[Robert's-Theory of Terrorism in Gestalt Psycholgy] The Psychological Impact ...

[Robert Nyakundi]

Objective: A wave of bombings struck

France in 1995 and 1996, killing 12 people
and injuring more than 200. The authors
conducted follow-up evaluations with the
victims in 1998 to determine the prevalence
of and factors associated with posttraumatic
stress disorder (PTSD).
Method: Victims directly exposed to the
bombings (N=228) were recruited into a
retrospective, cross-sectional study. Computer-
assisted telephone interviews were
conducted to evaluate PTSD, per DSM-IV
criteria, and to assess health status before
the attack, initial injury severity and
perceived threat at the time of attack, and
psychological symptoms, cosmetic impairment,
hearing problems, and health service
use at the time of the follow-up evaluation.
Factors associated with PTSD were
investigated with univariate logistic regression
followed by multiple logistic regression
analyses.
Results: A total of 196 respondents (86%)
participated in the study. Of these, 19%
had severe initial physical injuries (hospitalization
exceeding 1 week). Problems
reported at the follow-up evaluation included
attack-related hearing problems
(51%), cosmetic impairment (33%), and
PTSD (31%) (95% confidence interval=
24.5%–37.5%). Results of logistic regression
analyses indicated that the risk of PTSD
was significantly higher among women
(odds ratio=2.54), participants age 35–54
(odds ratio=2.83), and those who had
severe initial injuries (odds ratio=2.79) or
cosmetic impairment (odds ratio=2.74) or
who perceived substantial threat during
the attack (odds ratio=3.99).
Conclusions: The high prevalence of
PTSD 2.6 years on average after a terrorist
attack emphasizes the need for improved
health services to address the intermediate
and long-term consequences of terrorism.
(Am J Psychiatry 2004; 161:1384–1389)
Initially described in wartime combatants, posttraumatic
stress disorder (PTSD) is recognized as a common health
problem associated with exposure to traumatic events such
as natural catastrophes, motor vehicle accidents, assault,
rape, and robbery (1, 2). Research over the past 15 years has
also examined the psychological impact of terrorist acts
such as hostage-taking, bombings, and shootings, but
mainly in the short term (3–14). Estimates of the prevalence
of PTSD after terrorist attacks range from 7.5% to 50% in the
year after the event depending on the degree of victimization.
Despite the increase in terrorist attacks worldwide,
there is less evidence about the intermediate and long-term
psychological consequences of terrorism, in particular
PTSD, or about risk factors (5, 15–18). Studies of individuals
incurring physical injuries should also be considered in addressing
the long-term consequences of traumatic events.
Research on victims of motor vehicle accidents shows a
higher risk of PTSD, at rates that vary between 11% and
46%, 1–5 years postaccident (19, 20). While few studies have
evaluated the long-term prevalence of PTSD among burn
victims, it appears to fall between 22% and 45% after 1 year
and has been reported to be higher after discharge than
during hospitalization (21, 22).
Between July 25, 1995, and December 3, 1996, a wave of
bombings attributed to Islamist fundamentalist networks
hit France. Six struck Paris, and one struck the Lyon region;
most occurred in metro stations. Twelve people were
killed. Approximately 450 people applied for compensation
from the French Terrorism Victim Guarantee Fund, a
public guarantee fund to provide immediate financial aid
and indemnification for health consequences and longterm
sequelae. In 1998, we carried out a retrospective,
cross-sectional epidemiologic study of terrorist bombing
victims to evaluate the prevalence of and factors associated
with PTSD.
Method
Subjects
The target population was made up of victims who had been
directly exposed to the bombings. The French Terrorism Victim
Guarantee Fund required every person applying for compensation
to undergo an evaluation, carried out by independent experts,
to confirm exposure to the bombing and to assess its health
consequences. Participants were civilian, 18 years or older at the
time of the event, spoke French, and could be reached by telephone.
SOS Attentats, a nongovernmental organization created
in 1986 to represent French victims of terrorism, identified the
Am J Psychiatry 161:8, August 2004 1385
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sampling frame and contacted the subjects. Of 450 subjects who
applied for compensation, 222 (49.3%) chose not to undergo the
French Terrorism Victim Guarantee Fund evaluation. Thus, 228
subjects remained for whom direct exposure was confirmed and
who were contacted by SOS Attentats. In compliance with French
law, details about the target population, data collection protocol,
and procedures guaranteeing anonymity were reported to the
Commission for Computer Privacy.
