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

Self-compassion, self-coldness, and social support and their relationship with depression, anxiety, and PTSD symptoms following a massive terror attack: a prospective study

Background: On 7 October 2023, Israel suffered a massive deadly terror attack with 1400 civilians murdered and 240 kidnapped. Recent studies have documented an increase in depression, anxiety, and posttraumatic symptoms in the aftermath of the attack. In the area of trauma, it has been shown that while some individuals are vulnerable to developing psychopathology following exposure to a traumatic event, the majority are not.Objective: In the present prospective study, we examined the contributions of internal (self-compassion and self-coldness) and external (social support) resources to depression, anxiety, and posttraumatic symptoms among civilians following a massive terror attack.Method: A total of 250 participants - 126 females (50.4%) and 124 males (49.6%); 156 Jews (62.4%) and 94 Arabs (37.6%) - aged 21-60 (M  = 41.7, SD = 10.63) completed questionnaires at two time points: T1 was in September 2023 (3-4 weeks before the attack) and T2 was in February-March 2024 (19-20 weeks after the attack). Participants were assessed using the Multidimensional Scale of Perceived Social Support (MSPSS), Self-Compassion Scale - Short Form (SCS-SF), Depression, Anxiety, and Stress Scale-21 Items (DASS-21), and International Trauma Questionnaire (ITQ).Results: Self-compassion and social support were negatively associated with depression and anxiety, while self-coldness was positively associated with depression and anxiety. In addition, self-coldness uniquely contributed to the prediction of psychopathological outcomes, including the sense of threat symptoms cluster of posttraumatic stress disorder, beyond known risk factors.Conclusions: Our study highlights the role of self-coldness as a vulnerability factor for civilians following a terror attack. It is important to view the distinct facets of self-compassion as a therapeutic target when building both intervention and prevention programs for people exposed directly and indirectly to trauma.

Psychopathology in Dutch women with terrorist behaviours: empirical case series study

BACKGROUND

Current empirical understanding of the relationship between psychopathology and terrorist behaviours in women is limited, because most research focuses on male perpetrators and relies on secondary sources. Addressing this gap is crucial, particularly given previous research that highlights significant differences in mental health problems between women and men involved in non-terrorist violent activities.

AIMS

To empirically examine the presence of psychopathology in women exhibiting terrorist behaviours, as well as its potential role in these behaviours.

METHOD

A case series study of 14 Dutch female convicts associated with the (so-called) Islamic State of Iraq and Syria (ISIS), examining the occurrence and types of mental disorders, psychopathological problems and pathological personality traits, and exploring their potential role in terrorist behaviours based on forensic mental health reports from psychiatrists and psychologists.

RESULTS

Half of the women (n = 7) exhibited mental disorders during terrorist activities, primarily personality disorders. Psychopathological problems included susceptibility to influence (71%, n = 10), identity problems (64%, n = 9), feelings of inferiority (57%, n = 8) and naivety (50%, n = 7). A significant link between terrorism and mental disorders, psychopathological problems or pathological personality traits was identified in almost half of the women (43%, n = 6).

CONCLUSIONS

Psychopathology is present in some women involved in terrorist behaviours, influencing their involvement, but is absent or irrelevant in others. Identifying psychopathology in women with terrorist tendencies is essential for early prevention and should be a core competency for psychiatrists.

Have Coping Resources and Trust in State Institutions Helped Jews and Arabs to Overcome Stress During the Iron Swords War?

The events of 7 October 2023 and the subsequent Iron Swords War have profoundly impacted Israeli society, leaving both Jewish and Arab populations exposed to unprecedented levels of violence and uncertainty. This study examined the roles of trust in state institutions and a sense of coherence (SOC) as coping resources that may mitigate psychological distress following exposure to such events. Four hundred and seventy-one participants (69.9% Jewish, 30.1% Arab) filled out a questionnaire that addressed the demographics, war exposure, trust in institutions, SOC, and mental-health outcomes. The Jewish participants reported greater exposure to war events, a stronger SOC, and less psychological distress than the Arab participants. Levels of trust in different institutions varied significantly between the groups, with Jews expressing greater trust in the military and Arabs reporting higher levels of trust in the parliament, educational system, and media. SOC protected against psychological distress among both groups. Trust in the military was associated with lower levels of distress among Jews, whereas trust in the parliament was linked to higher levels of distress among Arabs. This study highlights the need for tailored interventions that enhance the SOC and address disparities in institutional trust, to foster resilience among different sociocultural groups.

