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The behavioral consequences of terrorism: a meta-analysis
Introduction
Terrorism is an ongoing concern throughout the world. The United States
Department of State documented 228 acts of worldwide terrorism between 1961
and 2003.1 Of these 197 were in the developing world. In the US, attention has
turned to the threat of terrorism with the September 11, 2001 terrorist bombings,
2 3 4
the largest single-day loss of human-life in US history since the Civil War.
Subsequent terrorist attacks such as the October 12, 2002 Bali nightclub
bombings, the March 11, 2004 Madrid train bombings, and the July 7, 2005
London bombings, have further brought the threat of terrorism to the forefront of
national and international discourse.
Several large-scale reviews of the consequences of disasters have been
published. 5 6, 7 These reviews have documented the prevalence and correlates
of specific psychiatric disorders and behaviors after mass events. Post-traumatic
stress disorder (PTSD) emerges from this work as the best studied, and likely
most common, psychopathology after disasters. One theme to arise from these
reviews is that disasters that are caused by human-intent (such as terrorism)
may be associated with a particularly high risk of psychopathology in their
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aftermath. 7 As such, explicit study of the mental health consequences of
terrorism may be warranted. To illuminate this issue, we undertook a review and
synthesis of quantitative studies of the behavioral health effects of terrorist
incidents focusing primarily on the prevalence and correlates of PTSD.
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Methods
We searched published and unpublished post-1980 studies of empirical data
utilizing survey methodology and presenting quantitative population-level results
of behavioral health effects of terrorist incidents. Papers presenting secondary
analyses of previously published data such as meta-analyses, studies of
qualitative data such as focus groups, editorials. review articles, commentaries,
and case reports were excluded.
Eligibility Criteria
After Arnold, for the purposes of this review terrorism was defined as “The
intentional use of violence--real or threatened--against one or more noncombatants and/or those services essential for or protective of their health,
resulting in adverse health effects in those immediately affected and their
community, ranging from a loss of well-being or security to injury, illness, or
death.”8 We limited our search to studies that were closely defined by time and
place, and excluded studies of torture and long-term political repression as well
as studies of the effects of expatriation on political refugees. We also excluded
incidents of random, non-politically motivated violence such as criminal shootings
by potentially psychotic individuals. Behavioral health effects were defined as:
post traumatic stress disorder, depression, substance abuse and potentially
related somatic signs and symptoms such as asthma and cardiovascular
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disease. These last two somatic disorders were chosen based on their presence
in the literature as an area of behavioral research. Studies of post-traumatic
stress disorder were limited to those with diagnostic criteria referenced to a
current Diagnostic and Statistical Manual. 9
Studies were eligible for analysis if they presented results in terms of proportions
or prevalences, odds ratios of dichotomous variables, means with standard
deviations, p-values, t-tests, F-statistics, and chi squares, or with data that could
be translated into one of those terms. Where possible, univariate data were
extracted from studies with results of multivariate analyses.
Search and Coding
We electronically searched: PubMed, Medline, Cumulative Index of Nursing and
Allied Health Literature (CINAHL), Allied and Complementary Medicine (AMED),
PsychINFO, Health and Psychosocial Instruments, ProQuest Digital Dissertation
Database, Papers First (a compendium of conference proceedings from the
British Library), Cochrane Reviews, ACP Journal Club, Database of Abstracts of
Reviews of Effectiveness (DARE), the Cochrane Controlled Trials Register
(CCTR), Sociologic Abstracts and Web of Science by entering the terms:
“terror*”, “post-traumatic stress”, “health” and “effects” “behavior*”, “disaster” and
“psychiatr*”, and“mass violence” singly and in combination. (* refers to a wildcard
characters).
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Articles were entered into Endnote 9.05. To identify quantitative epidemiologic
studies, titles and abstract text were electronically searched for the terms: “study,
investigation, incidence, prevalence, proportion, effect, random*, population,
research, cross-sectional, ecologic, and epidem*”. References to night terrors
and sleep disturbances were excluded by visual inspection. Primarily
bioterrorism-related articles were identified by searching for and visually
inspecting references to “smallpox, anthrax, plague, and radiologic” and were
omitted if they did not include a primary behavioral component. The remaining
titles and abstracts of these references were visually searched to remove
duplicates, articles primarily addressing physical injury and articles addressing
natural disasters.
Full-text versions of articles entered into the study were reviewed by the primary
author and coded for the following variables: mean age, race and gender
distribution, geographic area, mechanism of injury, specific event or incident,
time elapsed between incident and study, type of subjects, primary outcome of
interest, method of recruitment and enrollment, participation rate, type of
assessment, scale or instrument used and whether validation measures were
presented, and version of Diagnostic and Statistical Manual employed.
Analysis
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We first identified and described all eligible papers addressing the behavioral
consequences of terrorism. We then focused on the subset of papers presenting
results primarily concerned with PTSD. For these papers, results were tabulated
and effect sized calculated. Utilizing a random effect model, results were
analyzed for: (1) Central tendency or overall mean effect size, as well as it’s
variance and its statistical significance as estimated by 95% confidence intervals,
(2) Heterogeneity of the mean effect size as assessed and tested through Chi
square distribution of Q statistic and (3) Evaluation of the relationship of effect
size to moderator variables such as geographic location, type of incident,
magnitude of the incident measured in number injured, impact level on
individuals surveyed.
Summary statistics and Forrest plots were created using Comprehensive Meta
Analysis version 2 . Descriptive statistics were conducted using The SAS System
for Windows version 9.0 and SPSS version 11.5.
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Results
Behavioral Studies
Four thousand nine hundred seventy seven references were retrieved through
the electronic data base search. One thousand four hundred eleven remained
after removing duplicates, commentaries, case reports, general review articles,
essays, references to night terrors and sleep disturbances, and bioterrorismrelated articles if they did not include a primary behavioral component. Two
hundred fifty articles remained after removing additional duplicates, articles
primarily addressing physical injury and articles primarily addressing natural
disasters. Hand searching the references of articles eligible for inclusion
identified an additional 5 references. Of these 255 studies, 142 were excluded
for the following reasons: Commentary (27), Subjective data (13), Nonindependent or previously presented data (13), Not behavioral health as defined
for study (22), Review article or textbook chapter (23), Not terrorism as defined
for study (20), Not English (5), Insufficient info to code (8), Unable to locate or
retrieve (11). References of excluded articles were not hand searched. A total of
113 papers addressing behavioral health outcomes remained.
The majority of initially eligible studies (99/113) were based on inner city or urban
populations. Fifty one of the 113 selected papers addressed populations that
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were greater than 60% white. Ten studies included populations that were greater
than 40% black. One study included a population that was greater than 40%
Hispanic. Twelve studies (10.6%) explicitly studied children. Sixty papers (53%)
studied predominantly female populations.