Data Collection
SOS Attentats sent an information letter to eligible participants
10 days before the study began. This was followed by a telephone
invitation to participate in the study from a survey research institute.
After describing the study to subjects, oral consent was obtained.
Data were collected from September 16 to October 5,
1998, by computer-assisted telephone interviews conducted by
20 professional interviewers. The validity of using the telephone
to assess anxiety-related stress disorders has been demonstrated
in several studies (23, 24).
Measures
We defined PTSD at follow-up with a 22-item standardized instrument
based on DSM-IV criteria (25–27). The structure and details
of the instrument were very similar to the DSM-IV criteria—
we simply broke some criteria down into several items to make
them more understandable, as a back-translation confirmed. In a
different, unpublished study, the reliability (Cronbach’s alpha=
0.91), specificity (0.88), and sensitivity (0.73) of the instrument
were confirmed in a group of 15 subjects with PTSD and 33 subjects
with anxiety or depressive disorders; concurrent validity was
compared with the judgment of an external clinical expert with
substantial experience in the use of semistructured instruments
(G. Sydor, Faculty of Psychology, Catholic University of Louvain,
Belgium). Questions asked about symptoms associated with the
event (e.g., “Do you currently have, without wanting them, upsetting
memories about the attack?”), the duration of symptoms
(more or less than 1 month), and repercussions on social and
work life. Symptoms were rated on a 5-point intensity scale (0=
not at all; 4=very much). A score of at least 3 defined the presence
of a symptom.
Risk factors and health outcomes were also assessed by questionnaire.
An initial gravity score was used to classify injury severity
as mild (no hospitalization or surgery), moderate (initial hospitalization
of less than 1 week or delayed/deferred surgery), or
severe (initial hospitalization of more than 1 week). Perceived
threat was coded as present for subjects who answered “yes” to at
least one of two questions: Did you see people injured or killed
during the attack? Did you feel you were dying during the attack?
Hearing problems were assessed with four questions: Do you
have hearing problems related to the attack? Have you seen a specialist
in the past 4 weeks for a hearing problem related to the attack?
Have you had buzzing or ringing in one or both ears in the
past 4 weeks? Do you wear a hearing aid because of the attack?
Hearing problems were coded as severe for subjects who answered
yes to at least two questions and moderate for those who
answered yes to one question. Four questions from the Burn-Specific
Health Scale (28) were used to assess cosmetic impairment:
Did the attack change your appearance to the point of interfering
with your relationships? Would you like to forget that your appearance
has changed? Do you feel that members of your family
and friends are uncomfortable around you because of your appearance?
Do you have the impression that people would not
want to touch you? Questions were rated on a 5-point intensity
scale (1=very much or all the time; 5=not at all or never). Cosmetic
impairment was defined as a rating of 1, 2, or 3 in response
to at least one of the questions. Psychiatric history was assessed
with three questions. Two addressed the use of tranquilizers or
sleep-inducing drugs for at least 6 months at any time before the
attacks, and one addressed psychological problems: “Before the
attack, had you been followed by a general practitioner, psychiatrist,
psychologist or other psychotherapist for more than 6
months for a psychological problem?” A psychiatric history was
defined as present if at least one of the three questions was answered
positively.
Data Analysis
Factors associated with PTSD were investigated with univariate
logistic regression followed by multiple logistic regression analyses.
A forward/backward stepwise procedure was used to retain
explanatory variables in the models. At each step, a new variable
was entered in the model, which was then recomputed to test
whether this variable should remain in the model (and another be
withdrawn). This process continued until no variable in the equation
could be removed and no variables not already in the equation
could be added. The entry and exit thresholds for other variables
were p=0.15 and p=0.05, respectively; we used the Hosmer
and Lemeshow goodness-of-fit test and the c-index to evaluate
the fit of the resulting model. We used SAS (version 6.12) software
(SAS Institute, Cary, N.C.) for all statistical analyses.
Results
Of the 228 bombing victims who underwent medical
evaluation for the French Terrorism Victim Guarantee
Fund, 196 (86%) agreed to participate.
Respondent Characteristics
At the follow-up assessment, approximately three-quarters
of the respondents (74%) were younger than 50 years
old, were employed (76%), and were living with a partner
(70%) (Table 1). More than half were women and had completed
high school. The majority of respondents (83.7%)
were injured in one of the two Paris subway bombings.
