Psychological Responses to the New Terrorism: A NATO-Russia Dialogue (Nato Security Through Science Series E: Human Societal Dynamics)

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PSYCHOLOGICAL RESPONSES TO THE NEW TERRORISM: A NATO-RUSSIA DIALOGUE

NATO Security through Science Series This Series presents the results of scientific meetings supported under the NATO Programme for Security through Science (STS). Meetings supported by the NATO STS Programme are in security-related priority areas of Defence Against Terrorism or Countering Other Threats to Security. The types of meeting supported are generally “Advanced Study Institutes” and “Advanced Research Workshops”. The NATO STS Series collects together the results of these meetings. The meetings are co-organized by scientists from NATO countries and scientists from NATO’s “Partner” or “Mediterranean Dialogue” countries. The observations and recommendations made at the meetings, as well as the contents of the volumes in the Series, reflect those of participants and contributors only; they should not necessarily be regarded as reflecting NATO views or policy. Advanced Study Institutes (ASI) are high-level tutorial courses to convey the latest developments in a subject to an advanced-level audience Advanced Research Workshops (ARW) are expert meetings where an intense but informal exchange of views at the frontiers of a subject aims at identifying directions for future action Following a transformation of the programme in 2004 the Series has been re-named and re-organised. Recent volumes on topics not related to security, which result from meetings supported under the programme earlier, may be found in the NATO Science Series. The Series is published by IOS Press, Amsterdam, and Springer Science and Business Media, Dordrecht, in conjunction with the NATO Public Diplomacy Division. Sub-Series A. B. C. D. E.

Chemistry and Biology Physics and Biophysics Environmental Security Information and Communication Security Human and Societal Dynamics

Springer Science and Business Media Springer Science and Business Media Springer Science and Business Media IOS Press IOS Press

http://www.nato.int/science http://www.springeronline.nl http://www.iospress.nl

Sub-Series E: Human and Societal Dynamics – Vol. 3

ISSN: 1574-5597

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue

Edited by

Simon Wessely Department of Psychological Medicine, Institute of Psychiatry, King’s College, London and King’s Centre for Military Health Research

and

Valery N. Krasnov Moscow Research Institute of Psychiatry, Moscow

Amsterdam • Berlin • Oxford • Tokyo • Washington, DC Published in cooperation with NATO Public Diplomacy Division

Proceedings of the NATO Advanced Research Workshop on Social and Psychological Consequences of Chemical and Biological Terrorism Brussels, Belgium 25–27 March 2002

© 2005 IOS Press. All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without prior written permission from the publisher. ISBN 1-58603-554-1 Library of Congress Control Number: 2005935644 Publisher IOS Press Nieuwe Hemweg 6B 1013 BG Amsterdam Netherlands fax: +31 20 687 0019 e-mail: [email protected]

Distributor in the UK and Ireland IOS Press/Lavis Marketing 73 Lime Walk Headington Oxford OX3 7AD England fax: +44 1865 750079

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LEGAL NOTICE The publisher is not responsible for the use which might be made of the following information. PRINTED IN THE NETHERLANDS

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Contents List of Contributors Chapter 1. Introduction Simon Wessely and Valery N. Krasnov

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THE BACKGROUND Chapter 2.Introduction to and Mitigation of Psychological Effects of Weapons of Mass Destruction (WMD) Ross H. Pastel and Elspeth Cameron Ritchie Chapter 3. Emergency, Disaster, and Catastrophe: A Typology with Implications for Terrorism Response Thomas A. Glass Chapter 4. Cultural Precursors and Psychological Consequences of Contemporary Western Responses to Acts of Terror Bill Durodié Chapter 5. Towards a Public Mental Health Approach to Terror Johan M. Havenaar and Evelyn J. Bromet Chapter 6. Effects of Fear and Anger on Perceived Risks of Terrorism: A National Field Experiment Jennifer S. Lerner, Roxana M. Gonzalez, Deborah A. Small and Baruch Fischhoff Chapter 7. Threats, Chemicals and Bodily Symptoms: A Psychological Perspective Omer Van den Bergh