Only 2 of the initial 113 eligible behavioral health studies involved biological
incidents; the remaining studies addressing explosions or armed attacks. Sixty
percent (68/113) of the studies addressed an incident in which more than 2000
persons were killed. Twenty percent (22/113) involved an incident in which 100
to 250 persons were killed. Forty four papers (38.9%) studied a general
population sample, 16 papers (14.2%) studied survivors, 5 (4.4%) rescuers and
11 (9.7%) employment groups. Figure 1 represents the proportion of the 113
studies initially eligible for inclusion in the analysis by region of the world,
compared to the proportion of all reported terrorist incidents in the region during
the same time period. 1
Table 1 presents the behavioral health outcomes of the 113 behavioral health
papers. Of these 113 studies initially eligible for inclusion, 61 (54%) addressed
post-traumatic stress disorder and were entered into subsequent analysis
.
PTSD
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Forty six of the 61 PTSD studies listed explicit DSM-based diagnostic criteria;
the most commonly cited version (30/46) was DSM-III-R.10 Thirty seven of the 61
studies (61%) used validated screening instruments. The most frequently used
screening instrument (16/37=43.2%) was the Impact of Event Scale.11
The 61 PTSD papers included 146 outcome effects. Forty two (28.8%) of the
effects were prevalence measures; 80 (54.8%) were measures of association.
Seventy nine (54.1%) of the effect sizes were either an increased prevalence
compared to un-affected population estimates or a positive association with the
covariate under investigation. The majority (78.8%) of effects were measured
within 6 months of the terrorist incident.
We calculated an overall, global measure of post-traumatic stress disorder
prevalence after terrorist attacks that included all studies of victims, rescuers,
occupational groups and general population samples. Post-terrorism prevalence
of PTSD varied by time. For studies conducted up to 2 months after the event,
the over-all prevalence rate was approximately 16%. At 6 months, the
prevalence was approximately 14%; at one year, 12%. These declines were
statistically significant (p<0.0001). (Figure 2)
For the 14 studies with populations greater than 60% white, the global average
post-terrorist prevalence was 18.4% (95% CI 14.8, 22.6). Two studies had a
greater than 40% Black composition with an average prevalence of 14.8% (95%
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CI 1.7, 63.1). One study addressed a greater than 40% Hispanic population and
reported prevalence of 13.6% (95% CI 8.4, 21.4).
For studies with predominantly (>80%) male populations, the global average
prevalence was 11.3% (95% CI 6.0, 20.4). For predominantly female
populations the overall prevalence was 16.2% (95% CI 11.8, 21.8). There was a
slight decline in PTSD associated with increasing mean age in study samples
(Slope = -0.00763, p<0.0001).
Overall, studies conducted in Western Europe reported a higher prevalence
(23.6%; 95% CI 19.6%, 28.1%) when compared to studies conducted in North
America (12.7%; 95% CI 9.1%, 17.5%) or the Middle East (12.6%; 95% CI
8.8%, 17.9%) There were also variations within the same geographic area.
Studies of the Oklahoma City bombing reported a global PTSD prevalence of
17.35 (95% CI 12.9, 21.3). Studies of the New York City September 11 th attacks
reported a global prevalence of 13.0% (95% CI 12.4, 13.6) (Figure 3)
Studies of survivors reported an average PTSD prevalence of 18% (12.7, 24.9).
Rescuers had an average prevalence of 16.8% (11.4, 24.2), exposed
employment cohorts had an average prevalence of 15.8% (9.9, 24.2). Surveys
conducted on general population samples that did not explicitly target survivors,
rescuers or occupational groups reported an average prevalence of 10.9% (5.2,
21.6). (Figure 4) We divided these general population surveys into those
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geographically situated within 100 miles of the events (local populations) and
those farther than 100 miles of the events (distant populations). There was little
difference between studies that surveyed local populations (Prevalence = 7.9%,
95% CI 3.3%, 17.6%) versus those that surveyed distant populations
(Prevalence = 9.5%, 95% CI 7.5%, 12%). (Figure 5)
Nine studies examined the association between viewing media images of
terrorist events and subsequent assessments of PTSD. Overall, individuals who
viewed media images of events were twice as likely to be assessed as having
PTSD (OR for Association = 1.9, 95% CI 1.5, 2.5). This effect was time
dependent with the five studies conducted within 3 months of the events
indicating an odds ratio for association of 2.4 (95% CI 2.1, 2.8) and the three
studies conducted between 3 and 6 months after the events indicating an overall
odds ratio for association of 1.3 (95% CI 1.1, 1.6).
Four studies examined the association between prior psychiatric history and
subsequent assessments of PTSD. The summary odds ratio for association was
4.0 (95% CI 2.1, 7.4). Eight studies examined the association between female
gender and subsequent assessments of PTSD. The summary odds ratio for
association was 2.2 (95% CI 1.4, 3.3).
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Discussion
The behavioral consequences of terrorist incidents have received considerable
recent academic attention, much of it driven by the Oklahoma City bombings and
the attacks of September 11th in the United States. There are both immediate
and long-term implications for the emergency medicine community.12 These
include familiarity with the ways in which patients may present to emergency
departments following disasters and terrorist incidents, the need to identify
populations and groups most at risk of developing long-term behavioral sequellae
such as PTSD, and an appreciation of the impact such events may have on the
overall health status of ED patients.
The reported prevalence of all types of psychopathology following disasters
varies from 7 to 70%. 13 Our analysis indicates that in the year following terrorist
incidents PTSD prevalence in directly affected populations varies between 12%
and 16%. Our review also shows that this prevalence can be expected decline
25% over the course of that year. We could not assess how interventions affect
this decline.
These prevalence estimates mask great variability depending on who is being
studied, who is conducting the study and where the event occurred. The
populations studied tended to be white, adult, male North Americans, and the
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incidents were most likely to be explosions and violent attacks. Post-traumatic
stress disorder continues to attract most attention from researchers. The choice
of PTSD as an area of interest for researchers also likely reflects the availability
of validated screening tools amenable to research settings, the increasing
consensus that PTSD is a likely outcome of post-terrorist environments, and the
sense that PTSD is a marker or covariate for other behavioral disturbances.
Overall, studies show that survivors of terrorist incidents consistently suffering
the highest rates of PTSD. Rescuers and first responders were at next highest
risk. Although other outcomes such as depression and substance abuse have
garnered increasing attention, studies of non-injury somatic disturbances
received relatively little attention and may be an area for future research.