The effects of war-related experiences on mental health symptoms of individuals living in conflict zones: a longitudinal study

On October 7, 2023, a large-scale attack in southern Israel and the subsequent war resulted in extensive loss of life and injuries, with many individuals experiencing traumatic losses, such as family members or close friends being killed or kidnapped. This study aims to longitudinally examine its effects on mental health, specifically, clinical symptoms of anxiety, depression, and posttraumatic stress disorder (PTSD). We anticipated greater symptom severity among individuals who experienced traumatic loss, were forcibly displaced, or suffered income loss, as well as among women and members of ethnic minorities. This three-wave online survey study assessed mental health symptoms in a sample of 1052 individuals, aged 18-40, residing in conflict zones in Israel from February 2024 (day 1), through March 2024 (day 30), to May 2024 (day 90). Symptoms of anxiety, depression, and PTSD were measured using the Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), and Primary Care PTSD Screen (PC-PTSD). Individuals experiencing traumatic losses, forced displacement, or economic hardships, as well as females, consistently demonstrated higher rates of anxiety, depression, and PTSD symptoms compared to those without such experiences or to males, across all time points (F values ranged from 17.7 to 215.3, p < .001). For ethnic minorities (Arab and other), as compared to Jewish, anxiety and depression symptoms were higher at every time point (F = 8.3-97.1, p = .004 to < .001). This study highlights the urgent need for targeted mental health interventions in conflict zones, particularly for affected individuals. Further research should expand these findings to broader populations.

Subclinical imaging activity in multiple sclerosis patients during war-related psychological stress

OBJECTIVES

Psychological stress has been suggested as a contributory factor in the onset and progression of multiple sclerosis (MS). The 7 October 2023 terrorist attacks in Israel caused significant psychological stress, providing a unique context to study its impact on MS activity. This study aims to assess the impact of war-related psychological stress on MS activity using magnetic resonance imaging (MRI) scans and clinical follow-up.

METHODS

This observational retrospective case-control study includes 93 patients with MS (pwMS) who had routine annual MRI scans from three periods (7 October 2021 to 7 January 2022; 7 October 2022 to 7 January 2023; and 7 October 2023 to 7 January 2024). Data were collected from medical records and MRI scans at Hadassah Medical Center. MRI scans were classified as active if new or enlarging T2 lesions and/or enhancing T1 lesions were present.

RESULTS

MRI activity significantly increased among pwMS during the first 3 months of the war compared to the corresponding period in the preceding year (11/93 vs. 23/93, P = 0.0139), with an OR of 4.0 (95% confidence interval: 1.29-16.442). pwMS with an EDSS score ≥4 showed a significant increase in MRI activity (P = 0.045), whereas no significant increase was observed in patients with an EDSS score ≤3.5 (P = 0.23). Additionally, MRI activity increased later during the war compared to the previous year (P < 0.0001).

INTERPRETATION

This study provides evidence of increased MRI-detected disease activity in pwMS during periods of war-related psychological stress. Our findings highlight the importance of considering psychological stress in MS management. Healthcare providers should be aware of the potential for increased disease activity in pwMS during extreme stress and may consider more frequent monitoring, including MRI scans, or treatment adjustments during such periods.

Brief video intervention to increase treatment-seeking among individuals living in a conflict zone: A randomized controlled trial

BACKGROUND

On October 7, 2023, a large-scale attack in Southern Israel and the ensuing war led to widespread casualties and the displacement of hundreds of thousands in Southern and Northern Israel. The conflict has exacerbated mental health issues. This randomized controlled trial assessed a brief social-contact-based video intervention on a large sample of individuals living in conflict zones, aiming to examine its effects on increasing treatment-seeking intentions. As a secondary aim, we tested changes in treatment-seeking behavior.

METHODS

Participants (N = 1,052), civilians in conflict zones in Israel, were randomized into either a brief video-based or a psychoeducational control intervention. The 2.5-minute video featured the personal story of a terrorist attack survivor sharing his traumatic experiences and subsequent mental health struggles. Treatment-seeking intentions were assessed at baseline, immediately post-intervention, and at a 30-day follow-up. Treatment-seeking behavior was assessed at the 30- and 90-day follow-ups.

RESULTS

The brief video intervention elicited an immediate increase in treatment-seeking intentions. A significant group-by-time interaction emerged (χ²=10.5, df=2, p=.005; Cohen's d = 0.36), particularly among male viewers (p<.001; d = 0.47). However, these effects were not sustained 30 days after the initial viewing. We found no effect on treatment-seeking behavior.

CONCLUSIONS

This trial confirms the efficacy of a single brief social-contact-based video intervention in increasing treatment-seeking intentions, among those in conflict-affected areas. Although the impact was brief, this accessible intervention underscores its potential as a strategy to facilitate treatment-seeking intentions.

Digital Platform for Pediatric Mental Health Support During Armed Conflicts: Development and Usability Study

Background

The prevalence of mental health disorders among children and adolescents presents a significant public health challenge. Children exposed to armed conflicts are at a particularly high risk of developing mental health problems, necessitating prompt and robust intervention. The acute need for early intervention in these situations is well recognized, as timely support can mitigate long-term negative outcomes. Pediatricians are particularly suited to deliver such interventions due to their role as primary health care providers and their frequent contact with children and families. However, barriers such as limited training and resources often hinder their ability to effectively address these issues.

objectives

This study aimed to describe the rapid development of a digital mental health tool for community pediatricians, created in response to the urgent need for accessible resources following the October 7th terror attack in Israel. The goal was to create a comprehensive resource that addresses a wide range of emotional and behavioral challenges in children and adolescents, with a particular focus on those affected by armed conflict and significant trauma exposure. In addition, the study aimed to evaluate the platform's usability and relevance through feedback from primary users, thereby assessing its potential for implementation in pediatric practice.