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THE RUSSIAN PERSPECTIVE Chapter 8. Immediate Interventions – The Experience of the Emergency Mental Health Service of EMERCOM of Russia Sergei Aleksanin Chapter 9. Social, Community and Individual Responses to Terrorist Attacks Valery N. Krasnov Chapter 10. Approaches to the Study of Suicide Terrorism: A Perspective from Russia Valery N. Krasnov Chapter 11. Cross-Confessional Investigation of Religious Visions of the World in the Context of the Fight against Terrorism Victor F. Petrenko and Anna I. Yartseva Chapter 12. Special Features of Emergency Psychological Assistance during Acts of Terrorism Yulia S. Shoigu

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Chapter 13. Perception and Experiencing of “Invisible Stress” (in Relation to Radiation Incidents Nadejda V. Tarabrina Chapter 14. Can We Improve the Psychological Tolerance of Populations to Chemical and Biological Terrorism? Vassily Yastrebov Chapter 15. Stockholm Effects and Psychological Responses to Captivity in Hostages Held by Suicidal Terrorists Anne Speckhard, Nadejda Tarabrina and Natalia Mufel

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THE AFTERMATH Chapter 16. Tracking the Social Dynamics of Responses to Terrorism: Language, Behavior, and the Internet James W. Pennebaker and Cindy K. Chung Chapter 17. Treatment of Trauma Survivors with Acute Stress Disorder: Achievements of Systematic Outreach Arieh Y. Shalev, Sara Freedman, Yossef Israeli-Shalev, Sarah Frenkiel-Fishman and Rhonda Adessky Chapter 18. Short and Long Term Psychological Reactions to Terrorism: The Role of Information and the Authorities Simon Wessely Chapter 19. Responding to Chemical, Biological, or Nuclear Terrorism: The Indirect and Long-Term Health Effects May Present the Greatest Challenge Kenneth C. Hyams, Frances Murphy and Simon Wessely Chapter 20. Societal Responses to New Terrorism Ben Sheppard

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APPENDICES Chapter 21. Appendix 1. Conclusions of the NATO Advanced Research Workshop on Social and Psychological Consequences of Chemical and Biological Terrorism Brussels, Belgium, 25–27 March 2002 S. Wessely and V. Krasnov Chapter 22. Appendix 2. Guidelines for Communicating the Risk of Chemical, Biological or Nuclear Terrorism: How to Inform the Public, Improve Resilience and not Generate Panic S. Wessely, B. Fischhoff and V. Krasnov Author Index

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Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

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List of Contributors Professor Sergei Aleksanin, Deputy Director, All-Russian Center of Emergency and Radiation Medicine, EMERCOM of Russia Lebedeva str. 4/2, St. Petersburg, 194044, Russia. Professor Evelyn Bromet, Professor of Epidemiology, Department of Psychiatry, State University of New York at Stony Brook, USA. Dr Cindy Chung, Department of Psychology, The University of Texas at Austin, Austin, TX 78712. Bill Durodié, Senior Lecturer in Risk and Security, Resilience Centre, Cranfield University, Defence Academy of the United Kingdom, Shrivenham, Swindon SN6 8LA. Phone: +44 (0)1793 78 5296 (office), +44 (0)7957 559 099 (mobile). E-mail: w.durodie@ cranfield.ac.uk Web-site: http://www.durodie.net Professor Baruch Fischhoff, Howard Heinz University Professor, Department of Social and Decision Sciences, Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA 15213-3890. Thomas A. Glass, Ph.D. Associate Professor, Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe Street Baltimore, MD 21205. Professor Johan Havenaar, Department of Psychiatry, Vrije Universiteit Amsterdam, The Netherlands, Managing director of adult mental health care, Buitenamstel, Institute of mental health care, Locatie Oldenaller, Oldenaller 1, 1081 HJ, Amsterdam, The Netherlands, Tel +31 00 20 7884 555, Fax +31 00 20 6428 235, e-mail: j.havenaar@ggzba Dr Craig Hyams, Office of Public Health and Environmental Hazards, Department of Veterans Affairs, VA Central Office (13A), 810 Vermont Avenue NW, Washington, DC 20420. Professor Valery Krasnov, Director, Moscow Research Institute of Psychiatry, Poteshnaya v/3, 107076 Moscow. E-mail: [email protected] Dr Jennifer Lerner, Department of Social and Decision Sciences, Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA 15213-3890. Ross H. Pastel, Ph.D. Lieutenant Colonel, Medical Service Corps, U.S. Army Deputy Commander, Safety, Biosurety, Operations, Plans, and Security, USAMRIID, 1425 Porter St, Fort Detrick, MD 21702-5011 and Adjunct Assistant Professor, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814. Professor James Pennebaker, Department of Psychology, The University of Texas at Austin, Austin, TX 78712. Victor F. Petrenko, Ph.D., correspondent member of the Russian Academy of Sciences, professor of the Faculty of Psychology in Moscow State University, Moscow, Russia, Phone: (095) 458-75-13, e-mail: [email protected]