TABLE 1. Sociodemographic Characteristics of the 1995–
1996 Terrorist Bombing Victims (N=196) at a 1998 Follow-
Up Assessment
Characteristic N %
Age (years)
<35 63 32.1
35–54 104 53.1
≥55 29 14.8
Sex
Female 105 53.6
Male 91 46.4
Employed
Yes 149 76.0
No 47 24.0
Occupation
Artisan, shopkeeper, small business head 3 1.5
Manager, professional intellectual occupation 34 17.3
Intermediate white-collar occupation, office worker 38 19.4
Employee 57 29.1
Worker 17 8.7
Marital status at follow-up
Single 35 17.9
Married, remarried, living together 138 70.4
Widowed 5 2.6
Divorced 18 9.2
Highest diploma completed
None 17 8.7
Certificate of primary studies (6 years) 15 7.7
Vocational degrees 59 30.1
High school diploma and higher 105 53.6
1386 Am J Psychiatry 161:8, August 2004
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The mean interval between the event and follow-up was
2.6 years (SD=0.6, range=1.8–3.2).
Prevalence of PTSD
PTSD at the follow-up assessment was identified in 61
respondents (31.1%) (Table 2). The prevalence of PTSD in
those with severe injuries was 50% (95% CI=34.1%–65.9%)
and was lower in participants with moderate or mild injuries
(27% [95% CI=17.5%–36.8%] and 26% [95% CI=16.2%–
35.8%], respectively). The most and least frequent symptoms
were reexperiencing the event (76%) and avoidance
of reminders of the event and numbness of feelings (33%),
respectively.
Risk Factors Associated With PTSD
Results of univariate analyses indicated that the risk of
PTSD was significantly higher for women; participants 35–
54 years of age; those who were not working; those who
lived alone; those whose marital situation had changed after
the attack (divorce, widowed); those who had severe injuries,
cosmetic impairment, or hearing problems; and
those who reported a high perceived threat at the time of
the attack or who had received treatment by a psychologist
since the attack (Table 3). A history of psychiatric disorders
was associated with a nonsignificant increase in the
prevalence of PTSD. The prevalence of PTSD was not associated
with the site of the attack or the number of years
since the attack. Multiple logistic regression analyses
showed a significant association between PTSD and age
(35–54 years), sex, marital status, injury severity, cosmetic
impairment, and perceived threat (Table 3). The odds ratios
associated with these variables in the multiple logistic
regression analysis did not substantially change from
those in the univariate analysis. The Hosmer and Lemeshow
goodness-of-fit test and the c-index show that the
model fit the data well.
Discussion
This study surveyed 196 terrorist bombing victims (86%
of eligible respondents), a relatively high number compared
with most other studies focusing on the intermediate-
and long-term psychological consequences of terrorist
attacks (15, 16, 18, 29). According to the French Terrorism
Victim Guarantee Fund, this group included almost all people
injured during the 1995–1996 bombings.
The overall prevalence of PTSD was high (31.1%) at a
mean of 2.6 years (SD=0.6) after the event. Comparisons
with other studies focusing on intermediate- and longterm
psychological consequences of terrorist attacks are
difficult because of differences between populations,
study methods, and measures (15, 16, 18, 29). However,
the prevalence of PTSD was higher than the 18.1% prevalence
rate in a study of victims of bombings between 1982
and 1987 in France (17). Most studies report that the prevalence
of PTSD after a traumatic event decreases over
time. Moreover, in a study of PTSD subjects 15 to 54 years
of age in the U.S. general population, the median time to
remission was 64 months in people who were not treated
and 36 months in those who received treatment (1). Onethird
of respondents did not have a single remission in the
10 years following the onset of PTSD.
Our findings show a significant relation between injury
severity and PTSD prevalence at a follow-up evaluation 2.6
years after the attacks. A relation between the nature and
severity of injuries (including burns) and PTSD is reported
only inconsistently. Some studies observe no such relation
(3, 22, 30–33)—these authors stress instead the prominent
role of subjective perception of stressors in mediating the
development of PTSD. Others state that the severity of
physical injury is one of the most reliable predictors of
PTSD (10, 17, 34–36). Two hypotheses have been proposed.
Solomon (34) hypothesized that more severe injuries
may be associated with a more traumatic initial reaction
that is also predictive of a PTSD that progresses more
rapidly and lasts longer. Others have suggested that results
may depend on the length of time elapsed since the accident,
with extent of injury becoming a more important
predictor over time (35); long-term disability due to severe
injury serves as a constant reminder of the trauma and
thereby tends to extend the duration of PTSD.