While we limited our analysis to studies presenting outcomes based on validated
diagnostic and screening instruments, changes in diagnostic criteria for PTSD
over time 14 10 9 and the myriad available screening instruments available for
assessing PTSD15 11, 16 17, 18 make comparisons difficult even within the same
geographic region. These different diagnostic and screening standards demand
cautious interpretation of literature syntheses.
The higher prevalence reported in Western Europe lends credence to the idea
that there are also local, cultural aspects to the diagnosis of PTSD that preclude
easy comparisons. It is unfortunate that there were insufficient studies to include
such regions as Asia, South America and the Indian Subcontinent, but there was
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sufficient variation among the regions that were represented to demonstrate the
importance of taking geographic variation into account as well.
Several studies have addressed the effect of disasters on children. The risk for
developing post-disaster PTSD varies by age with an increase during school age,
followed by a second more prominent increase during middle age. 6 Most such
studies present symptoms rather than diagnoses. Although we did not explicitly
exclude children, by requiring diagnostic assessments for a study to be included,
there were no studies of children that met inclusion criteria for our analysis.
It
should be noted, for example, that though our regression of age on the logit of
event rate indicates an age effect, the data do not include pediatric populations.
There is a need for further study addressing this important group.
The 40% higher prevalence of post-terrorism PTSD among predominantly female
populations that we found mirrors the general disaster literature. Ninety-four
percent of studies that looked at gender found that being female was associated
with an increased risk of post-disaster behavioral health disturbance,7 with
women reported as being twice as likely to develop PTSD.
parenthood are also associated with increased risk.
6
19
Marriage and
Taken together, these
associations point to the potential common mediating factor of an imbalance of
resources, or the stress of caring for others and being obligated to provide more
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resources than are received. 7 The only post-disaster behavioral outcome
associated with males is alcohol abuse.7
Although there was a suggestion of variation by race, our results were
statistically inconclusive. Minority status and lower socioeconomic status are
generally associated with increased risk of post-disaster behavioral diagnoses.
This is due, at least in part, to increased risk of exposure. 6
We found an association between media exposure and PTSD, but many of the
studies were cross-sectional. Causality might equally plausibly flow from the
exposure of viewing media images to PTSD or from individuals with PTSD being
drawn to media images of the event. That the association of viewing media
images with PTSD declined with time in a fashion similar to overall PTSD
prevalence supports both the notion that the presence of PTSD in an individual
drives media viewing as well, perhaps, as the expected decline in media
coverage with time.
We did not demonstrate a substantial difference in prevalence of PTSD among
samples drawn from populations close to events (but excluding survivors and
rescuers) compared to those drawn from populations father removed from the
event. This is due in part to the relatively few number of studies available for
comparison, and perhaps also the role of the media in dispersing images of
events, particularly in Western nations. It also reflects the contradictory evidence
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on the effects of terrorist events on the general population. In the immediate
post-attack period, there were reports of anxiety-related diagnoses of nearly 50%
in New York City’s Chinatown (located in the immediate vicinity of the World
Trade Center).20 Another study reported that symptoms of emotional distress
were evident even at long distances from the east coast with 91% of respondents
to a national survey having at least one stress-related symptom, and 44% having
one or more substantial symptom.21 In contrast, there was no increased demand
for mental health services in Canada following 9/11.22 In the Midwest United
State, 5.9% of respondents to a survey had evidence of PTSD, exactly matching
the prevalence of national surveys preceding the events of 9/11.23 This, though,
might be due to our inability to categorize geographic distances more finely.
This study was subject to a number of potential limitations, some of which have
already been mentioned. Meta-analyses should be interpreted cautiously. An
over-reliance on summary statistics may obscure theory. Studies may be so
heterogeneous as to challenge the basis of combining them, and there may be
undetected systematic variation among studies. A meta-analysis can only be as
valid and reliable as the studies upon which it is based.24 Part of our analysis, for
example, pooled studies of survivors, rescue personnel and local populations.
These are three disparate groups likely to have different responses to terrorist
incidents.
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Despite these difficulties, synthetic analysis has the advantages of providing a
disciplined, theoretically sound, and systematic approach that avoids some of the
subjective and indiscriminant aspects of traditional literature reviews. We took
efforts to apply the most valid aspects of meta-analytic technique and avoid
potential pitfalls. A priori variable definitions and study criteria were posited. The
search process was explicitly described and documented. Studies were coded
so as to enhance the ability to combine them in valid ways. A random effects
statistical approach was adopted for all analyses in recognition of the likely
heterogeneity of included studies. And, we attempted to balance the quantitative
aspects of the review with the qualitative.
This review has implications for treatment and public health control. Prior
psychiatric diagnoses are strongly associated with subsequent PTSD and may
be a useful triage factor, particularly when taken with such factors as female
gender and direct exposure to events as either a survivor or rescuer. Our review
indicates that these associations are consistent across study types and
environments, and represent important variables to consider when developing
triage, outreach and treatment programs.
Terrorism is psychological warfare 25, and behavioral disturbance is the primary
intent of terrorists. Effective post-terrorist public health interventions require the
recognition that behavioral consequences are, in fact, the intent of terrorists.
Although most people in the general population can be expected to recover
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spontaneously within several months to a year, emergency department
practitioners can contribute to interventions to facilitate and speed the process.
These include recognition of honest appraisals of behavioral health effects in
community health announcements, preserving as much as possible community,
family and social networks and returning individuals to normal activities as soon
as feasible. Finally, some individuals such as survivors, rescuers and those with
a prior psychiatric history are at increased risk of conditions such as PTSD and
may require outreach efforts and individual interventions.
Page 19
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Tables and Figures
Figure 1: Comparison of proportion of post-terrorism behavioral health studies
entered into analysis (black) to proportion of reported terrorist incidents since
1980 (grey) by region of the world.
