Physical injury and posttraumatic stress reactions. A study of the survivors of the 2011 shooting massacre on Utøya Island, Norway

Linking affected community and academic knowledge: a community-based participatory research framework based on a Shichigahama project

Earthquakes that cause extensive damage occur frequently in Japan, the most recent being the Noto Peninsula earthquake on January 1, 2024. To facilitate such a recovery, we introduce a community-based participatory research program implemented through cooperation between universities and local communities after the 2011 Great East Japan Earthquake. In this project, the university and the town of Shichigahama, one of the affected areas, collaborated to hold annual workshops in the target area, which evolved into a climate monitoring survey. Even in Japan, where disaster prevention planning is widespread, various problems arise in the process of emergency response, recovery and reconstruction, and building back better when disasters occur. As is difficult for residents and local governments to solve these problems alone, it is helpful when experts participate in the response process. In this study, we interviewed town hall and university officials as representatives of local residents regarding this project and discussed their mutual concerns. The community-based participatory research framework developed in the Shichigahama project could be used in the recovery from the Noto Peninsula Earthquake as well as in future reconstruction and disaster management projects.

Inhibitory control as possible risk and/or resilience factor for the development of trauma related symptoms-a study of the Utøya terror attack survivors

PTSD symptomatology is known to be associated with executive dysfunction. Inhibitory control is a core component of executive functioning, and inhibitory skills are essential both for adequate functioning in everyday life and important in situations following trauma. The aim of the present study was to examine the relationship between trauma exposure, inhibitory control and PTSD symptomatology in adolescent survivors of the terror attack at Utøya, Norway on the 22nd of July, 2011. In this cross-sectional case-control study, 20 trauma exposed adolescents and 20 healthy controls matched in age and gender were compared on a neuropsychological test of cognitive inhibition (Color-Word Interference Test) and a self-report measure of inhibition ability (BRIEF-A). Our analyses revealed that the trauma exposed group differed significantly on the self-reported measure of inhibitory control compared to the control group, but there were no differences between groups on the objective measures of cognitive inhibition. Follow-up analyses with subgroups in the trauma exposed group based on PTSD symptomatology (PTSD + and PTSD-) and the control group revealed that the PTSD- group showed significantly better results than both the PTSD + and the control group on the measures of inhibitory control. Moreover, the follow-up analyses showed that the PTSD + group showed significantly poorer results from the other two groups on the measures of inhibitory control and self-reported inhibition. We conclude that impaired inhibitory control, measured both objectively and by self-reported questionnaire, is related to PTSD symptomatology. Findings suggest that inhibitory dysfunctions may be a vulnerability factor for the development of PTSD symptomatology in trauma exposed adolescents, and thus it seems that the ability to exhibit inhibitory control could be a possible resilience factor to prevent the development of PTSD symptoms.

Anxiety, Depression and Posttraumatic Stress Disorder after Terrorist Attacks: A General Review of the Literature

Terrorism, though not well-defined, is a violent act that has been shown to have longstanding effects on the mental health of those who witness it. The aim of this general literature review is to explore the effect that terrorism has on posttraumatic stress disorder (PTSD), major depressive disorder (MDD) and anxiety disorders, as well as the bio-psycho-social determinants that mediate its impact. This paper describes the prevalence, risk factors, protective factors, common presentations and interventions identified for PTSD, depression and anxiety disorders occurring following terrorist attacks. We conducted a literature search in MEDLINE using a number of keywords detailed below. After applying inclusion and exclusion criteria, we kept 80 articles, which we summarized in tabular form. A majority of articles found detailed the impact of terrorism on PTSD, and took place in a Western, mainly American setting. The main factors that impacted the presentation of mental illness include gender, ethnicity, social supports, socioeconomic status, level of preparedness, level of exposure, pre-existing trauma and mental illness, and subsequent life stressors. The main intervention detailed in this article as showing evidence post-terrorism is trauma-focused cognitive-behavioural therapy. This study highlights the importance of this topic, and in particular, its implications for public health policy and practice.

