Terrorism, distress and coping: High versus low impact regions and direct versus indirect civilian exposure

Perception of the Threat of Terrorism

In light of the tense and ongoing security situation in Israel, one important issue that needs to be analyzed and understood is the perception of terrorism threats. Most studies focused mainly on the psychological implications of terrorist acts; this study examines the complexity of the manner in which the individual perceives the threat of terrorism. In all, 40 Israeli adults (22 women and 18 men) were interviewed using semistructured in-depth interviews. Qualitative analysis indicates that the components of the perception of terrorism that construct the evaluation and subjective perception of the participants are as follows: (a) perception of control, which is a feeling of loss of control and helplessness due to uncertainty, inability to predict threats, and the vagueness of the threat; (b) perception of vulnerability to the threat, such as a feeling of vulnerability to and potential victimization by terrorism; and (c) perception of fear of terrorism that includes responses of fear, anxiety, feeling of danger, and emotional distress. In addition, gender differences were found in the analysis. The findings of this study help gain a better understanding as to how people perceive the threat of terrorism. The findings also enable an understanding of the complexity of living under ongoing terrorism threats and may assist in understanding how citizens cope with and adjust to this threat.

Construct Validity and Psychometric Properties of the Hebrew Version of the City Birth Trauma Scale

As many as third of the women perceive their childbirth as traumatic and although prevalence rates vary between studies, around 2-5% of women in community samples may develop childbirth-related postpartum post-traumatic stress disorder (PPTSD). The City Birth Trauma Scale (BiTS) was developed to address the need for a DSM-5-based instrument that assesses PPTSD. The BiTS is a self-report questionnaire, which covers all DSM-5 PTSD criteria, including the four symptom clusters - re-experiencing, avoidance, negative mood and cognitions and hyperarousal symptoms. The present study aimed to describe the psychometric properties and validate the Hebrew version of the BiTS. Five hundred and four mothers of 0- to 12-month-old infants were sampled using social media and the snowball method. Respondents completed an online survey consisting of a demographic questionnaire and the Hebrew versions of the BiTS, the impact of event scale-revised (IES-R), the Edinburgh postpartum depression scale (EPDS), and the Pittsburgh Sleep Quality Index (PSQI). The Hebrew BiTS demonstrated high internal consistency for the total scale (Cronbach α = 0.90) and good internal consistency (Cronbach's α = 0.75-0.85) for the subscales. An exploratory factor (EFA) analysis yielded a two-factors solution, accounting for 45% of variance, with general symptoms loaded on Factor 1, and childbirth-related symptoms loaded on Factor 2, with both factors demonstrating high internal consistency (Cronbach's α = 0.90, 0.85, respectively). High convergent validity for the symptom cluster subscales was demonstrated with the parallel IES-R subscales, EPDS and PSQI. A two-step cluster analysis indicated that dysphoric and hyperarousal symptoms best differentiated the severity of symptoms of respondents across measures. In sum, the Hebrew BiTS was psychometrically sound, indicating its utility for clinical and non-clinical research. The EFA and cluster analyses support the differentiation between symptoms of dysphoria and hyperarousal from trauma (i.e., childbirth) specific symptoms, suggesting that symptoms relating to specific aspects of the trauma differ qualitatively from general symptom in the phenomenology of PPTSD. Further research using clinical samples and comparing the BiTS to DSM-5 diagnosis using clinical interview is needed.

Patterns in response to chronic terrorism threats: A construct of emotional, cognitive, and behavioral responses among Israeli citizens

Israeli citizens are exposed to unpredictable and chronic terrorism threats that significantly jeopardize their personal sense of safety. The purpose of the present study is to present how Israeli discourse is structured with regard to emotional, cognitive, and behavioral responses to chronic terrorism threats and to understand the range of responses as well as map the risk and protective factors of this existential threat. Semistructured in-depth interviews were conducted with 40 Israeli adults (22 women and 18 men). Qualitative analysis revealed three patterns of responses to ongoing terrorism: emotional, cognitive, and behavioral. Emotional responses include fear, worry, sense of empathy, and detachment. Cognitive responses include situational assessment and pursuit of solutions, the use of traumatic imagining, beliefs in fate and luck, and optimism. Behavioral responses include looking for information, alertness, and habituation. The findings also revealed another response, which combines cognitive and behavioral responses. Some of the responses are innovative and unique to the threat of terrorism. Mapping the responses revealed mental health risk factors, as well as protective factors that can help structure personal and national resilience. These findings have implications on the treatment and prevention of personal and social pathologies, and how to effectively cope with terrorism threats.