Methods

A digital platform was developed using a collaborative approach that involved pediatricians and mental health professionals from various hospital clinics. The initial framework for the modules was drafted based on key emotional and behavioral issues identified through prior research. Following this, the detailed content of each module was cocreated with input from specialized mental health clinics within the hospital, ensuring comprehensive and practical guidance for community pediatricians. A focus group of 7 primary users, selected for their relevant hospital and community roles, provided feedback on the platform's user experience, content relevance, and layout. The evaluation was conducted using a structured questionnaire complemented by qualitative comments.

Results

Fifteen detailed modules were created, each providing information, including anamnesis, initial intervention strategies, parental guidance, and referral options. The focus group feedback demonstrated high satisfaction, indicating a very good user experience (mean 4.57, SD 0.53), content relevance (mean 4.71, SD 0.48), and layout suitability (mean 4.66, SD 0.52). Specific feedback highlighted the value of concise, actionable content and the inclusion of medication information. Participants expressed a strong willingness to regularly use the platform in their practice (mean 4.40, SD 0.53), suggesting its potential for broad application.

Conclusions

This study demonstrates the effectiveness of a collaborative development process in creating a digital tool that addresses the mental health needs of children in crisis situations. The positive feedback from pediatricians indicated that the platform has the potential to become a valuable resource for early recognition, crisis intervention, and parental support in community pediatric settings. Future research will focus on broader implementation and assessing the platform's impact on clinical outcomes.

Collective ambiguous loss after mass hostage-taking in war: exploring public mental health outcomes and resilience

Objective: Collective ambiguous loss can arise in communities facing the unresolved absence or presence of loved ones, marked by uncertainty and confusion. This study examines the impact of such loss on the general public in Israel after 251 individuals were taken hostage by Hamas on October 7 2023.Method: A diverse sample of 740 participants (ages 18-85, 58.2% women) took part in a comprehensive survey from December 2023 to January 2024. The survey measured boundary ambiguity (BA), separation distress related to disappearance (Ambiguous Loss Inventory Plus - ALI + - SD), general psychological distress (Mini-DASS), and personal resilience factors: ambiguity tolerance (Need for Closure Scale-Revised, NCSR) and psychological flexibility (PF).Results: Public stances indicated that 85% of respondents had moderate to very low confidence in the hostages' return, coupled with high endorsement of psychological engagement indicators such as emotional pain, intrusive thoughts, and survivor guilt. Those acquainted with a hostage (12%) showed no differences in stances or ALI + -SD and Mini-DASS levels, except for higher BA and greater engagement in demonstrations activities for their return. SEM analysis showed that ALI + -SD mediated the relationship between BA and Mini-DASS (high BA related to high general distress). In this model, BA and ALI + -SD explained over half of the variation in general psychological distress (R2 = 53%). A second model revealed serial mediation by BA and ALI + -SD in the relationship between NCSR and Mini-DASS, with lower ambiguity tolerance related to increased general distress. However, no such mediation was observed in the relationship between PF and Mini-DASS, and overall, the effect of personal resilience on general distress was relatively small.Conclusions: Mass hostage-taking substantially impacts society's mental health, extending beyond personal acquaintance with a hostage. The findings underscore the need to shift focus from personal resilience to community-based policies and therapeutic approaches to effectively address communal ambiguous loss amid collective trauma.

Comorbidity of problematic substance use and other addictive behaviors and anxiety, depression, and post-traumatic stress disorder: a network analysis

BACKGROUND

Among those with common mental health disorders (e.g. mood, anxiety, and stress disorders), comorbidity of substance and other addictive disorders is prevalent. To simplify the seemingly complex relationships underlying such comorbidity, methods that include multiple measures to distill which specific addictions are uniquely associated with specific mental health disorders rather than due to the co-occurrence of other related addictions or mental health disorders can be used.

METHODS

In a general population sample of Jewish adults in Israel (N = 4002), network analysis methods were used to create partial correlation networks of continuous measures of problematic substance (non-medical use of alcohol, tobacco, cannabis, and prescription sedatives, stimulants, and opioid painkillers) and behavioral (gambling, electronic gaming, sexual behavior, pornography, internet, social media, and smartphone) addictions and common mental health problems (depression, anxiety, and post-traumatic stress disorder [PTSD]), adjusted for all variables in the model.

RESULTS

Strongest associations were observed within these clusters: (1) PTSD, anxiety, and depression; (2) problematic substance use and gambling; (3) technology-based addictive behaviors; and (4) problematic sexual behavior and pornography. In terms of comorbidity, the strongest unique associations were observed for PTSD and problematic technology-based behaviors (social media, smartphone), and sedatives and stimulants use; depression and problematic technology-based behaviors (gaming, internet) and sedatives and cannabis use; and anxiety and problematic smartphone use.

CONCLUSIONS

Network analysis isolated unique relationships underlying the observed comorbidity between common mental health problems and addictions, such as associations between mental health problems and technology-based behaviors, which is informative for more focused interventions.