Effects of Mass Shootings on the Mental Health of Children and Adolescents

PURPOSE OF REVIEW

To examine mass shootings in youth including mass shooting trends, risk and protective factors for emotional sequelae, mental health, prevention of mass shootings, and the assessment and treatment of survivors.

RECENT FINDINGS

Many youth are exposed to gun violence, with a smaller subset exposed to mass shootings. While youth have varying responses to mass shootings, possibly due to risk and protective factors as well as level of exposure, the mental health outcomes are significant and include posttraumatic stress, suicide, depression, substance abuse, and anxiety. Efforts at developing effective prevention and treatment programs are still underway but generally take a tiered public health approach. Mass shootings have significant mental health outcomes for youth survivors, particularly those with direct exposure or risk factors. Continued efforts are needed to better understand the effects of mass shootings and how to prevent them from occurring as well as how to best address the needs of survivors.

Early Pain and Other Somatic Symptoms Predict Posttraumatic Stress Reactions in Survivors of Terrorist Attacks: The Longitudinal Utøya Cohort Study

Survivors of traumatic events commonly suffer from long-term pain and related somatic symptomatology. To test the predominant hypothesis that survivors' pain comprises sequela of persistent posttraumatic stress symptoms (PTSS), we assessed the sequential order of symptom development among young survivors of a terrorist attack. All 490 survivors of the 2011 Utøya (Norway) attacks were invited to the longitudinal Utøya cohort study; 355 (72.4%) participated. The mean survivor age was 19.3 years (SD = 4.6) and 169 were female (47.6%). Somatic symptoms, including headache, other pain and fatigue, and PTSS, were measured 4-5 months (T1), 14-16 months (T2), and 32-33 months (T3) after the attack. Longitudinal associations between somatic symptoms and PTSS were assessed in cross-lagged structural equation model (SEM) analyses, which were adjusted for known confounders. Higher pain levels and other somatic symptoms at T1 consistently predicted PTSS at T2 in SEM analyses, r = .473, p < .001. Beyond this early-to-intermediate posttraumatic phase, somatic symptoms did not significantly predict PTSS: T2-T3, r = .024, p = .831; T1-T3, r = -.074, p = .586. PTSS did not significantly predict later somatic symptomatology at T1-T2, r = .093, p = .455; T2-T3, r = .272, p = .234; or T1-T3, r = -.279, p = .077. The findings indicate that survivors' early pain and related somatic symptoms strongly and consistently predict later psychopathology. After severe psychological trauma, early interventions may need to address individuals' pain to hinder chronification.

Trust After Terror: Institutional Trust Among Young Terror Survivors and Their Parents After the 22nd of July Terrorist Attack on Utøya Island, Norway

In the aftermath of terrorist attacks and disasters, public institutions play an important role in re-establishing safety and justice. However, little is known about the importance of institutional trust for victims' potential for healing in the aftermath of mass trauma. This study examines levels of post-terror trust in the police and in the justice system among young survivors from the 2011 Utøya terror attack and their parents. Furthermore, it investigates how institutional trust develops over time among directly affected populations, and whether it is associated with psychological distress. 325 survivors and 463 parents were interviewed face-to-face at wave one (4-5 months post-terror) and 285 survivors and 435 parents at wave two (14-15 months). Levels of institutional trust in victims were compared to general population data from the European Social Survey adjusted for age, gender, and ethnic background. Measures included trust in the police and justice system, post-traumatic stress reactions, anxiety and depression, and quality of life. Trust in the police among survivors and parents was higher than or comparable to trust levels in the general population at wave one, but decreased for survivors and parents at wave two. Trust in the justice system was higher among those directly affected than in the general population, and increased from wave one to wave two. Levels of institutional trust were negatively associated with distress for survivors in both waves and for parents in wave two. Levels of institutional trust were positively associated with perceived quality of life in parents and survivors. Directly affected groups' institutional trust differed from that of the general population following the terrorist attack, although being directly affected did not necessarily imply weakened institutional trust. This study found trust to be institution specific, however, trust in institutions changed with time, and the passing of time might be an important factor in better understanding whether trust will generalize across institutions or not. Institutional trust was negatively associated with psychological distress. This finding highlights the potential for institutions to create a healing post-disaster environment.