Glycemic control of diabetes patients under continuous rocket attacks

Background

Evidence regarding the detrimental effects of exposure to stress on glycemic control among diabetes patients has mainly focused on personal life events or acute trauma. However, the effects of continuous exposure to extreme stress on type 2 diabetes patients have rarely been studied. The aim of the current study was to examine the association of continuous exposure to rocket attacks with glycemic control and with risk factors for diabetes complications among civilian type 2 diabetes patients. We focus on patients residing in the Western Negev in the south of Israel that has been subjected to rocket attacks fired from Gaza since the end of 2001.

Methods

A two-arm retrospective cohort study of type 2 diabetes patients, aged 35–70 years, residing in a region with chronic exposure to rocket attacks (N = 1697) and in a non-exposed comparison region in Israel (N = 3000). Data were retrieved from the Health Maintenance Organization (HMO)’s database for four time periods representing exposure: chronic—2008; elevated—2009 (post’Cast Lead’ operation); return to chronic—2010, 2011. Data included socio-demographic variables, HbA_1c, BMI, LDL cholesterol, blood pressure. General Linear Models (GLM) were used for analysis.

Results

For HbA_1c, the model yielded a significant main effect for time, a borderline significance main effect for region, and a significant time by region interaction: no differences in HbA_1c levels between the regions in 2008 and 2009, followed by significant differences between the regions in 2010 and 2011 when HbA_1c continued to increase in the exposed region but decreased in the comparison region. Regarding risk factors, a significant main effect for time for LDL cholesterol only, and significant main effects for region were found in all factors: BMI and LDL cholesterol were higher in the exposed than in the comparison region, but blood pressure values were lower.

Conclusions

Continuous exposure to rocket attacks is associated with glycemic control and risk factors in a complex pattern. These preliminary findings require further studies of diverse types of civilian exposure to continuous extreme stress.

In the shadow of terror: posttraumatic stress and psychiatric co-morbidity following bombing in Iraq: the role of shattered world assumptions and altered self-capacities

Whilst research has looked at posttraumatic stress disorder (PTSD) and psychiatric co-morbidity among civilians exposed to bombing, there is a lack of longitudinal data on the development of these outcomes and the psychological factors associated with them, particularly among Iraqi civilians. This study aimed to: investigate 1) the trajectory of PTSD and psychiatric co-morbidity following bombing among civilians in Iraq and 2) the link between shattered world assumptions, altered self-capacities and identified health outcomes. One hundred and eighty (F = 90, M = 90) Iraqi civilians exposed to first time bombing were recruited approximately one month (time 1) after the bombing and five months (time 2) after the baseline assessment. A control group data (178, F = 91, M = 87) from people who were not exposed to bombing was also collected. They completed the Posttraumatic Stress Diagnostic Scale, the General Health Questionnaire-28, the World Assumptions Questionnaire and the Inventory of Altered Self-Capacities. The results showed that there was a significant decline in the proportion of people meeting the screening criteria for PTSD and psychiatric co-morbidity symptoms over time. For the cross-sectional analysis, controlling for demographic variables, regression analysis showed that severity of the bombing (β = .16), controllability of events (β = -.21), safety and vulnerability (β=.31) and affect dysregulation (β = .37) significantly predicted PTSD time 1. Controllability of events (β = -.20) and affect dysregulation (β = .37) also predicted psychiatric co-morbidity at time 1. For the prospective analysis, controlling for PTSD and psychiatric co-morbidity at time 1, none of these dimensions predicted PTSD and psychiatric co-morbidity at time 2. Findings are discussed in terms of individual resilience. It can be concluded that following bombing, civilians developed PTSD and psychiatric co-morbidity which declined over time. Civilians' perceptions of their ability to control events in the world and regulate their affect had a short term impact on the severity of these symptoms.