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Page 23
Table 1: Primary Outcomes of Studies Included in Systematic Review of PostTerrorist Behavioral Health Disturbances
Frequency
Percent
Post Traumatic Stress Disorder
61
54.0
Depression
10
8.8
Stress/Anxiety
5
4.4
Substance Abuse
7
6.2
Other Primarily Behavioral
Outcome
Respiratory Symptoms
18
15.9
2
1.8
Cardiac Symptoms
1
.9
Other Somatic Disorder
8
7.1
Unable to Determine
1
.9
113
100.0
Total
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Figure 2: PTSD Prevalence by Time from Event. All Effects Included in Systematic
Review of Post-Terrorist Behavioral Health Disturbances
Overall PTSD Prevalence by Time from Event
Group by
time
Study name
1: Two Months
1: Two Months
1: Two Months
1: Two Months
1: Two Months
2: Six Months
2: Six Months
2: Six Months
2: Six Months
2: Six Months
2: Six Months
2: Six Months
2: Six Months
3: One Year
3: One Year
3: One Year
3: One Year
3: One Year
3: One Year
3: One Year
3: One Year
4: Five Years
4: Five Years
4: Five Years
4: Five Years
4: Five Years
4: Five Years
4: Five Years
4: Five Years
4: Five Years
4: Five Years
4: Five Years
4: Five Years
Indeterminate
Indeterminate
Indeterminate
Indeterminate
Indeterminate
Synthesis
Franklin, 2002
Galea, 2002
Mason, 2003
Njenga, 2004
Synthesis
Shalev, 1992
Sprang, 2001
CDC, 2002b
Lamberg, 2003
Pantin, 2003
Galea, 2003a
Jordan, 2004
Statistics for each study
Event
rate
Amir, 1998
Grieger, 2003
Galea, 2003 b
Lating, 2004
Sciancalepore, 2004
de Bocanegra, 2004
Gidron, 2004
Synthesis
Desivilya, 1996
Pfefferbaum, 2000
Kawana, 2001
North, 2002
Bleich, 2003
Cardenas, 2003
Grieger, 2004a
Grieger, 2004b
Verger, 2004a
Boscarino, 2004a
CDC, 2004
Synthesis
Synthesis
Curran, 1990
Abenhaim, 1992
Loughry, 1998
Hyman, 2004
0.330
0.075
0.050
0.354
0.159
0.333
0.082
0.389
0.309
0.136
0.023
0.079
0.142
0.267
0.143
0.015
0.183
0.171
0.208
0.101
0.123
0.085
0.435
0.028
0.133
0.094
0.059
0.226
0.226
0.311
0.083
0.197
0.142
0.230
0.181
0.232
0.136
0.209
Lower
limit
0.271
0.060
0.028
0.336
0.060
0.131
0.053
0.343
0.292
0.084
0.017
0.072
0.063
0.104
0.081
0.010
0.167
0.114
0.131
0.062
0.058
0.036
0.323
0.014
0.090
0.071
0.037
0.175
0.175
0.250
0.072
0.175
0.096
0.196
0.138
0.197
0.077
0.177
Event rate and 95% CI
Upper
limit
0.395
0.093
0.088
0.372
0.359
0.624
0.124
0.437
0.326
0.214
0.031
0.087
0.287
0.533
0.240
0.023
0.200
0.248
0.313
0.160
0.240
0.188
0.553
0.055
0.190
0.122
0.092
0.288
0.288
0.379
0.095
0.221
0.206
0.269
0.233
0.272
0.229
0.246
-1.00
Page 25
DiMaggio, et al. 2005
-0.50
0.00
0.50
1.00
Figure 3: Terrorism-Related PTSD Prevalence Effect Sizes Grouped by Event
Within the US: (OKC = Oklahoma City Bombing, Sept 11 = World Trade
Center Attacks)
Study name
OKC
OKC
OKC
OKC Synthesis.
Sept 11
Sept 11
Sept 11
Sept 11
Sept 11
Sept 11
Sept 11
Sept 11
Sept 11
Sept 11
Sept 11
Sept 11
Sept 11
Sept 11
Sept 11
Sept 11
Sept 11
Sept 11 Synthesis.
Pfefferbaum, 2000
Sprang, 2001
North, 2002
CDC, 2002b
Franklin, 2002
Galea, 2002
Grieger, 2003
Mason, 2003
Pantin, 2003
Cardenas, 2003
Galea, 2003a
Galea, 2003 b
Grieger, 2004a
Grieger, 2004b
Jordan, 2004
Lating, 2004
Sciancalepore, 2004
Boscarino, 2004a
CDC, 2004
de Bocanegra, 2004
Statistics for each study
Prevalence Lower
limit
Upper
limit
0.435
0.082
0.133
0.173
0.389
0.330
0.075
0.143
0.050
0.136
0.059
0.023
0.015
0.226
0.226
0.079
0.183
0.171
0.083
0.197
0.208
0.130
0.553
0.124
0.190
0.213
0.437
0.395
0.093
0.240
0.088
0.214
0.092
0.031
0.023
0.288
0.288
0.087
0.200
0.248
0.095
0.221
0.313
0.136
0.323
0.053
0.090
0.139
0.343
0.271
0.060
0.081
0.028
0.084
0.037
0.017
0.010
0.175
0.175
0.072
0.167
0.114
0.072
0.175
0.131
0.124
Prevalence and 95% CI
-1.00
Page 26
-0.50
0.00
0.50
1.00
Figure 4: Terrorism-Related PTSD Prevalence Effect Sizes Grouped by
Exposure Category. (Survivors, Rescuers, Employees, General
Population)
Study name
1: Survivors
1: Survivors
1: Survivors
1: Survivors
1: Survivors
1: Survivors
1: Survivors
1: Survivors
1: Survivors Synthesis
2: Rescuers
2: Rescuers
2: Rescuers Synthesis
3: Employment
3: Employment
3: Employment
3: Employment
3: Employment
3: Employment
3: Employment Synthesis
4: Population
4: Population
4: Population
4: Population
4: Population
4: Population
4: Population
4: Population
4: Population
4: Population
4: Population Synthesis
Curran, 1990
Shalev, 1992
Abenhaim, 1992
Desivilya, 1996
Loughry, 1998
Amir, 1998
Kawana, 2001
Verger, 2004a
North, 2002
CDC, 2004
Grieger, 2003
Grieger, 2004a
Grieger, 2004b
Hyman, 2004
Jordan, 2004
Lating, 2004
Pfefferbaum, 2000
Sprang, 2001
CDC, 2002b
Galea, 2002
Bleich, 2003
Galea, 2003a
Galea, 2003 b
Njenga, 2004
Boscarino, 2004a
Gidron, 2004
Statistics for each study
Prevalence Lower
limit
Upper
limit
0.230
0.333
0.181
0.085
0.232
0.267
0.028
0.311
0.180
0.133
0.197
0.168
0.143
0.226
0.226
0.136
0.079
0.183
0.158
0.435
0.082
0.389
0.075
0.094
0.023
0.015
0.354
0.083
0.101
0.109
0.269
0.624
0.233
0.188
0.272
0.533
0.055
0.379
0.249
0.190
0.221
0.242
0.240
0.288
0.288
0.229
0.087
0.200
0.242
0.553
0.124
0.437
0.093
0.122
0.031
0.023
0.372
0.095
0.160
0.216
0.196
0.131
0.138
0.036
0.197
0.104
0.014
0.250
0.127
0.090
0.175
0.114
0.081
0.175
0.175
0.077
0.072
0.167
0.099
0.323
0.053
0.343
0.060
0.071
0.017
0.010
0.336
0.072
0.062
0.052
Prevalence and 95% CI
-1.00
Page 27
-0.50
0.00
0.50
1.00
Figure 5: Terrorism-Related PTSD Prevalence Effect Sizes Grouped by General
Population Categories: (Local = Less than 20 miles; National = Greater
than 100 miles)
Study name
Statistics for each study
Prevalence and 95% CI
PTSD Prevalence by Subjects
Prevalence
Local
Group by
subjects
Local
Local
Local
1: Survivors
Local
1: Survivors
1: Survivors
Local
1: Survivors
Local
1: Survivors
Local Synthesis