Factors associated with mental health outcomes in a Muslim community following the Christchurch terrorist attack

BACKGROUND

On 15 March 2019, a white supremacist terrorist attacked two mosques in Christchurch, New Zealand. Fifty-one people were killed and another 40 sustained non-fatal gunshot injuries.

AIMS

To examine the mental health of the Muslim community, and individual and exposure-related factors associated with mental health outcomes.

METHOD

This is the baseline analysis of a longitudinal study of adults from the Muslim community interviewed 11-32 months after the shootings. It included a diagnostic interview (MINI), measures of sociodemographic factors, prior mental health, prior traumatic events, exposure in the attacks, discrimination, life stressors, social support and religious coping. Logistic regression models examined associations with mental health outcomes.

RESULTS

The sample comprised 189 participants (mean age 41 (s.d. = 13); 60% female), and included: bereaved, 17% (n = 32); injured survivors 12% (n = 22); non-injured survivors, 19% (n = 36); family members of survivors, 35% (n = 67); and community members without the above exposures, 39% (n = 74). Overall, 61% had at least one mental disorder since the attacks. Those bereaved (P < 0.01, odds ratio 4.28, 95% CI 1.75-10.49) and survivors, whether injured (P < 0.001, odds ratio 18.08, 95% CI 4.70-69.60) or not (P < 0.01, odds ratio 5.26, 95% CI 1.99-13.89), had greater odds of post-traumatic stress disorder. Those bereaved (P < 0.001, odds ratio 5.79, 95% CI 2.49-13.46) or injured (P = 0.04, odds ratio 4.43, 95% CI 1.07-18.28) had greater odds of depression.

CONCLUSIONS

Despite unique features of this attack on a Muslim population, findings accord with previous studies. They suggest generalisability of psychopathology after terror attacks, and that being bereaved or directly experiencing such events is associated with adverse mental health outcomes.

TRIAL REGISTRATION NUMBER

The study is registered on the Australian NZ Clinical Trials Registry (ACTRN12620000909921).

The impact of potentially morally injurious experience of betrayal on PTSD and depression following the October 7th terror attack

With about 1200 individuals murdered, the massacre of October 7th was one of the deadliest terrorist attacks in modern history. The mental health consequences of terrorist attacks have been documented. However, little is known of the impact of the potentially morally injurious experience (PMIE) of betrayal--in which individuals feel betrayed by leaders they once trusted--on levels of psychological burden in the aftermath of such an attack. In this national prospective cohort study, we examined to what extent the PMIE of betrayal exacerbates the risk for posttraumatic stress disorder (PTSD) and depression in the wake of the October 7th terrorist attack. A representative sample of 710 Israeli adults (362 female, 51.1%), Jews (557, 79.9%) and Arabs (153, 20.1%), aged 18-85 (M = 41.01, SD = 13.72) completed validated self-report questionnaires assessing PTSD, depression, and PMIE-betrayal at two timepoints: T1, in August 2023 (6-7 weeks before the attack) and T2, in November 2023 (5-6 weeks after the attack). In two hierarchical logistic regressions, we found that experience of PMIE-betrayal predicted diagnoses of both PTSD (OR 1.92, 95% CI 1.26-2.92) and depression (OR 2.03, 95% CI 1.37-3.01) at T2, beyond probable PTSD/depression at T1 and demographic and trauma-related variables. Moreover, in two repeated-measure analyses predicting PTSD/depression symptoms, we found significant interactions between PTSD/depression trajectories and PMIE-betrayal, meaning that the increase of PTSD/depression symptoms was significantly higher among participants experiencing betrayal in the context of the attack. Our study highlights the impact of PMIE of betrayal on the dramatic increase in psychopathology following the October 7th terror attack on Israel's population. Clinicians treating individuals coping with PTSD and depression should attend to their patients' possible exposure to betrayal following the attack. Moreover, national leaders and policymakers should take significant steps to repair the public's betrayal experience.

Terror catastrophizing: association with anxiety, depression, and transgenerational effects

Background & Objectives: Terror catastrophizing, defined as an ongoing fear of future terrorist attacks, is associated with a higher incidence of anxiety disorders, among other psychological impacts. However, previous studies examining terror catastrophizing's relationship to other mental health disorders are limited. The current study sought to determine if patients diagnosed with anxiety and depression would experience increased terror catastrophizing. Additionally, this study aimed to investigate whether parental terror catastrophizing increases children's internalizing symptoms.Design & Methods: Individuals were randomly drawn from the Danish Civil Registration System and invited to complete a series of questionnaires to measure terror catastrophizing tendency, lifetime parental trauma, and children's internalizing symptoms. In total, n = 4,175 invitees completed the survey of which 933 reported on a child between 6 and 18 years. Responses were analyzed using a generalized linear regression model.Results: Participants diagnosed with anxiety alone or comorbid with depression were more likely to experience symptoms of terror catastrophizing than undiagnosed participants (β = 0.10, p < .001; β = 0.07, p = .012). Furthermore, the parental tendency to catastrophize terror was associated with higher internalizing symptoms in children (β = 0.09, p = .006), even after taking parental diagnoses, as well as lifetime and childhood trauma into account.Conclusion: The results can inform clinical practices to account for a patient's potential to exhibit increased terror catastrophizing tendencies or be more affected by traumatic events. Additionally, they can offer insights for designing novel preventative interventions for the whole family, due to the relation between parental tendencies for terror catastrophizing and the internalizing symptoms observed in children.