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List of Contributors

COL Elspeth Cameron Ritchie, MD. MPH, Psychiatry Consultant to the Army Surgeon General, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20901. Dr Yulia S. Shoigu, the chief of the Center of Emergency Psychological Aid of the EMERCOM, Russia. Mr Ben Sheppard, Research Associate, King’s Centre for Risk Management, King’s College London. Professor Arieh Y. Shalev, Professor of Psychiatry, Head, Department of Psychiatry Hadassah University Hospital, Ein Kerem Campus, Jerusalem, 91120, Israel. Anne Speckhard, Ph.D. Adjunct Associate Professor of Psychiatry, Georgetown University Medical Center and Professor of Psychology, Vesalius College, Free University of Brussels. Nadejda Tarabrina, Ph.D., Associate Professor of Psychology and Director of the Traumatic Stress Disorder Laboratory, Institute of Psychology, Russian Academy of Sciences. Dr Omer Van den Bergh, Research Group for Stress, Health and Well-being, Department of Psychology, Tiensestraat 102, B-3000 Leuven, Belgium. Professor Simon Wessely, Director, King’s Centre for Military Health Research, Professor of Epidemiological and Liaison Psychiatry, Institute of Psychiatry, Weston Education Centre, King’s College London, Cutcombe Rd., Denmark Hill, London SE5 9RJ, e-mail: [email protected] Anna I. Yartseva, psychologist, graduate of the Faculty of Psychology of Moscow State University. Vassily Yastrebov, MD, Professor, Head of Mental Health Support Systems Research Center, Russian Academy of Medical Sciences, 2-2, Zagorodnoje Shosse, 117152, Moscow, Russia, Phone: (095) 952 8929; (095) 952 9201, Fax: (095) 952 8940; (095) 952 9201, e-mail: [email protected]; [email protected]


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Introduction Simon Wessely a,1 and Valery Krasnov b a Institute of Psychiatry, Weston Education Centre, King’s College London, Cutcombe Rd., Denmark Hill, London SE5 9RJ b Moscow Research Institute of Psychiatry, Poteshnaya v/3, 107076 Moscow

Why a Workshop? When President Putin met with NATO Secretary General Robertson in October 2001 it was agreed that one area of co operation between NATO and Russia was studying the effects of terrorism – for reasons that do not need to be spelt out, this was a topic of pressing interest to both Russia and all the NATO nations. The sense of psychological dislocation and disturbance that had echoed around the world in the wake of the television coverage of the events of Sept 11th 2001 were clearly very much in mind, when they identified studying the psychological and social consequences of the new terrorism as a priority. One result was to convene the first ever NATO-Russia Advanced Research Workshop (ARW) on the subject, and indeed to convene it in record time, largely thanks to the unsung efforts of NATO scientists and staff such as Dr Kees Wientjes and Dr Fernando Carvalho Rodriguez. A remarkably diverse group of academics and practitioners made their way to Brussels at the end of March 2002 to discuss the issues, and also to witness the first occasion that the flag of Russia had flown at NATO Headquarters.