Our finding of an association between cosmetic impairment
and PTSD is similar to the findings in a study of Japanese
burn patients, which found that facial disfigurement
was associated with PTSD only among women (29).
This difference may be due to cultural differences or to the
methods used to assess physical sequelae (clinical examination
in the study by Fukunishi [29], self-report in ours).
Cosmetic impairment may constantly remind the victims
of the traumatic event, which may explain the poorer
long-term adjustment and greater distress than for other
respondents. Nonetheless, negative appraisal of cosmetic
impairment may also be associated with the presence of
depressive or PTSD symptoms that may increase patients’
focus on threats to their self-image (21). Our study design
did not allow us to confirm a causal relation between
PTSD and cosmetic impairment, but it raises a novel and
TABLE 2. Frequency of DSM-IV PTSD Criteria Among the
1995–1996 Terrorist Bombing Victims (N=196) at a 1998
Follow-Up Assessment
Criteriona N %
Reexperiencing the event 148 75.5
Avoidance of reminders of the event and numbness
of feelings 64 32.7
Hyperarousal 134 68.4
Duration of preceding symptoms 1 month or longer 179 91.3
Repercussions of the preceding symptoms on activities
of daily living 146 74.5
Meets criteria for PTSD 61 31.1b
a According to DSM-IV criteria, PTSD is present after exposure to a
traumatic event when each of the five criteria listed in the table
are present; each of the first three criteria is considered present
when the subcriteria reach a specified number.
b 95% CI=24.5–37.5.
Am J Psychiatry 161:8, August 2004 1387
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potentially quite important hypothesis regarding this risk
factor, which deserves further research.
We also found a higher prevalence of PTSD among respondents
with moderate and mild injuries (27.2% and
26.0%, respectively) compared with the general population
(1). This suggests that factors other than those associated
with physical trauma, such as perceived threat, may play a
role in the development of PTSD. The highest odds ratio
(3.99) was found between perceived threat and PTSD; this
result is supported by studies showing that factors such as
the threat of death or the viewing of mutilated bodies are
associated with the onset of PTSD (2, 37).
Our finding of a higher prevalence of PTSD in women is
supported by results from several studies (1, 38–41). There
is mixed support in the literature for our finding of an association
between age and PTSD (40, 42, 43), although several
studies have observed an increased risk of PTSD in 35–
54-year-olds during natural catastrophes (43–45). These
findings may be explained by the substantial economic
consequences experienced by respondents with PTSD in
this age group.
Failure of prior psychiatric history to be a strong predictor
of PTSD may be related to the proxy variables used,
which did not allow a thorough reconstruction of the nature
and severity of past psychiatric disorders. It might
also result from insufficient statistical power: relatively
few subjects reported a past history of psychiatric disorders
(11 subjects without and nine with PTSD).
TABLE 3. Factors Associated With PTSD Diagnosis in the 1995–1996 Terrorist Bombing Victims (N=196) at a 1998 Follow-
Up Assessment
Factor
No PTSD PTSD
Univariate Logistic
Regression
Multiple Logistic
Regressiona
N % N % Odds Ratio 95% CI Odds Ratio 95% CI
Sex
Men 70 76.9 21 23.1 1.00 1.00
Women 65 61.9 40 38.1 2.05* 1.09–3.83 2.54* 1.22–5.27
Age
<35 50 79.4 13 20.3 1.00 1.00
35–54 65 62.5 39 37.5 2.31* 1.11–4.78 2.83* 1.25–6.41
≥55 20 69.0 9 31.0 1.73 0.64–4.68 2.44 0.79–7.52
Employment
Yes 108 72.5 41 27.5 1.00
No 27 57.4 20 42.6 1.95* 0.98–3.85
Education
High 72 68.6 33 31.4 1.00
Low 63 69.2 28 30.8 1.03 0.56–1.89
Relationship status
With a partner 103 74.6 35 25.4 1.00 1.00
Alone 32 55.2 26 44.8 2.39* 1.26–4.55 2.29* 1.09–4.77
Change in marital status
No 126 70.8 52 29.2 1.00
Yes 8 47.1 9 52.9 2.72* 0.99–7.45
Native language
French 110 70.1 47 29.9 1.00
Other 25 64.1 14 35.9 1.31 0.63–2.74
Place of birth
France 96 70.6 40 29.4 1.00
Other 39 65.0 21 35.0 1.29 0.67–2.47
Injury severity (initial gravity score)
Low 57 74.0 20 26.0 1.00 1.00
Moderate 59 72.8 22 27.2 1.06 0.52–2.15 1.26 0.57–2.79
High 19 50.0 19 50.0 2.85* 1.26–6.44 2.79* 1.05–7.44
Cosmetic impairment
No 103 78.0 29 22.0 1.00 1.00
Yes 32 50.0 32 50.0 3.55* 1.87–6.74 2.74* 1.33–5.64
Hearing problems
No 37 80.4 9 19.6 1.00
Moderate 35 68.6 16 31.4 1.88 0.74–4.8
Severe 63 63.6 36 36.4 2.35* 1.02–5.42
Perceived threat
No 25 89.3 3 10.7 1.00 1.00
Yes 110 65.5 58 34.5 4.39* 1.27–15.17 3.99* 1.08–14.76
Psychological treatment since attack
No 61 79.2 16 20.8 1.00
Yes 74 62.2 45 37.8 2.32* 1.19–4.5
Psychiatric history
No 124 70.5 52 29.5 1.00
Yes 11 55.0 9 45.0 1.95 0.76–4.99
a Hosmer and Lemeshow goodness-of-fit test: 0.82; c-index: 0.79.