Reported Increase in Substance Use Following Mass Terrorism and the Role of Psychosocial Factors

Importance

Research has shown evidence of increased substance use (ISU) in populations affected by mass terrorism; however, less is known regarding how psychosocial factors interact to estimate ISU following such events.

Objective

To examine which factors are associated with reporting ISU, test whether psychological distress (PD) mediated the association between exposure to trauma and reporting ISU, and whether the mediation effect differed among those with prior mental health (MH) difficulties and those without.

Design, Setting, and Participants

A partially representative cross-sectional survey of the adult Jewish population in Israel (aged 18-70 years) was conducted 4 weeks after October 7, 2023 (October 31 to November 5, 2023). A national Web panel using quotas based on national distributions was used. Randomly chosen adult Jewish members were invited to participate until a predetermined sample size was reached.

Main Outcomes and Measures

The study measures included reporting ISU (outcome), PD (mediator), exposure to terror events and sociodemographic characteristics (variables), and prior MH difficulties (moderator). Hypotheses regarding outcome and variables were formulated before data collection.

Results

A total of 7000 invitations were distributed, 2679 individuals consented, 1432 were excluded owing to quota limits, 74 failed attention tests, and 205 opted out, resulting in 968 participants (490 women [50.6%]; mean [SD] age, 41.5 [14.6] years). Hierarchical regression analysis revealed that participants were significantly more likely to report ISU if they had experienced direct exposure (odds ratio [OR], 5.75; 95% CI, 2.53 to 13.05), indirect exposure (OR, 1.84; 95% CI, 1.27 to 2.67), media exposure (OR, 1.22; 95% CI, 1.09 to 1.36), PD (OR, 1.80; 95% CI, 1.44 to 2.25), or previous MH difficulties (OR, 2.76; 95% CI, 1.86 to 4.09). PD partially mediated the association between indirect exposure (b = 0.20; 95% CI, 0.11 to 0.31) and media exposure (b = 0.14; 95% CI, 0.10 to 0.19) and reporting ISU. No evidence was found to support previous MH difficulties as a moderator of these indirect effects (indirect exposure, b = -0.003; 95% CI, -0.28 to 0.28; media exposure, b = 0.01; 95% CI, -0.06 to 0.08).

Conclusions and Relevance

This study contributes to the research on the association of mass terrorism with ISU while shedding important light on the role it may play in the self-medication of PD following exposure, even in those who might have no previous MH difficulties. These insights are crucial for planning essential health services and preventive measures.

The moderating role of belongingness in the contribution of depression to suicide ideation following the October 7, 2023, terrorist attack in Israel: A nationwide prospective study

INTRODUCTION

With >1300 civilians murdered, the terrorist attack of October 7 is one of the deadliest terrorist attacks in modern history. Previous research documented a sharp increase in depression in the aftermath of the attacks and the military conflict that followed. In this national prospective cohort study, we examined to what extent perceived belongingness (PB) moderates the association between depression and suicide ideation (SI) in the wake of the October 7th terrorist attack.

METHODS

A representative sample of 710 Israeli adults (of them, 362 females, 51.1 %), Jews (557, 79.9 %), and Arabs (153, 20.1 %), aged 18-85 (M = 41.01, SD = 13.72) completed questionnaires assessing depression, current SI, and perceived belongingness at two timepoints: T1 (in August 2023) and T2 (in November 2023).

RESULTS

Perceived belongingness at T1 predicted SI at T2 beyond demographic and trauma-related characteristics. Importantly, we found a significant interaction in which a PB at T1 moderated the link between depression and current SI at T2. Specifically, the level of depression at T2 contributed to current SI-T2 more strongly for individuals with low PB levels than for individuals with high PB levels.

DISCUSSION

Our study highlights the impact of PB on SI following the October 7th terrorist attack. Clinicians treating individuals coping with depression should attend to their patients' sense of belongingness, as low PB comprises a significant risk factor for current SI. Moreover, community and national initiatives that could increase levels of PB among the citizens may help to diminish suicide risk in the aftermath of the attack.

The mental health impact of the October 7th terror attack on Jews and Arabs in Israel: A nationwide prospective study

INTRODUCTION

On October 7, 2023, Israeli citizens came under an unprecedented terrorist attack that impacted the entire country. Recent research has begun to document the mental health impact of the attack but has yet to address the question of whether the attack had a differential impact across ethnic communities. In this nationwide prospective cohort study, we aimed to determine possible differences in psychopathology between Jews and Arabs in the post-October 7th attack. Specifically, we aimed to understand the role ethnicity may play in changes in probable PTSD, depression, and anxiety diagnoses from pre- to post-attack.

METHODS

The sample comprised 656 participants (332 female, 50.7%) aged 18-85 (M = 41.01, SD = 13.72). Of this cohort, 557 participants (84.9%) were Jews, and 99 (15.1%) were Arabs, reflecting their national proportionality. Validated self-report questionnaires were completed to assess PTSD, depression, and anxiety at two time points: August 20 to 30th, 2023 (T1; 6-7 weeks before the attack) and November 9-19, 2023 (T2; 5-6 weeks after the attack).