Psychological screening of adults and young people following the Manchester Arena incident

BACKGROUND

Terrorist attacks have increased globally since the late 1990s with clear evidence of psychological distress across both adults and children and young people (CYP). After the Manchester Arena terrorist attack, the Resilience Hub was established to identify people in need of psychological and psychosocial support.

AIMS

To examine the severity of symptoms and impact of the programme.

METHOD

The hub offers outreach, screening, clinical telephone triage and facilitation to access evidenced treatments. People were screened for trauma, depression, generalised anxiety and functioning who registered at 3, 6 and 9 months post-incident. Baseline scores were compared between screening groups (first screen at 3, 6 or 9 months) in each cohort (adult, CYP), and within groups to compare scores at 9 months.

RESULTS

There were significant differences in adults' baseline scores across screening groups on trauma, depression, anxiety and functioning. There were significant differences in the baseline scores of CYP across screening groups on trauma, depression, generalised anxiety and separation anxiety. Paired samples t-tests demonstrated significant differences between baseline and follow-up scores on all measures for adults in the 3-month screening group, and only depression and functioning measures for adults in the 6-month screening group. Data about CYP in the 3-month screening group, demonstrated significant differences between baseline and follow-up scores on trauma, generalised anxiety and separation anxiety.

CONCLUSIONS

These findings suggest people who register earlier are less symptomatic and demonstrate greater improvement across a range of psychological measures. Further longitudinal research is necessary to understand changes over time.

DECLARATION OF INTEREST

None.

What are the long-term consequences of youth exposure to firearm injury, and how do we prevent them? A scoping review

The long-term consequences of exposure to firearm injury-including suicide, assault, and mass shootings-on children's mental and physical health is unknown. Using PRISMA-ScR guidelines, we conducted a scoping review of four databases (PubMed, Scopus, PsychINFO, and CJ abstract) between January 1, 1985 and April 2, 2018 for articles describing long-term outcomes of child or adolescent firearm injury exposure (n = 3582). Among included studies (n = 31), most used retrospective cohorts or cross-sectional studies to describe the correlation between firearm injury and post-traumatic stress. A disproportionate number of studies examined the effect of mass shootings, although few of these studies were conducted in the United States and none described the impact of social media. Despite methodologic limitations, youth firearm injury exposure is clearly linked to high rates of post-traumatic stress symptoms and high rates of future injury. Evidence is lacking on best practices for prevention of mental health and behavioral sequelae among youth exposed to firearm injury. Future research should use rigorous methods to identify prevalence, correlates, and intervention strategies for these at-risk youth.

Prevention of Firearm Injuries Among Children and Adolescents: Consensus-Driven Research Agenda from the Firearm Safety Among Children and Teens (FACTS) Consortium

IMPORTANCE

Firearm injuries are the second leading cause of death among US children and adolescents. Because of the lack of resources allocated to firearm injury prevention during the past 25 years, research has lagged behind other areas of injury prevention. Identifying timely and important research questions regarding firearm injury prevention is a critical step for reducing pediatric mortality.

OBJECTIVE

The Firearm Safety Among Children and Teens (FACTS) Consortium, a National Institute for Child Health and Human Development-funded group of scientists and stakeholders, was formed in 2017 to develop research resources for the field, including a pediatric-specific research agenda for firearm injury prevention to assist future researchers and funders, as well as to inform cross-disciplinary evidence-based research on this critical injury prevention topic.