1: Survivors
National
1: Survivors
National
1: Survivors
1: Survivors
National
Synthesis
2: Rescuers
2: Rescuers
2: Rescuers
3: Employment
3: Employment
3: Employment
3: Employment
3: Employment
3: Employment
3: Employment
4: Population
4: Population
4: Population
4: Population
4: Population
4: Population
4: Population
4: Population
4: Population
4: Population
4: Population
Sprang,Study
2001 name
Galea, 2002
Galea, 2003a
Galea, Curran,
2003 b 1990
Njenga,Shalev,
2004 1992
Abenhaim,
Boscarino,
2004a 1992
Desivilya,
1996
CDC, 2004
Loughry, 1998
Amir, 1998
Bleich, Kawana,
2003
2001
Gidron,Verger,
2004 2004a
North, 2002
CDC, 2004
Grieger, 2003
Grieger, 2004a
Grieger, 2004b
Hyman, 2004
Jordan, 2004
Lating, 2004
Pfefferbaum, 2000
Sprang, 2001
CDC, 2002b
Galea, 2002
Bleich, 2003
Galea, 2003a
Galea, 2003 b
Njenga, 2004
Boscarino, 2004a
Gidron, 2004
0.082
0.075
0.023
0.015
0.354
0.083
0.197
0.079
0.094
0.101
0.095
Lower
limit
Upper
limit
0.053 for each
0.124
Statistics
study
Odds Ratio and 95% CI
0.060
0.093
Event
Lower
Upper
rate 0.017 limit 0.031 limit
0.230 0.010 0.196 0.023 0.269
0.333 0.336 0.131 0.372 0.624
0.181 0.072 0.138 0.095 0.233
0.085 0.175 0.036 0.221 0.188
0.232
0.197
0.272
0.033
0.176
0.267
0.104
0.533
0.028 0.071 0.014 0.122 0.055
0.311 0.062 0.250 0.160 0.379
0.180 0.075 0.127 0.120 0.249
0.133
0.090
0.190
-1.00
-0.50
0.00
0.50
1.00
0.197
0.175
0.221
0.168
0.114
0.242
0.143
0.081
0.240
0.226
0.175
0.288
0.226
0.175
0.288
0.136
0.077
0.229
0.079
0.072
0.087
0.183
0.167
0.200
0.158
0.099
0.242
0.435
0.323
0.553
0.082
0.053
0.124
0.389
0.343
0.437
0.075
0.060
0.093
0.094
0.071
0.122
0.023
0.017
0.031
0.015
0.010
0.023
0.354
0.336
0.372
0.083
0.072
0.095
0.101
0.062
0.160
0.109
0.052
0.216
-1.00
-0.50
0.00
0.50
Page 28
1.00
Appendix: List of 113 Studies Eligible for Inclusion in Post-Terrorism Behavioral Health Meta-Analysis. * Indicates 61 PTSDRelated Studies.  Indicates article identified through hand search of references. Note Indicates Group Studied and Synthetic
Analysis Into Which Study Was Entered. Where not otherwise indicated, population is US based.
Lead Author
Abenhaim L
*
Aber J
Adams ML
*
Ahern J
*
Ahern J
*
Amir M
*
Amir M 
*
Asmundson GJ
Auger RWr
Austin PC
*
Blanchard EB
*
Bleich A
Title, Journal, Volume
Study of civilian victims of terrorist attacks (France 1982-1987) J Clin Epidemiol
Feb 1992;45(2):103-109
Estimating the effects of September 11th and other forms of
violence on the mental health and social development of
New York City's youth: A matter of context Applied Developmental Science
Jul;8(3):111-129
Predictors of help seeking among Connecticut adults after September 11, 2001 Am J Public
Health
Sep 2004;94(9):1596-1602
Television images and psychological symptoms after the September 11 terrorist attacks
Psychiatry
Winter 2002;65(4):289-300
Television images and probable posttraumatic stress disorder after September 11:
the role of background characteristics, event exposures, and perievent panic J Nerv Ment Dis
Mar 2004;192(3):217-226
Type of trauma, severity of posttraumatic stress disorder core symptoms,
and associated features J Gen Psychol
Oct 1996;123(4):341-351
Debriefing with brief group psychotherapy in a homogenous group of
non-injured victims of a terrorist attack: a prospective study
Acta Psychiatr Scand
Sep 1998;98(3):237-242
Psychological sequelae of remote exposure to the September 11th
terrorist attacks in Canadians with and without panic Cogn Behav Ther
2004;33(2):51-59
Responding to Terror: The Impact of September 11 on K-12 Schools and Schools' Responses
Professional School Counseling Apr;7(4):222-230
Anxiety-related visits to Ontario physicians following September 11, 2001
Canadian Journal of Psychiatry
2003;48(6):416-419
Studies of the vicarious traumatization of college students by the
September 11th attacks: effects of proximity, exposure and connectedness
Behav Res Ther
Feb 2004;42(2):191-205
Exposure to terrorism, stress-related mental health symptoms, and
coping behaviors among a nationally representative sample in Israel
Page 29
Note
Survivors
Pediatric (Urban,
Population Based)
Media & PTSD
Primary Care Population
General Population (Urban)
Media & PTSD
General Population (Urban)
Psychiatric History &
PTSD
Survivors
Survivors
General Population (Candadian)
Psychiatric History &
PTSD
Pediatric (School Based)
Primary Care Population
Population
College-Aged Students
General Population (Israeli, National)
PTSD Prevalence;
Blendon RJJ
Bock BC
Boscarino JA
*
Boscarino JA
Boscarino JA
Brennan M
*
Cardenas J
CDC
*
CDC
CDC
CDC
JAMA
2003;289:612-620
The impact of anthrax attacks on the American public
Med Gen Med
Apr 17 2002;4(2):1
Stress and anxiety after 9/11: a prospective study
Med Health R I
Nov 2003;86(11):340-341
Compassion fatigue following the September 11 terrorist attacks:
a study of secondary trauma among New York City social workers
Int J Emerg Ment Health
Spring 2004;6(2):57-66
Adverse reactions associated with studying persons recently
exposed to mass urban disaster J Nerv Ment Dis
Aug 2004;192(8):515-524
Psychiatric medication use among Manhattan residents
following the World Trade Center disaster
J Trauma Stress
Jun 2003;16(3):301-306
The September 11th Attacks and Depressive Symptomatology
Among Older Adults with Vision Loss in New York City
J Gerontological Social Work
2003;40(4):55-71
PSTD, major depressive symptoms, and substance abuse
following September 11, 2001, in a midwestern university population
Int J Emerg Ment Health
Winter 2003;5(1):15-28
Impact of September 11 attacks on workers in the vicinity of the
World Trade Center--New York City
MMWR
Sep 11 2002;51 Spec No:8-10
Mental health status of World Trade Center rescue and recovery