RESULTS

At T2, Arab Israeli participants reported significantly higher prevalences of probable PTSD, depression, and anxiety diagnoses than Jewish Israeli participants. A series of hierarchical logistic regressions revealed that, compared with Jews, Arab participants presented with higher prevalence of probable PTSD (OR = 2.53 95% CI = 1.46-4.37, p < 0.0001), depression (OR = 1.68 95% CI = 1.35-3.01, p < 0.0001) and anxiety (OR = 6.42 95% CI = 3.95-10.52, p < 0.0001), controlling for prevalences of probable diagnoses at T1 as well as for trauma-related variables.

DISCUSSION

Citizens belonging to the Arab ethnic minority in Israel were found to be at higher risk for psychopathology in the aftermath of the October 7, 2023, terrorist attack compared with their Jewish majority counterparts. Thus, it becomes critical to employ culturally sensitive assessments and interventions following the attack to prevent the development of chronic symptoms and disorders.

Differences in predictive factors for post-traumatic stress disorder encompassing partial PTSD and full PTSD: a cross-sectional study among individuals exposed to the November 13, 2015 Paris attacks

Background

When faced with a surge of physically injured individuals, especially following a traumatic event like an attack, frontline practitioners prioritize early triage. Detecting potential psychological injuries soon after such events remains challenging. Some individuals might develop post-traumatic stress disorder (PTSD) according to DSM-V criteria. Others may exhibit PTSD symptoms without meeting full diagnostic criteria, termed partial or sub-syndromal PTSD, a less-explored area in literature. This study aims to identify predictive factors for both full and partial PTSD.

Method

In a cohort of victims of the 2015 Paris attacks, multinomial logistic regressions explored predictive factors for partial or full PTSD status 8 to 18 months post-attacks. Analyses considered pre, peri, and posttraumatic factors chosen from literature review and univariate analysis within each group.

Results

Within the cohort, 50 individuals showed no signs of PTSD, 35 experienced partial PTSD, and 30 presented with full PTSD. After logistic regression, risk factors associated with full PTSD included a history of trauma (OR = 1.30, CI [1.02-1.66], p < 0.05), the intensity of peri-traumatic physical reactions (OR = 1.22, CI [1.09-1.36], p < 0.001), the difficulties in suppressing intrusive thoughts (OR = 1.11, CI [1.02-1.21], p < 0.013). Only the intensity of peri-traumatic physical reactions emerged as a risk factor for partial PTSD (OR = 1.13, [CI 1.02-1.24], p < 0.001).

Discussion

This study revealed that a history of trauma, the intensity of peri-traumatic physical reactions (e.g., tachycardia, trembling, flushes, numbness.), and the difficulties in suppressing intrusive thoughts constitute risk factors for the development of full PTSD. Moreover, the study identified that only the intensity of peri-traumatic physical reactions emerged as a risk factor for partial PTSD. These findings seem to underscore the significance of peri-traumatic experiences in influencing the development of post-traumatic stress symptoms.

Conclusion

This study emphasizes the significance of examining peri-traumatic reactions in PTSD development, suggesting its potential as a straightforward screening tool for post-traumatic stress disorder. It also underscores the influence of prior traumatic experiences, before de novo traumatization, in shaping vulnerability to PTSD and illuminates the crucial role of compromised control of intrusive thoughts that could perpetuate PTSD.

The psychosocial aid response after the 22/03/2016 attacks in Belgium: a community case study

Introduction

After the terrorist attacks, early psychosocial care is provided to people considered at risk of developing mental health issues due to the attacks. Despite the clear importance of such early intervention, there is very few data on how this is registered, who is targeted, and whether target-recipients accept such aid.

Methods

Using registry data from the Centre General Wellbeingwork (CAW), a collection of centers in the regions Brussels and Flanders that provide psychosocial care, we examined the early psychosocial care response after the terrorist attacks of 22/03/2016 in Belgium.

Results

In total, 327 people were listed to be contacted by the CAW, while only 205 were reached out to (62.7%). Most were contacted within a month (84.9%), and were victims of the attacks (69.8%). Overall, the majority was female (55.6%).

Conclusion

Overall, target recipients were witnesses and survivors of the attacks, though a large proportion of people were not reached by the early outreach.

PTSD, depression, and anxiety after the October 7, 2023 attack in Israel: a nationwide prospective study

Background

The magnitude of the Oct 7, 2023 attack in southern Israel was without precedent. More than 1300 civilians were murdered, and 240 civilians were kidnapped and taken hostage. In this national cohort study, for which baseline outcome data were established before the attacks, a prospective assessment of posttraumatic stress disorder (PTSD), depression, and generalized anxiety disorder (GAD) was conducted one month after the attack.

