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Exposure to Terrorism, Stress-Related Mental Health Symptoms, and Coping Behaviors Among a Nationally Representative Sample in Israel
Avraham Bleich, MD;
Marc Gelkopf, PhD;
Zahava Solomon, PhD
JAMA. 2003;290:612-620.
Context The terrorist attacks on Israeli society have been ongoing since September 2000. However, few studies have examined the impact of terrorism on nationally representative population samples, and no study has examined the psychological impact of ongoing terrorism in Israel.
Objectives To determine the level of exposure to terrorist attacks and the prevalence of traumatic stress–related (TSR) symptoms, symptoms of posttraumatic stress disorder (PTSD), and sense of safety after 19 months of terrorism in Israel, and to identify correlates of the psychological sequelae and the modes of coping with the terrorism.
Design, Setting, and Participants Telephone survey conducted April-May 2002, using a strata sampling method, of 902 eligible households and a representative sample of 742 Israeli residents older than 18 years (82% contact rate) and a final participation of 512 (57%).
Main Outcome Measures Number of TSR symptoms, rates of those with symptom criteria for PTSD and acute stress disorder assessed by the Stanford Acute Stress Reaction Questionnaire, self-reported feelings of depression, optimism, sense of safety, help-seeking, and modes of coping.
Results Of 512 survey participants, 84 (16.4%) had been directly exposed to a terrorist attack and 191 (37.3%) had a family member or friend who had been exposed. Of 510 participants who responded to questions about TSR symptoms, 391 (76.7%) had at least 1 TSR symptom (mean, 4.0 [SD, 4.5]; range, 0-23; mean intensity, 0.8; range, 0-4). Symptom criteria for PTSD were met by 48 participants (9.4%) and criteria for acute stress disorder, by 1 participant; 299 (58.6%) reported feeling depressed. The majority of respondents expressed optimism about their personal future (421/512 [82.2%]) and the future of Israel (307/509 [66.8%]), and expressed self-efficacy with regard to their ability to function in a terrorist attack (322/431 [74.6%]). Most expressed a low sense of safety with respect to themselves (307/509 [60.4%]) and their relatives (345/507 [67.9%]). Few reported a need for professional help (27/506 [5.3%]). Female sex, sense of safety, and use of tranquilizers, alcohol, and cigarettes to cope were associated with TSR symptoms and symptom criteria for PTSD; level of exposure and objective risk were not. The most prevalent coping mechanisms were active information search about loved ones and social support.
Conclusions Considering the nature and length of the Israeli traumatic experience, the psychological impact may be considered moderate. Although the survey participants showed distress and lowered sense of safety, they did not develop high levels of psychiatric distress, which may be related to a habituation process and to coping mechanisms.
Author Affiliations: Lev-Hasharon Mental Health Center, affiliated with Tel-Aviv University Sackler School of Medicine, Tel-Aviv, Israel (Drs Bleich and Gelkopf); Department of Psychiatry, Tel-Aviv Sackler School of Medicine and Israel Trauma Center for Victims of Terror and War (NATAL) (Dr Bleich); Shappel School of Social Work and Adler Research Center, Tel-Aviv University (Dr Solomon).
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