workers and volunteers - New York City, July 2002-August 2004
MMWR
Sep 10 2004;53(35):812-815
Psychological and emotional effects of the September 11 attacks
on the World Trade Center--Connecticut, New Jersey, and New York, 2001
MMWR
2002;51(35):784-786
Self-reported increase in asthma severity after the September 11
attacks on the World Trade Center--Manhattaan, New York, 2001
Page 30
Gender & PTSD
General Population (National)
Smoking Cessation Patients
Health Care Providers
(Social Work)
Local Population
PTSD Prevalence
General Population (Urban,
Close Proximity to Event)
Geriatric Population (Urban)
College-Age Students
PTSD Prevalence
Occupational Groups
(Close Proximity to Event)
Rescue Workers
General Population(Local States)
General Population (Local , Urban)
CDC
Chen H
Chi JS
*
Connery HS
Creson DL
*
Curran PS 
de Bocanegra
*
de Jong JT
*
DeLisi LE
*
Desivilya HS
Druss BG
MMWR
2002;51(35):781-784
Psychological and emotional effects of the September 11 attacks
n the World Trade Center--Connecticut, New Jersey, and New York, 2001
JAMA
Sep 25 2002;288(12):1467-1468
The emotional distress in a community after the terrorist attack
on the World Trade Center
Community Ment Health J
Apr 2003;39(2):157-165
Cardiovascular mortality in New York City after September 11, 2001
American Journal of Cardiology
2003;92(7):857-861
Acute symptoms and functional impairment related to September 11
terrorist attacks among rural community outpatients with severe mental illness
Harv Rev Psychiatry
Jan-Feb 2003;11(1):37-42
Stress and behavior change in a substance-abusing population following
September 11, 2001
Addictive Disorders
2003;2(2):59-61
Psychiatric aspects of terrorist violence in Northern Ireland (1969 to 1989)
Med Leg J
1990;58 ( Pt 2):83-96
Mental Health Impact of the World Trade Center Attacks on Displaced
Chinese Workers
Journal of Traumatic Stress
Feb;17(1):55-62
Lifetime events and posttraumatic stress disorder in 4 postconflict settings
JAMA
Aug 1 2001;286(5):555-562
A survey of New Yorkers after the Sept 11, 2001, terrorist attacks
Am J Psychiatry
Apr 2003;160(4):780-783
Extent of victimization, traumatic stress symptoms, and adjustment of
terrorist assault survivors: a long-term follow-up
Journal of Traumatic Stress
1996;9(4):881-889
Use of psychotropic medications before and after Sept 11 2001
American Journal of Psychiatry
2004;161(8):1377-1383
Page 31
General Population (Local States)
PTSD Prevalence
General Population (Urban,
Close Proximity to Event)
General Population (Urban,)
Psychiatric Outpatients
Substance Abuse Outpatients
General Population (Irish, National)
Local Ethnic Group (Asian)
Survivors
General Population (Urban)
Survivors
Psychiatric Patients
Factor S
*
Fagan J
Ford CA
*
Franklin CL
*
Galea S
*
Galea S
Gibson M
Gidron Y
*
Gidron Y
Gil-Rivas V
Gobble R
*
Gould MS
*
Grieger TA
Drug use frequency among street-recruited heroin and cocaine users in
Harlem and the Bronx before and after September 11 2001.
J. Urban. Health
2002: 79 [3): 404-8
Relationship of self-reported asthma severity and urgent health care
utilization to psychological sequelae of the September 11, 2001
Psychosom Med
Nov-Dec 2003;65(6):993-996
Reactions of young adults to September 11, 2001
Arch Pediatr Adolesc Med
Jun 2003;157(6):572-578
Psychiatric patients' vulnerability in the wake of the September 11th terrorist attacks
J Nerv Ment Dis
Dec 2002;190(12):833-838
Psychological sequelae of the September 11 terrorist attacks in New York City
N Engl J Med
Mar 28 2002;346(13):982-987
Trends of probable post-traumatic stress disorder in New York City
after the September 11 terrorist attacks Am J Epidemiol
Sep 15 2003;158(6):514-524
An Empirical Study into the Psychosocial Reactions of Staff Working as
Helpers to those Affected in the Aftermath of two Traumatic Incidents
British Journal of Social Work
Oct;33(7):851-869
Bus commuters' coping strategies and anxiety from terrorism:
An example of the Israeli experience Journal of Traumatic Stress
Jan 1999;12(1):185-192
Prevalence and moderators of terror-related post-traumatic stress
disorder symptoms in Israeli citizens Isr Med Assoc J Jul 2004;6(7):387-391
Adolescent vulnerability following the September 11th terrorist attacks:
A study of parents and their children Applied Developmental Science
Jul;8(3):130-142
The impact of the September 11, 2001 terrorist attacks and aftermath
on the incidence of recurrent abdominal pain syndrome in children
Clinical Pediatrics 2004;43(3):275-277
Impact of the September 11th terrorist attacks on teenagers' mental health
Applied Developmental ScienceJul;8(3):158-169
Posttraumatic stress disorder, depression, and perceived safety
13 months after September 11 Psychiatr Serv Sep 2004;55(9):1061-1063
Page 32
Substance Abusers
Urgent Care/ED Patients
Pediatric (General Population)
Psychiatric Patients
PTSD Prevalence;
Psychiatric History &
PTSD
General Population (Urban)
PTSD Prevalence
General Population (Urban)
PTSD Prevalence;
Psychiatric History &
PTSD
Health Care Workers
General Population (Israeli,
Commuters)
General Population (Israeli, National)
PTSD Prevalence
Pediatric (Adolescent)
Pediatric (Outpatients)
Pediatric (Adolescent)
Occupational Group
PTSD Prevalence
Heim C
Henry DB
*
Hyman O
Johnston SC
*
Jordan NN
*
Kawana N
Khan W
*
Lamberg L
Laraque D
*
Lating JMr
*
Loughrey GC
Mason BW
*
Murphy RT
Nakonezny PA
*
Njenga FG
*
North CS
*
North CS
Regional prevalence of fatiguing illnesses in the United States
before and after the terrorist attacks of September 11, 2001
Psychosom MedSep-Oct 2004;66(5):672-678
Have There Been Lasting Effects Associated With the September 11, 2001,
Terrorist Attacks Among Inner-City Parents and Children?