EVIDENCE REVIEW

A nominal group technique process was used, including 4 key steps (idea generation, round-robin, clarification, and voting and consensus). During idea generation, stakeholders and workgroups generated initial research agenda topics after conducting scoping reviews of the literature to identify existing gaps in knowledge. Agenda topics were refined through 6 rounds of discussion and survey feedback (ie, round-robin, and clarification steps). Final voting (using a 5-point Likert scale) was conducted to achieve consensus (≥70% of consortium ranking items at 4 or 5 priority for inclusion) around key research priorities for the next 5 years of research in this field. Final agenda questions were reviewed by both the stakeholder group and an external panel of research experts not affiliated with the FACTS Consortium. Feedback was integrated and the final set of agenda items was ratified by the entire FACTS Consortium.

FINDINGS

Overall, 26 priority agenda items with examples of specific research questions were identified across 5 major thematic areas, including epidemiology and risk and protective factors, primary prevention, secondary prevention and sequelae, cross-cutting prevention factors, policy, and data enhancement.

CONCLUSIONS AND RELEVANCE

These priority agenda items, when taken together, define a comprehensive pediatric-specific firearm injury prevention research agenda that will guide research resource allocation within this field during the next 5 years.

Chronic pain among the hospitalized patients after the 22 July 2011 terror attacks in Oslo and at Utøya Island

BACKGROUND

On 22 July 2011, 48 people were hospitalized due to physical injuries from gun shots or explosion, following 2 terror attacks in the Oslo area, Norway. In this study, we have investigated the occurrence of chronic pain, the severity and consequences of chronic pain in these patients, 3 to 4 years after the incidents.

METHODS

Totally 43 eligible terror trauma patients were invited to participate in the study, 30 patients were included. They underwent a consultation with a psychologist and a physician; containing psychological assessment, neuropsychological screening, a standardized clinical interview, medical examination, and a pain protocol.

RESULTS

In 18 (60%) the injury was severe, as defined by New Injury Severity Score > 15. Twenty-four patients (80%) reported injury-related chronic pain after the trauma, in 22 with consequences on daily life. Analgesics were used by 20 patients, including 5 in need of opioids. Ten patients had unmet needs of further specialist pain care. In 12 patients, the average pain score last week was above three on a 0-10 Numeric Rating Scale. In these patients, clinical signs of neuropathic pain were evident in 10, as tested by the Douleur Neuropathique score. There were significant correlations (P < 0.05) between severity of chronic pain and presence of post-traumatic stress symptoms, reduced quality of life, reduced psychosocial and physical function; but no correlation with pre-injury patient characteristics or the degree of physical injury.

CONCLUSION

Chronic pain was frequent and significant, irrespective of injury severity, in these patients who obtained their physical injuries under extreme psychological conditions.

[Mass casualty incidents and attacks involving a multitude of children and adolescents-Overview of policy recommendations and challenges]

Fortunately, mass casualty incidents involving a large number of children and adolescents are rare and the experience in this field, both in terms of medical as well as psychosocial emergency care is comparatively low. Children represent a vulnerable group and have a particularly high risk of developing posttraumatic stress disorder in the aftermath of experiencing disasters. A selective literature search was carried out in Medline. The peculiarity of damaging events with a large number of children and adolescents affected is that in addition to emergency medical care, an early approach to psychosocial emergency care must be provided. Accordingly, it makes sense to integrate such structures into the respective deployment concepts. A specific screening algorithm for children could so far not prevail but due to the physiological and anatomical characteristics appropriate emergency medical care concepts should be provided. Furthermore, hospitals must adapt to this patient group in a suitable manner.

Persons injured in the 2011 terror attacks in Norway - Relationship between post-traumatic stress symptoms, emotional distress, fatigue, sleep, and pain outcomes, and medical and psychosocial factors

