% reported disrupted work schedules including changed number of hours and job loss. A striking theme that emerged in all 19 focus groups was that many had not made the connection between the terrorist attacks and the psychological distress they were experiencing.

Differentiating psychological distress from psychiatric illness is a critical public health intervention.[17] In the days and weeks following a terrorist event, well-planned public education and information campaigns are invaluable. Distress is universal and the accompanying symptoms will abate for most people over several weeks.[18] Educating the public and emphasizing the natural recovery process is important. Linking anticipated reactions and behaviors provides a measure of individual control and improves coping. Active coping strategies can be presented in multiple media forums, particularly as this has been shown to be one of the most protective strategies against ongoing distress.[11] The education and preparation of healthcare providers to evaluate and recognize the manifestations of distress and make simple interventions is important. Following the 2001 anthrax attacks, 77% of a representative sample of Americans reported that they would trust their own doctor most as a reliable source of information.[10]


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