Methods

A representative sample of 710 Israeli adults (362 female, 51.1%), Jews (557, 79.9%) and Arabs (153, 20.1%), aged 18-85 years (mean = 41.01, SD = 13.72) completed the study at two timepoints: T1, on Aug 20-30, 2023 (6-7 weeks before the attack) and T2, on Nov 9-19, 2023 (5-6 weeks after the attack). 30 (4.2%) of the 710 participants had direct exposure to the attack, and 131 (18.5%) had loved ones who were murdered, kidnapped, or injured during the attack.

Findings

Probable PTSD prevalence almost doubled from 16.2% at T1 to 29.8% at T2 (p < 0.0001), with the prevalence of probable GAD and depression also increasing from 24.9% at T1 to 42.7% at T2, and from 31.3% at T1 to 44.8% at T2, respectively. Direct exposure to the attack was found to contribute to probable PTSD (OR = 3.15, 95% CI = 1.48-6.65) and probable depression (OR = 2.18, 95% CI = 1.02-4.87) at T2.

Interpretation

Our study suggests a broad and significant impact of the Oct 7, 2023 attack on the mental health of the Israeli population. The findings underscore the need to provide rapid, nationwide assessments and triage for interventions to address the mental health needs of Jewish and Arab citizens.

Funding

Not applicable.

Prevalence of increased alcohol use and alcohol use disorders in adult victims of terrorist attacks: a systematic and meta-analytic review

Background: Previous studies have reviewed the evidence on the increase in alcohol consumption after a terrorist attack. However, an increase does not necessarily imply the presence of an alcohol use disorder.Objectives: To conduct a systematic and meta-analytic review of the literature on the prevalence of increased alcohol consumption and alcohol use disorders in adult exposed to terrorism.Methods: A search of PsycINFO, MEDLINE and PTSDpubs identified 29 studies published up to March 2023 in which 38 adult samples totaling 282,753 persons exposed to terrorism were assessed. Using inverse variance heterogeneity models, pooled prevalence rates of increased alcohol use and alcohol use disorders were calculated.Results: 6% (95% CI [2.9, 9.5]) of the adults exposed to a terrorist attack increased their alcohol consumption. The prevalence of increased alcohol use varied depending on the degree of exposure (p = .006, R2 = .18) and the procedure for measuring increases (p = .043, R2 = .37). The prevalence of alcohol use disorders in adults exposed to a terrorist attack was 5.5% (95% CI [3.7, 7.5]), a rate that was not higher than that obtained in the general population and varied depending on the type of alcohol disorder (p = .015, R2 = .30).Conclusions: A relevant number of adults exposed to terrorist attacks will subsequently increase their alcohol consumption, but this increase is not associated with an increase in the prevalence of alcohol use disorders. Effects of terrorism on people's health are potentially widespread, but concerns of excessive alcohol use after terrorist attacks may be unwarranted.

Evolution of Anxiety Disorder Prevalence and Associated Factors in First Responders in Both the Medium and Long Terms after the January 2015 Terrorist Attacks in France

First responders intervening in crisis situations are likely to subsequently develop mental disorders. We aimed to identify factors associated with anxiety disorders after a terrorist attack in both the medium and long terms. We used data collected on 180 first responders (medical/psychological health professionals and emergency rescue teams) interviewed face to face at 6-10 months (medium term) and 18-22 months (long term) after the January 2015 terrorist attacks in France. Anxiety disorders were measured using the Mini-International Neuropsychiatric Interview V6 and several other variables including terror exposure (comprising perceived level of exposure and real exposure level), sociodemographic characteristics, social support, mental health history, and access to psychological support resources. We developed a structural equation model to examine the interactions between these different factors. Postattack anxiety disorder prevalence in the medium and long terms was 16% and 14%, respectively. The main associated factors in the medium term were barriers to social support, perceived level of exposure, and a lack of psychological support resources. In the long term, the presence of anxiety disorders in the medium term and barriers to social support were directly associated with having anxiety disorders, while reexposure was indirectly associated. Barriers to social support played a crucial role in the prevalence of anxiety disorders in first responders following this traumatic event, both in the medium and long terms. Promoting stronger social cohesion and providing more psychological support resources following a disaster could help prevent anxiety disorders in this population.

PTSD and Partial PTSD among First Responders One and Five Years after the Paris Terror Attacks in November 2015

Following the Paris terror attacks in November 2015, a large number of first responders (FR) were mobilized and consequently were at risk of developing posttraumatic stress disorder (PTSD). Based on the ESPA 13 November survey, the objectives of this study were to 1) describe the prevalence of PTSD and partial PTSD in FR five years after the attacks, 2) describe the changes in PTSD and partial PTSD from one to five years after the attacks, and 3) examine factors associated with PTSD and partial PTSD five years after the attacks. Data were collected using an online questionnaire. PTSD and partial PTSD were measured using the Post-Traumatic Stress Disorder Checklist based on the DSM-5 (PCL-5). Gender, age, responder category, education level, exposure, mental health history, history of traumatic events, training, social support, concern about the COVID-19 epidemic, and somatic problems present after the attacks were all analyzed as potential factors associated with PTSD and partial PTSD using multinomial logistic regression. A total of 428 FR were included 5 years after the attacks, of which 258 had participated also 1 year after the attacks. Five years after the attacks, the prevalence of PTSD and partial PTSD were 8.6% and 22%, respectively. Presence of somatic problems after the attacks were associated with PTSD. Involvement in dangerous crime scenes was associated with a higher risk of partial PTSD. No awareness of psychological risks in the context of professional activity through specific training was associated with partial PTSD, in particular among participants aged 45 years or more. To mitigate PTSD for FR, monitoring mental health symptoms, providing mental health education, and providing treatment may be needed for several years after the attacks.