*p<0.05.
1388 Am J Psychiatry 161:8, August 2004
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The main limitation of this study is its retrospective design.
The psychological consequences of the terrorist
bombings were assessed through retrospective self-reports.
Respondents’ recollections of the attack and its sequelae
may have been influenced by their psychological
state at follow-up (37, 46). However, it is unlikely that respondents
overreported PTSD symptoms to seek financial
gain. Participants were aware that all information they
provided was confidential and would not be passed on to
the French Terrorism Victim Guarantee Fund. They had
already been recognized as victims and entered into the
indemnification process by the French Terrorism Victim
Guarantee Fund at the time of the study.
We have restricted our study to those who were directly
exposed to the bombings; because of the high response
rate, reconstruction of this group was substantially complete.
Victims who were not directly exposed were excluded.
It is very difficult to predict the consequence of
this exclusion on the estimate of PTSD prevalence, since
PTSD, perhaps less severe, may also occur in these subjects.
Because our comparisons involved subjects with
relatively similar experiences, the odds ratios associated
with injury severity, cosmetic impairment, and perceived
threat may be underestimated.
In conclusion, few studies have evaluated the long-term
prevalence of PTSD several years after terrorist attacks. We
surveyed a large sample of victims (N=196), evaluated psychological
outcomes a mean of 2.6 years after the 1995–
1996 attacks with rigorous measures, and found a high
prevalence of PTSD in injured victims. Our findings suggest
that psychological care for some victims may have been inadequate
in the 2–3-year period after the event and thus
highlights the need for improved health services to address
the intermediate and long-term physical, psychological,
and social consequences of terrorism. Risk factors associated
with PTSD that may help to identify those at highest
psychological risk include female gender, severe initial injuries,
and high perceived threat. Finally, results suggest the
role of cosmetic impairment in the persistence of PTSD.
Received Oct. 28, 2002; revision received Sept. 9, 2003; accepted
Nov. 20, 2003. From the Regional Health Observatory-INSERM U379,
Marseille, France; the Conservatoire National des Arts et Métiers,
Paris; the Health Services Research Unit, London School of Hygiene
and Tropical Medicine, London, U.K.; McGill University, Jewish General
Hospital, Montreal; Cemka-Eval, Bourg-la-Reine, France; and the
Albert Chenevier and Henri Mondor University Hospital Center,
Créteil—Paris XII Faculty of Medicine, Paris, France. Address reprint
requests to Dr. Verger, Observatoire Régional de la Santé Paca, 23 rue
Stanislas Torrents, 13006 Marseille, France.
This study received financial support from the Directorate General
of Health (a section of the Ministry of Health) and the Association
“Les Gueules Cassées.”
The authors thank the members of the scientific committee of the
study; SOFRES Medical for undertaking the interviews; Anne Duburcq
from EVAL for data analysis; Stéphane Hautecouverture, France Lert,
and Anne Lowell for comments on draft versions of the manuscript;
and Jo Ann Cahn for the translation.
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Posted By Robert Nyakundi to Robert's-Theory of Terrorism in Gestalt Psycholgy at 3/01/2010 11:39:00 AM