The Psychological Consequences of Terrorism
Terrorism involves the use of sudden, violent acts to provoke fear and uncertainty in a particular population, usually for political aims. It has been defined as “the deliberate killing of innocent people, at random, in order to spread fear through a whole population and force the hand of its political leaders.” Since the 1970s, the Global Terrorism Database has documented more than 200,000 terrorist attacks worldwide.
While the most immediate and acute effects of terrorism may be physical, involving bodily injury or loss of life, terrorism also has psychological consequences. It aims to instil fear into the minds of the public, making people feel vulnerable in their everyday lives. In this sense, terrorism can be thought of as “psychological warfare waged on the public mind.”
As well as having a widespread effect on people’s general sense of security, acts of terror are particularly traumatic for people who witness and survive them. In this post, we examine the effects of terrorism as a traumatic event and consider its psychological effects. We then look at the various factors that increase the likelihood that someone will suffer psychological damage from a terrorist attack.
Terrorism as a Traumatic Event
Traumatic events typically represent a significant threat to the life or bodily integrity of an individual. They tend to be sudden and unexpected, causing people to feel frightened and shocked. Examples of traumatic events include car crashes or other serious accidents, natural disasters, war, domestic abuse, sexual violence, witnessing death, and more.
It is widely documented that people who suffer or witness a terrorist attack experience helplessness and fear. In fact, studies have shown that deliberate acts of violence (such as terrorism and war) are significantly more likely to be traumatic than natural disasters (such as earthquakes, tsunamis, and storms) or accidental, human-induced disasters (such as oil spills and car accidents).
The Psychological Effects of Terrorism on Survivors
One of the most common psychological consequences for the survivors of terrorist attacks is post-traumatic stress disorder (PTSD).
A person who suffers from PTSD will continue to relive the traumatic experience after the event, often in the form of intrusive memories, flashbacks, or nightmares. These may cause people to experience feelings of anger, irritability, or guilt. People may also have trouble sleeping. People with PTSD may take significant measures to avoid coming into contact with reminders of the traumatic event, which can have a debilitating effect on their social and psychological functioning.
Epidemiologically, PTSD is much more common in terrorist attack survivors than in the general population. A study of survivors from a series of 12 terrorist bombings that took place in France from 1995-1996 found that over 30% of those who had been present at the attack showed signs of PTSD. More recently, similar statistics were found in studies of the survivors of the 11 September 2001 attacks in New York City. The prevalence of PTSD among survivors was found to be around 30%, lowering to just over 20% after one year.
As well as PTSD, researchers have identified other psychological effects of terrorism, such as anxiety and depression. In fact, previous research has shown that there is often a significant overlap between PTSD and other psychiatric conditions in the survivors of terrorist attacks. In studies of survivors of the Manchester Arena bombing on 22 May 2017, for example, 90% of adults were found to have anxiety, and 55% of them showed signs of PTSD. Meanwhile, 25% of young people at the event (aged between 8 and 18) were found to have clinically significant depression, and 83% of them had possible PTSD.
More broadly, a general review of 567 studies of terrorist-attack survivors found that between 20% and 30% of victims present at an attack showed symptoms of depression. This was demonstrated, for example, by three studies of the survivors of the terrorist attacks in Madrid on 11 March 2004. The first of these studies found that 28.6% of the victims who requested hospital assistance on the day of the attacks had major depressive disorder, and the percentage was even higher in the second study, rising to 31.5%. The third study found that 31.3% of people who had been present at the attacks or who had lost friends or relatives suffered from major depressive disorder.
The Factors that Increase the Likelihood of Psychological Damage
As with any traumatic event, contextual factors are important in determining different individuals’ psychological responses. Research clearly shows that “just because someone experiences or witnesses an act of violence does not mean that he or she will inevitably develop psychiatric morbidity.” There are several factors that increase the likelihood that someone will be psychologically affected by a terrorist attack, including pre-existing conditions, gender, and proximity.
Pre-existing Conditions
People with pre-existing or comorbid conditions may be more adversely affected by terrorist attacks than others. A study of prescriptions for psychotropic drugs (such as antidepressants, antipsychotics, anxiolytics, and more) before and after 9/11 found that while there was no significant increase in the rate of new prescriptions among New Yorkers following the attacks, people with pre-existing prescriptions increased their dosages, suggesting that pre-existing conditions were exacerbated by the traumatic experience.
Moreover, this was also borne out by another study of the psychological consequences of the 9/11 attacks, which found that 80% of the patients who were suffering from PTSD in the wake of the attack were also suffering from a comorbid mental health disorder.