Purpose: The main aim was to assess long-term post-traumatic stress symptoms, emotional distress, fatigue, sleep disturbances and pain in individuals hospitalized with physical injuries after two terror attacks in Oslo in 2011, approximately three years after the events. A secondary aim was to explore the relationship between these outcomes and medical and psychosocial factors.Materials and methods: Thirty of 43 potential persons participated. Injury characteristics were collected from medical charts. Level of post-traumatic stress, emotional distress, fatigue, sleep disturbances and pain was assessed and the association with injury severity, resilience, optimism, neuroticism and extroversion, and perceived access to social support was explored.Results: Nine of 30 met criteria for full or partial PTSD, and 14 of 30 displayed clinical levels of emotional distress. Fifteen reported moderate to severe fatigue, and 16 said sleep disturbances affected their daily life. Twelve indicated that pain affected daily activities and work ability, and 15 that pain affected their quality of life. I Resilience, optimism, neuroticism, and perceived social support, were associated with outcomes, but injury severity was not. When controlling for pain, many of the psychosocial variables failed to reach significance.Conclusions: Injury severity was not associated with outcomes. On the other hand, psychosocial factors were, but seemed to be influenced by pain.Implications for rehabilitationPersons who have obtained physical injuries under extreme psychological conditions such as terror, are at high risk of poor long-term outcomes, and will often be in need of comprehensive interdisciplinary rehabilitation services.Psychological outcomes are not associated with severity of physical injury, but premorbid and current psychological variables such as resilience, optimism, personality, and access to social support are highly associated with long-term outcome.Longstanding pain seems to diminish or weaken the role of protective psychological factors and should be addressed in the rehabilitation context.

Psychosocial care for hospitalized young survivors after the terror attack on Utøya Island: A qualitative study of the survivors' experiences

OBJECTIVE

The objective of the study was to explore hospitalized youths' experiences with psychosocial care in the hospital after the shooting on Utøya Island, Norway, in 2011.

METHODS

17 hospitalized youths were interviewed face-to-face 30-31 months after the attack. The interviews were analysed using interpretative phenomenological analysis (IPA). The initial reading and coding of the interviews was carried out inductively. To explore the emphasis placed on everyday conversation and ordinary interaction detected during the initial reading, the text was re-read while bearing in mind concepts from the research field of sociology concerning the therapeutic potential in commonplace conversations and situations.

RESULTS

The youths highlighted the need for health care workers to embrace essential aspects of their past, present and future. Therefore, three overarching categories emerged related to 1) Remembering the past, 2) Dealing with the present and 3) Preparing for the future. For each temporal category, two related subcategories were identified: Past:Engaging in the trauma narrative; Understanding the trauma reminders; Present: Bringing back normalcy; Being there; Future: Supporting confidence; Instilling trust.

CONCLUSIONS

For the youths in the current study, talking with the hospital staff about their traumatic experiences was mostly perceived as positive and linked to various helpful outcomes. In addition to engaging in the trauma narrative, the staff needed to comprehend and address how the traumatic experiences and the hospitalization resulted in the survivors' extended fear and changed appraisals about the world and themselves. Having the time to stay physically and mentally close to the youths and engage in everyday interaction was crucial in rebuilding their sense of safety and bringing back normalcy. The hospital staff played a significant role in strengthening the survivors' confidence in own capabilities and trust in others. The different professionals in the hospital contributed to various aspects of psychosocial care, and both trauma-focused interventions and commonplace conversations and actions were emphasized as important and meaningful approaches.

Healthcare to parents of young terrorism survivors: a registry-based study in Norway

OBJECTIVES

To assess changes in parents' short-term and long-term primary and specialised healthcare consumption following a terrorist attack threatening the lives of their children.

DESIGN

Registry-based study comparing parental healthcare service consumption in the 3 years before and the 3 years after a terrorist attack.

SETTING

The aftermath of the Utøya terrorist attack. The regular, publicly funded, universal healthcare system in Norway.

INTERVENTION

Parents learning of a terrorist attack on their adolescent and young adult children.

PARTICIPANTS

Mothers (n=226) and fathers (n=141) of a total of 263 survivors of the Utøya terrorist attack (54.6% of all survivors 13-33 years, n=482).

MAIN OUTCOME MEASURES

We report primary and specialised somatic and mental healthcare service consumption in the early (0-6 months) and delayed (>6-36 months) aftermath of the attack, both in terms of frequency of services consumed (assessed by age-adjusted negative binomial hurdle regression) and proportions of mothers and fathers provided for (mean semiannual values). The predisaster and postdisaster rates were compared by rate ratios (RRs), and 95% CI were generated through bootstrap replications.