Threat through the Screen? Association between Proximity and/or Watching Media Coverage of a Terrorist Attack and Health

INTRODUCTION

After terrorist attacks, media coverage of the attacks is extensive. There are some indications that there is an association between watching the media coverage and certain health reactions, both mental and somatic. Most studies occur in the United States and often months after the initial attack. In the current study, we investigated the terrorist attacks in Belgium on 22 March 2016.

METHODS

An online cross-sectional survey was conducted one week after the attacks among the general population of Belgium. We measured hours of media watching of the terrorist attacks (hereafter media watching), adjusted scales of the Patient Health Questionaire-4 (PHQ-4) to measure mental symptoms and the Patient Health Questionaire-15 (PHQ-15) to measure somatic symptoms, proximity to Brussels (home, work and overall proximity) and background factors such as gender, age and level of education. Respondents were included if they answered the survey between 29 March 2016 and 5 April 2016.

RESULTS

A total of 2972 respondents were included. Overall, media watching was significantly associated with both mental symptoms (p < 0.001) and somatic symptoms (p < 0.001), while controlling for age, gender, level of education and proximity. Watching more than three hours of media was associated with more mental and somatic symptoms (p < 0.001). Compared to proximity, media watching was, in general, a better association. For geographical factors, watching more than three hours of media indicated equally high scores for mental symptoms and somatic symptoms as work proximity (p = 0.015) and overall proximity to the attacks (p = 0.024).

CONCLUSION

Media-watching is associated with acute health reactions after terrorist attacks. However, the direction of the relationship is unclear, as it might also be that people with health issues seek out more media.

The impact of a terrorist attack: Survivors' health, functioning and need for support following the 2019 Utrecht tram shooting 6 and 18 months post-attack

Background

Extremely violent events such as terrorist attacks and mass shootings form a severe risk for the health and wellbeing of affected individuals. In this study based on a public health monitor, we focus on the health impact (including PTSD symptoms, physical problems and day-to-day functioning) of the Utrecht tram shooting, which took place in the morning of March 18th 2019. A lone gunman opened fire on passengers within a moving tram. Four people died, and six people were injured in this attack. The attack resulted in nationwide commotion and drew much media attention. Aim of this study was to increase insight into the health effects for the survivors (those directly impacted by a terrorist attack and the bereaved), and whether they received the needed care and support.

Methods

Semi-structured interviews with accompanying questionnaires were conducted at six and 18 months post-attack. Overall, 21 survivors (victims/witnesses and loved ones of deceased victims) participated in the first series of interviews, 15 in the second series. Qualitative data were analyzed using reflexive thematic analysis, quantitative data was only described because of the low sample size.

Results

At both six and 18 months after the attack many survivors had been able to resume daily life, and most rated their overall health as (very) good or excellent. At the same time, a substantial portion suffered from health problems such as posttraumatic stress symptoms and other complaints, and needed professional care. Furthermore, those in need did not always find their own way to appropriate care through the existing health system: half of the survivors still needed support in finding the right care 18 months later.

Conclusion

Although the design and implementation of this public health monitor were accompanied by multiple challenges, it was possible to track a portion of the survivors and gain insight in the considerable health burden of the attack. Also, it is clear in this study that the health impact of terrorism affects survivors in the long run and requires attention from health authorities and professionals, as survivors were not able to find the right care by themselves.

Integrating general practitioners into crisis management would accelerate the transition from victim to effective professional: Qualitative analyses of a terrorist attack and catastrophic flooding

Background

In 2018, Trèbes, 6,000 inhabitants with nine general practitioners (GPs) in southern France, experienced two tragedies; a terrorist attack in March, in which four people were killed, and a catastrophic flood in October, in which six people died and thousands more were affected.

Objectives

We aimed to obtain a substantive theory for improving crisis management by understanding the personal and professional effects of the two successive disasters on GPs in the same village.

Methods

This qualitative study conducted complete interviews with eight GPs individually, with subsequent analyses involving the conceptualisation of categories based on grounded theory.

Results

The analysis revealed that GPs underwent a double status transition. First, doctors who experienced the same emotional shock as the population became victims; their usual professional relationship changed from empathy to sympathy. The helplessness they felt was amplified by the lack of demand from the state to participate in the first emergency measures; consequently, they lost their professional status. In a second phase, GPs regained their values and skills and acquired new ones, thus regaining their status as competent professionals. In this context, the participants proposed integrating a coordinated crisis management system and the systematic development of peer support.

Conclusion

We obtained valuable information on the stages of trauma experienced by GPs, allowing a better understanding of the effects on personal/professional status. Thus, the inclusion of GPs in adaptive crisis management plans would limit the effects of traumatic dissociation while increasing their professional effectiveness.