Resilience and distress: Israelis respond to the disengagement from Gaza and the second Lebanese war

Resilience and distress in Israeli society were assessed at three points in time: before and after the Israeli disengagement from Gaza, and after the second Lebanese war. A random sample of 366 Israelis was assessed for nation-related anxiety and hostility, personal resources and post-traumatic symptoms. The lowest levels of anxiety were observed at the second time point, after the disengagement. Respondents with high-resilience profiles showed lower levels of post-traumatic symptoms and higher levels of personal resources. The findings underscore Israelis' resilience and the importance of personal resources in ongoing nationally stressful situations.

Development and Validation of the Coping With Terror Scale

Terrorism creates lingering anxiety about future attacks. In prior terror research, the conceptualization and measurement of coping behaviors were constrained by the use of existing coping scales that index reactions to daily hassles and demands. The authors created and validated the Coping with Terror Scale to fill the measurement gap. The authors emphasized content validity, leveraging the knowledge of terror experts and groups of Israelis. A multistep approach involved construct definition and item generation, trimming and refining the measure, exploring the factor structure underlying item responses, and garnering evidence for reliability and validity. The final scale comprised six factors that were generally consistent with the authors’ original construct specifications. Scores on items linked to these factors demonstrate good reliability and validity. Future studies using the Coping with Terror Scale with other populations facing terrorist threats are needed to test its ability to predict resilience, functional impairment, and psychological distress.

Relationships between right-wing authoritarianism, terrorism threat, and attitudes towards restrictions of civil rights: a comparison among four European countries

The present study tested the role of right-wing authoritarianism (RWA), terrorist threat, and sociopolitical 'climate' as predictors of support for governmental anti-terrorism policies and actions. Two dimensions of analysis were defined: the presence versus absence of al-Qaeda attacks, and adherence to surveillance versus anti-surveillance mainstream politics. In order to study the influence of these two contextual dimensions on the expression of attitudes, we selected four European countries that fall into these two dimensions--Poland, Belgium, Spain, and the UK. Results from our study provide support for the contention that attitudes towards restrictions of civil rights are related to RWA independently of the cultural context. Moreover, in the UK sample, we found that the threat of terrorism increases acceptance of limitations of civil liberties, but only among people who hold authoritarian beliefs. However, in Spain, the other country that experienced terrorist attacks, this moderation effect was not found which is interpreted in terms of differences in the sociopolitical climate in both countries. As predicted, we did not find such moderation effect in countries in which threat is relatively low (Poland and Belgium). The results are discussed with reference to the conceptual framework based on the importance of fear experiences, security-focused policies, as well as the specific cultural context in the study of reaction to terrorist threat.

Exposure to and fear of terror as predictors of self-rated health among apparently healthy employees

The effects of exposure to terror on physical health were investigated by relating objective exposure to terror and fear of terror to self-rated health (SRH), a proxy measure of health status. Our respondents were apparently healthy (N=4,877, 38% women) adults who completed self-report questionnaires. Objective exposure was assessed by the number of terrorist attacks and their casualties in a respondent's urban area prior to her/his completion of the questionnaire. Using several alternative assessments, objective exposure to terror did not predict SRH for both the genders. As hypothesized, fear of terror negatively predicted SRH for both females and males (beta=-0.04, -0.05, respectively). The effects of subjective and objective exposure were not found to be more pronounced among women relative to men, thus disconfirming our hypotheses in this regard. Our findings suggest that living under continuous fear of terror may adversely influence physical health irrespective of objective exposure.

Patients with multiple sclerosis in a war zone: coping strategies associated with reduced risk for relapse