RESULTS

Frequency of primary healthcare service consumption increased significantly in both mothers and fathers in the early aftermath of the attack (mothers: RR=1.97, 95% CI 1.76 to 2.23; fathers: RR=1.73, 95% CI 1.36 to 2.29) and remained significantly elevated throughout the delayed aftermath. In the specialised mental healthcare services, a significant increase in the frequency of service consumption was observed in mothers only (early: RR=7.00, 95% CI 3.86 to 19.02; delayed: RR=3.20, 95% CI 1.49 to 9.49). In specialised somatic healthcare, no significant change was found.

CONCLUSION

Following terrorist attacks, healthcare providers must prepare for increased healthcare needs in survivors and their close family members, such as parents. Needs may present shortly after the attack and require long-term follow-up.

Physical Injury and Somatic Complaints: The Mediating Role of Posttraumatic Stress Symptoms in Young Survivors of a Terror Attack

Physically injured trauma survivors have particularly high risk for later somatic complaints and posttraumatic stress symptoms (PTSS). However, the potential mediating role of PTSS linking injury to later somatic complaints has been poorly investigated. In this study, survivors (N = 255) were interviewed longitudinally at 2 timepoints after the terror attack on Utøya Island, Norway, in 2011. Assessments included injury sustained during the attack, PTSS (after 4-5 months), somatic complaints (after 14-15 months), and background factors. Causal mediation analysis was conducted to evaluate the potential mediating role of PTSS in linking injury to somatic complaints comparing 2 groups of injured survivors with noninjured survivors. For the nonhospitalized injured versus the noninjured survivors, the mediated pathway was significant (average causal mediation effect; ACME = 0.09, p = .028, proportion = 55.8%). For the hospitalized versus the noninjured survivors, the mediated pathway was not significant (ACME = 0.04, p = .453, proportion = 11.6%). PTSS may play a significant mediating role in the development of somatic complaints among nonhospitalized injured trauma survivors. Intervening health professionals should be aware of this possible pathway to somatic complaints.

Does posttraumatic stress predict frequency of general practitioner visits in parents of terrorism survivors? A longitudinal study

Background: Life threat to children may induce severe posttraumatic stress reactions (PTSR) in parents. Troubled mothers and fathers may turn to their general practitioner (GP) for help. Objective: This study investigated frequency of GP visits in mothers and fathers of adolescent and young adult terrorism survivors related to their own PTSR and PTSR in their surviving children. Method: Self-reported early PTSR (4-5 months post-disaster) in 196 mothers, 113 fathers and 240 survivors of the 2011 Utøya terrorist attack were linked to parents' three years pre- and post-disaster primary healthcare data from a national reimbursement claims database. Frequency of parents' GP visits was regressed on parent and child PTSR, first separately, then in combination, and finally by including an interaction. Negative binominal regressions, adjusted for parents' pre-disaster GP visits and socio-demography, were performed separately for mothers and fathers and for the early (<6 months) and delayed (6-36 months) aftermath of the terrorist attack. Results: Parents' early PTSR were significantly associated with higher early frequency of GP visits in mothers (rate ratio, RR = 1.31, 95%CI 1.09-1.56) and fathers (RR = 1.40, 95%CI 1.03-1.91). In the delayed aftermath, early PTSR were significantly associated with higher frequency of GP visits in mothers only (RR = 1.21, 95%CI 1.04-1.41). Early PTSR in children were not significantly associated with an overall increase in GP visits. On the contrary, in mothers, child PTSR predicted significant decrease in GP visits the delayed aftermath (RR = 0.83, 95%CI 0.71-0.97). Conclusions: Our study suggests that GPs may play an important role in identifying and providing for parents' post-disaster healthcare needs. GPs need to be aware that distressed individuals are likely to approach them following disasters and must prepare for both short- and long-term healthcare needs.