Professional Psychology Oct;35(5):542-547
Perceived social support and secondary traumatic stress symptoms
in emergency responders J Trauma Stress Apr 2004;17(2):149-156
Effects of the September 11th attacks on urgent and emergent medical
evaluations in a Northern California managed care plan
Am J MedNov 2002;113(7):556-562
Mental health impact of 9/11 Pentagon attack validation of a rapid assessment
American Journal of Prev Med May 2004;26(4):284-293
Psycho-physiological effects of the terrorist sarin attack on the
Tokyo subway system Mil Med Dec 2001;166(12 Suppl):23-26
Impact of terrorism on mental health and coping strategies of
adolescents and adults in Kashmir J of Personality & Clinical Studies
Mar 2002;18(1-2):33-41
In the wake of tragedy: studies track psychological response to mass violence
JAMA Aug 6 2003;290(5):587-589
Reactions and needs of tristate-area pediatricians after the events of
September 11th: implications for children's mental health services
Pediatrics May 2004;113(5):1357-1366
PTSD reactions and functioning of American Airlines flight
attendants in the wake of September 11 J Nerv Ment Dis
Jun 2004;192(6):435-441
Post-traumatic stress disorder and civil violence in Northern Ireland
Br J Psychiatry Oct 1988;153:554-560
Acute psychological effects of suspected bioterrorism
J Epidemiol Community Health May 2003;57(5):353-354
Stress symptoms among African-American college students after the
September 11, 2001 terrorist attacks J Nerv Ment Dis Feb 2003;191(2):108-114
Did divorces decline after the Oklahoma City bombing?
Journal of Marriage & Family Feb;66(1):90-100
Post-traumatic stress after terrorist attack: psychological reactions
following the US embassy bombing in Nairobi: Naturalistic study
Br J Psychiatry Oct 2004;185:328-333
Psychiatric disorders among survivors of the Oklahoma City Bombing
JAMA 1999; 282: 755-762
Psychiatric disorders in rescue workers after the Oklahoma City
Bombing Am J Psychiatry May 2002;159(5):857-859
Page 33
General Population (National)
General Population (Urban)
First Responders
PTSD Prevalence
Urgent Care Patients
Occupational Exposure Group
PTSD Prevalence
Survivors
PTSD Prevalence
Pediatric (Adolescent) Relatives
Of Victims
Local Population
PTSD Prevalence
Health Care Providers (Pediatricians)
Occupational Group
(Flight Attendants)
PTSD Prevalence
General Population (National, Irish)
PTSD Prevalence
College-Aged Students
General Population (Local State)
General Populaiton (Local)
PTSD Prevalence
Survivors
Gender & PTSD
First Responders
PTSD Prevalence
*
Pantin HM
Perrine MW
Peterson C
*
Pfefferbaum B
*
Pfefferbaum Bl
Pfefferbaum B
*
Pfefferbaum B
*
Pfefferbaum B
Pfefferbaum B
*
Pfefferbaum B
*
Pfefferbaum B
*
Pfefferbaum B
*
Pfefferbaum B,
*
Pfefferbaum B,
Pfefferbaum B
Piiparinen RA
Posttraumatic Stress Disorder Symptoms in Hispanic Immigrants after t
he September 11th Attacks: Severity and Relationship to Previous Traumatic Exposure
Hispanic of Behavioral Sciences 2003, 25, 1, Feb, 56-72
The impact of the September 11, 2001, terrorist attacks on alcohol
consumption and distress: reactions to a national trauma 300 miles from Ground Zero
Journal of Studies on Alcohol 2004;65(1):5-15
Character strengths before and after September 11 Psychological Science
2003;14(4):381-384
The impact of the Oklahoma City bombing on children in the community
Mil Med Dec 2001;166(12 Suppl):49-50
Traumatic grief in a convenience sample of victims seeking
support services after a terrorist incident Ann Clin Psychiatry
Mar 2001;13(1):19-24
Increased alcohol use in a treatment sample of oklahoma city bombing victims.
Psychiatry 2001; 64: 296-303
Exposure and peritraumatic response as predictors of posttraumatic
stress in children following the 1995 Oklahoma City bombing
J Urban Health Sep 2002;79(3):354-363
Television exposure in children after a terrorist incident
Psychiatry Fall 2001;64(3):202-211
The impact of the 1995 Oklahoma City bombing on the partners of firefighters
J Urban Health Sep 2002;79(3):364-372
Posttraumatic stress and functional impairment in Kenyan
children following the 1998 American Embassy bombing
Am J Orthopsychiatry Apr 2003;73(2):133-140
The emotional impact of injury following an international terrorist incident
Public Health Rev 2001;29(2-4):271-280
Teachers' Psychological Reactions 7 Weeks After the 1995
Oklahoma City Bombing Am J Orthopsychiatry Jul;74(3):263-271
Case finding and mental health services for children in the
aftermath of the Oklahoma City bombing J Behav Health Serv Res
Apr-Jun 2003;30(2):215-227
Posttraumatic stress two years after the Oklahoma City bombing
in youths geographically distant from the explosion
Psychiatry
Win 2000;63(4):358-370
The effect of loss and trauma on substance use behavior in
individuals seeking support services after the 1995 Oklahoma City bombing
Ann Clin Psychiatry Jun 2002;14(2):89-95
Stress symptoms of two groups before and after the terrorist attacks of 9/11/01
Page 34
Ethinic Group, (Hispanic)
PTSD Prevalence;
Media & PTSD;
Gender & PTSD
General Population (Distant State)
General Population (National)
Pediatric (General Population)
Outpatients (Local, Exposed to Event)
Survivors
Pediatric (Local Population)
Pediatric (Local Population)
Media & PTSD
Family Members of Survivors
Pediatric (Local Population)
Survivors
Media & PTSD
Occupational Group (Teachers)
Pediatric (Local Population)
Pediatric (Distant Population)
PTSD Prevalence;
Media & PTSD
Outpatients (Local Population)
College Age Students (Distant)
Raphael KG
Reissman DB
Riemann BC
Rosenheck R
*
*
Rosenheck RA
Rothman PD
Ryan AM
Salib E
*
Saylor CF
*
Schlenger WE,
Schuster MA,
*
Sciancalepore R
*
Shalev AY
Shalev AY
*
Silver RC
Percept Mot Skills Oct 2003;97(2):360-364
A community-based survey of fibromyalgia-like pain complaints
following the World Trade Center terrorist attacks
Pain Nov 2002;100(1-2):131-139
One-year health assessment of adult survivors of Bacillus anthracis infection