The objective of this article is to examine the role of coping strategies in multiple sclerosis outcomes among civilians under a military attack during the 2006 war between Hezbollah and Israel. Participants were 156 patients with relapsing—remitting multiple sclerosis. We analysed the relationships between coping and emotional distress and between coping and multiple sclerosis exacerbation. We also assessed a model of the relationship between perceived stress, event-related stress, and coping with increased risk of multiple sclerosis exacerbations using multivariate logistic regression. Ways of coping and subjective stress were evaluated by means of structured interviews using questionnaires previously validated. The more distressed our respondents were during the war, the more likely they were to employ a variety of ways of coping. Correlation coefficients between coping scores and perceived war stress ranged from 0.2 to 0.44 ( p < 0.001—0.01). Correlation coefficients between the various coping scores and broader indices of distress ranged from 0.28 to 0.5 ( p < 0.001). Of the remitting patients during and following the war, 47.1% reported the use of ‘direct coping and planning’, compared to 16.7% of patients who relapsed during the same period ( p = 0.014). ‘Direct coping and planning’ was negatively related to exacerbation of multiple sclerosis symptoms (OR = 0.1, 95% CI = 0.02—0.5). The Nagelkerke R2 was 0.26. Our findings point to an association between ‘direct coping and planning’ and reduced multiple sclerosis relapse rate during wartime. Further research should explore whether the employment of specific ways of coping can reduce the risk for relapse among patients with multiple sclerosis during periods of distress.

Ways of coping and sense of belonging in the face of a continuous threat

This study examined the contribution of ways of coping and sense of belonging to stress responses among students in a conflict zone. Students at a college situated in an area exposed to continuous threat were divided according to their place of residence: locations inside and outside of the conflict zone. Rate of posttraumatic stress disorder (PTSD) was similar to rates in previous studies conducted among Israelis who had been exposed to terror. Acceptance as a way of coping and sense of belonging contributed to reducing PTSD symptoms, whereas use of alcohol and seeking support contributed to increasing stress responses. The discussion examines the results in light of the literature on ways of coping and sense of belonging in the face of continuous threat.

The psychological impact of the Israel-Hezbollah War on Jews and Arabs in Israel: the impact of risk and resilience factors

Although there is abundant evidence that mass traumas are associated with adverse mental health consequences, few studies have used nationally representative samples to examine the impact of war on civilians, and none have examined the impact of the Israel-Hezbollah War, which involved unprecedented levels of civilian trauma exposure from July 12 to August 14, 2006. The aims of this study were to document probable post-traumatic stress disorder (PTSD), determined by the PTSD Symptom Scale and self-reported functional impairment, in Jewish and Arab residents of Israel immediately after the Israel-Hezbollah War and to assess potential risk and resilience factors. A telephone survey was conducted August 15-October 5, 2006, following the cessation of rocket attacks. Stratified random sampling methods yielded a nationally representative population sample of 1200 adult Israeli residents. The rate of probable PTSD was 7.2%. Higher risk of probable PTSD was associated with being a woman, recent trauma exposure, economic loss, and higher psychosocial resource loss. Lower risk of probable PTSD was associated with higher education. The results suggest that economic and psychosocial resource loss, in addition to trauma exposure, have an impact on post-trauma functioning. Thus, interventions that bolster these resources might prove effective in alleviating civilian psychopathology during war.

The well being of children living in chronic war zones: The Palestinian—Israeli case

The paper presents a comprehensive review and integration of available studies on the effects of severe traumatic experiences on children, especially in the context of short and enduring exposure to harsh events and adversities, as they relate to children who live in violent war zones, in particular in Israel and the Palestinian territories. The review focuses on the role of risk and protective factors in determining the debilitating and damaging effects as well as resiliencies of short term and chronic catastrophic experiences on the future well being of children and emerging adults.

The mental health impact of terrorism in Israel: a repeat cross-sectional study of Arabs and Jews

OBJECTIVE

Since September 2000 Israeli society has been subjected to numerous deadly terror attacks. Few studies have studied the comparative mental health vulnerability of minorities and majorities to continuous terror attacks.

METHOD

Two telephone surveys (N = 512 and 501) on two distinct representative samples of the Israeli population after 19 months and after 44 months of terror. The Arab minority and Jewish majority were compared on measures of exposure to terrorism, posttraumatic stress symptomatology, feeling depressed, coping, sense of safety, future orientation, and previous traumatic experiences.

RESULTS

After 19 months of terrorist attacks Arab Israelis and Jewish Israelis reacted roughly similarly to the situation, however after 44 months of terror, posttraumatic symptom disorder in the Arab population increased three-fold, posttraumatic symptomatology doubled and resiliency almost disappeared.

CONCLUSION

We suggest that certain conditions inherent to political conflict situations may potentially put minorities at risk and may only be observable as terrorism-related stressors become chronic.