Gender
In general, women are more at risk than men of developing PTSD following a traumatic event. The reasons for this difference are unclear, though some studies have posited that there may be a genetic or neurobiological cause.
When it comes to terrorist attacks specifically, the same distinction has been observed between the psychological responses of men and women. A study of 182 survivors of the bombing in Oklahoma City on 19 April 1995, for example, found that women were more at risk of experiencing psychological distress than men. Similarly, a study of more than 1800 people affected by the Oslo bombing on 22 July 2011 found that women experienced higher levels of PTSD symptoms. This was true among people who were directly affected by the bombing and those who were indirectly affected by it or who witnessed the attack.
Finally, this last point is also demonstrated by a 2008 study of Israeli citizens living in cities impacted by terrorism, which found that even when women were less exposed to the violence than men, they still suffered “higher levels of negative mood and posttraumatic stress disorder”.
Proximity
Reports of terrorist attacks often divide victims into two categories: direct (or primary) victims and indirect (or secondary) victims. Direct victims are those who were physically present at the site of the terrorist attack. They are people who were killed or injured as a direct result of the attack, or who witnessed the event first-hand. A person can be a direct victim even if they were not physically harmed (a near-miss). When it comes to physical closeness, studies of terrorist attacks have found that proximity to the site of the attack is significantly correlated with the development of psychological distress.
Indirect or secondary victims are people who are connected to the primary victims in some way but who were not present at the attack. These may be the friends, relatives, coworkers, and family members of the people involved in the attack. They may have arrived on the scene soon after the event or witnessed the effects in hospital. In a medico-legal context, as we discussed in our post on secondary victims, the burden of proof for people seeking compensation for psychological damage when they are only indirectly connected to a traumatic event is very high. This is to mitigate the possibility of potentially limitless claims following a large-scale trauma.
As well as direct or indirect victims, some reports also identify a third category of tertiary or community victims. These are the people who are affected by the infrastructural damage caused by a terrorist attack, whose daily lives are altered as a result. This group of people may also feel a broad sense of loss for a particular part of their community or an increased sense of fear for the place they call home. This category might apply, for example, to Londoners after the bombings on the London Underground on 7 July 2005, or New Yorkers after 9/11. While these people might be saddened and affected by the event, they would not be expected to suffer lasting psychological damage.
Exposure through Media
This is also true for people who witness a terrorist attack on television or through electronic media. In fact, the definition of “traumatic event” was changed in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), to reflect this point. The new definition stipulates that an event must be witnessed “in person” if it is to count as a “traumatic experience”. Under the previous definition contained in the 4th edition of the DSM, it was possible for someone to experience psychological trauma even if they just witnessed images of an event. As a review of this definition pointed out, however, this would have meant that “nearly anyone living in the United States of America” at the time of the 9/11 attacks could have been considered “trauma-exposed”.
The updated definition reflects the more prominent exposure that people have to terrorist attacks in the modern world, particularly given the rapid dissemination of images online. The update continues to reflect what has been known for a long time, however, namely that the psychological consequences of terrorism are more acute for those who experience them directly than for those who experience them second-hand.
Summary
Though acts of terrorism are rare, and deaths from terrorism represent only a small proportion of global casualties, terrorist acts continue to garner significant media attention and remain a present public concern. As a form of psychological warfare, terrorism has the power to unsettle people’s sense of security, exposing them to significant levels of fear. A person who survives or witnesses a terrorist attack is at significantly more risk of psychological disorders such as PTSD, anxiety, and depression.
Moreover, certain factors make people more likely to suffer psychological damage from a terrorist attack. People with pre-existing conditions are often more vulnerable to terrorist attacks, and women are more likely than men to be psychologically affected by traumatic events. As is to be expected, proximity to the event is also a significant predictive factor.
Finally, while the modern media sphere means that acts of terrorism are disseminated widely and people are readily aware of terrorism as a threat, exposure to terrorism through the media is not the same as witnessing the event first-hand. Individuals who are exposed to terrorist attacks through the media should not be expected to suffer lasting psychological damage.
This post is provided for general information purposes and is not intended to cover every aspect of the topics with which it deals. It does not constitute medical, legal, or professional advice, nor is it necessarily an endorsement of the views of Professor Elliott, the U.K. Centre for Medico-Legal Studies, its employees, or its affiliates. Though we aim to ensure that all information is accurate at the time of posting, we make no representations, warranties or guarantees, whether express or implied, that the content in the post is complete or up to date.