Jama Apr 28 2004;291(16):1994-1998
Effects of September 11 on patients with obsessive compulsive disorder
Cogn Behav Ther 2004;33(2):60-67
Use of mental health services by veterans with PTSD after the terrorist attacks of September
11
Am J Psychiatry Sep 2003;160(9):1684-1690
Post-september 11 admission symptoms and treatment response among veterans with
posttraumatic
stress disorder Psychiatr Serv Dec 2003;54(12):1610-1617
The influence of the quality of adult attachment and degree of exposure to the World Trade
Center
Disaster on Post-Traumatic Stress symptoms in a college population
Dissertation Abstracts Int 2004;64(8-B):4060
Effects of the terrorist attacks of 9/11/01 on employee attitudes
Journal of Applied Psychology 2003;88(4):647-659
Effect of 11 September 2001 on suicide and homicide in England and Wales
British Journal of Psychiatry 2003;183:207-212
Media Exposure to September 11: Elementary School Students'
Experiences and Posttraumatic Symptoms American Behavioral Scientist
2003, 46, 12, Aug, 1622-1642
Psychological reactions to terrorist attacks: findings from the
National Study of Americans' Reactions to September 11
Jama Aug 7 2002;288(5):581-588
A national survey of stress reactions after the September 11, 2001, terrorist attacks
N Engl J Med Nov 15 2001;345(20):1507-1512
Gender related correlates of posttraumatic stress symptoms in
a World Trade Center tragedy sample Int J Emerg Ment Health
Winter 2004;6(1):15-24
Posttraumatic stress disorder among injured survivors of a terrorist
attack. Predictive value of early intrusion and avoidance symptoms
J Nerv Ment Dis Aug 1992;180(8):505-509
Psychophysiologic assessment of mental imagery of stressful events in
Israeli civilian posttraumatic stress disorder patients
Compr Psychiatry Sep-Oct 1997;38(5):269-273
Nationwide longitudinal study of psychological responses to September 11 JAMA
Sep 11 2002;288(10):1235-1244
Page 35
General Population (National)
Survivors
General Population (Distant)
Occupational Group (Military
Veterans)
Occupational Group(Military
Veterans)
College-Age Students
Media & PTSD;
Gender & PTSD
Occupational Group (Local to Event)
General Population (National,
England)
Media & PTSD
General Population (National)
General Population (National,)
Survivors
PTSD Prevalence:
Gender & PTSD
Survivors (Israeli)
Psychiatric Patients (Israeli)
General Population (National)
Psychiatric History & PTSD;
Gender & PTSD
*
Sprang G
Stein BD
*
Szema AM,
Thiel de Bocanegra
H
*
Trautman R
*
Tucker P
*
Tucker P
*
Tucker P,
*
Ursano RJ,
*
van Zelst W,
*
Verger P
Vlahov D
Von Hippel CC
*
Wayment HA
Weissman EM
Vicarious stress: patterns of disturbance and use of mental health
services by those indirectly affected by the Oklahoma City bombing
Psychol Rep Oct 2001;89(2):331-338
A national longitudinal study of the psychological consequences of the
September 11, 2001 terrorist attacks: reactions, impairment, and help-seeking
Psychiatry Summer 2004;67(2):105-117
Clinical deterioration in pediatric asthmatic patients after September 11, 2001
J Allergy Clin Immunol Mar 2004;113(3):420-426
Mental health impact of the World Trade Center attacks on displaced
Chinese workers J Trauma Stress Feb 2004;17(1):55-62
Effects of prior trauma and age on posttraumatic stress symptoms in
Asian and Middle Eastern immigrants after terrorism in the community
Community Ment Health J Dec 2002;38(6):459-474
Traumatic reactions as predictors of posttraumatic stress six months
after the Oklahoma City bombing Psychiatr Serv Sep 1997;48(9):1191-1194
Body handlers after terrorism in Oklahoma City: Predictors of
posttraumatic stress and other symptoms American J Orthopsychiatry
Oct 2002;72(4):469-475
Predictors of post-traumatic stress symptoms in Oklahoma City:
exposure, social support, peri-traumatic responses J Behav Health Serv Res
Nov 2000;27(4):406-416
Traumatic death in terrorism and disasters: The effects on posttraumatic stress and behavior
Terrorism and disaster 2003:308-332
Effects of the September 11th attacks on symptoms of PTSD on
community-dwelling older persons in the Netherlands Int J Geriatr Psychiatry
Feb 2003;18(2):190
The psychological impact of terrorism: an epidemiologic study of
posttraumatic stress disorder and associated factors in victims
of the 1995-1996 bombings in France Am J Psychiatry Aug 2004;161(8):1384-1389
Consumption of cigarettes, alcohol, and marijuana among
New York City residents six months after the September 11 terrorist attacks
Am J Drug Alcohol Abuse May 2004;30(2):385-407
The effects of political violence on childhood aggression in Israel,
California School of Professional Psychology - Berkeley/alameda, US; 1997
Dissertation Abstracts Int: Vol 57(12-B), Jun 1997, 7746
It could have been me: vicarious victims and disaster-focused distress
Pers Soc Psychol Bull Apr 2004;30(4):515-528
Volume of VA patients with posttraumatic stress disorder
Page 36
Local Population
PTSD Prevalence
General Population (National)
Pediatric Outpatients
Local Ethnic Group (Asian)
PTSD Prevalence
Ethnic Group (Local)
Local Population
Occupational Group (Body Handlers)
Local Population
Media & PTSD
Textbook Chapter (Review)
Geriatric (Distant, National,
Netherlands)
Survivors
PTSD Prevalence;
Psychiatric History &
PTSD;
Gender & PTSD
Local Population
Pediatric School Sample (Israeli)
College Students
Local Occupational Group
*
Wilson WC 
Wolinsky FD
Zywiak WH
in the New York metropolitan area after September 11
Psychiatr Serv Dec 2003;54(12):1641-1643
Psychological effects of attack on the World Trade Center: analysis before and after
Psychol Rep Apr 2004;94(2):587-606
9-11, personal stress, mental health, and sense of control among older adults
J Gerontol B Psychol Sci Soc Sci
May 2003;58(3):S146-150
Alcohol relapses associated with September 11, 2001: a case report
Substance Abuse 2003;24(2):123-128
Page 37
(Military Veterans)
Pediatric (Local Population)
Geriatric Outpatients
Alcohol Detox Patients
Page 38