What Happened? In the first appendix to this book (Chapter 21) we reproduce the report on the workshop itself. Since then we have also assembled twenty manuscripts developing some of the themes of the workshop, and we are grateful to all the contributors who have provided this material. As frequent attendees at international meetings and workshops ourselves, in which a convivial and successful interaction is blighted by the subsequent request for a chapter for a previously unmentioned publication, we are aware of the efforts required to produce these manuscripts. We also have every sympathy for those unable to fulfil our belated request, and can assure them that they remain very much our friends! Nevertheless, the reader might like to break convention and start with this chapter (Chapter 21) to get an impression of the richness of all the material presented, and the broad scope of the subject. Turning to the contributions, we can discern several themes emerging. First, the universal acknowledgement that runs as a constant theme through each and every contribution of the importance of psychological factors in understanding and mitigating our 1 E-mail: [email protected]

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S. Wessely and V. Krasnov / Introduction

response to terrorism. The word “terrorism” itself makes its purpose all too clear – it is to create a state of terror, of fear. The killing, maiming and destruction of property that accompanies terrorism is not the end in itself – if that were the case it would have little impact. Terrorism is the creation of states of mind, of reducing people’s resilience and will to resist, and causing such psychological and social pressure that eventually the political aims of a terrorist group will be fulfilled. This book is not about the prevention of terrorism. It is not about better security, increased detection, more sophisticated technology and so on. Nor is about understanding the mind of the terrorist, important though that this (having said that, the rise of suicide terrorism in Russia in the recent past meant that it was felt important to reflect something of this issue – see for example the contribution of Petrenko and Yartseva on religion and terrorism, Chapter 11). This volume is primarily concerned with the consequences of acts of terror, and their impact on populations. And it is concerned with what we are citizens, professionals and governments can do to mitigate these consequences. In general we focussed less on the “timeless” or “universal” trauma reactions captured by labels such as post traumatic stress disorder, but more on culture and place specific reactions (see Havenaar and Bromet, Chapter 5). A comparison of the responses visible in Russia to large scale adversity on a scale unimaginable in the West [1], as well as recent terrorist situations, with the new western cultural shift towards an age of anxiety and risk aversion (see Durodie, Chapter 4, in which he argues that such anxiety and risk aversion is acting as a force multiplier to increase the psychological impact of terrorism) makes this point. We start therefore with a an outline of the problem, provided by Cameron Richie and Ross Pastel, who have written much on the social and psychological consequences of what we have elected to call the “new” terrorism. Their focus, on chemical, biological and nuclear terrorism reflects the broadening of our perception of possible new hazards, risks and opportunities open to terrorist organisations, not least because of the spread of simple new technologies. Nevertheless, we must not forget that in practice most terrorist attacks remain steadfastly conventional. Simple knives are used to convert aircraft into large flying bombs, cars are crammed with explosives, or fanatics seize theatres and schools armed with conventional weaponry. To date, and of course we speak advisedly and almost sotto voce, the examples of the “new terrorism” have been few and far between, and remarkable mainly for their lack of success. The workshop heard accounts of the sarin attack on the Tokyo subway in which the wonder was just how small was the final death toll. We also heard how the cult group responsible had made previous attempts to use other “new terrorist” agents, but failed. The anthrax attacks which convulsed the United States, and remain still unsolved, nevertheless in terms of their direct effects might well have gone almost unnoticed, as indeed did the almost farcical attempts by the Bhagwan cult to use salmonella as a biological weapon. In that instance no one did notice – this was therefore by definition not a terrorist incident, since it failed to cause any terror, only food poisoning. For examples of the possible effects of radiological weapons we were forced to extrapolate from non terrorist events such as the radiation poisoning in Goanna or the nuclear accident at Chernobyl. As Professor Sir Lawry Freedman has said, terrorists remain quintessential risk entrepreneurs, but to date have found conventional means more profitable than the chemical, biological and radiological weapons that we were discussing. Sadly it would be a brave person who would dare to predict that this will not change.


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Emergencies, Disasters and the People Nevertheless, in a contribution that is as arresting on paper as it was in the flesh, American sociologist Tom Glass looks critically at what actually happens in disasters. He reminds us that people are more resilient than we think, and more resourceful than we imagine. Much of the rescue at disasters is carried out not by our trained emergency services, but by bystanders and participants themselves. In particular, he reminds us that if the above paragraph turns out not to be true, and terrorists do acquire the means to generate mass casualties on a scale that defeats the capacity of the system to cope, then we are going to need to mobilise these innate resources and a far greater scale than we have assumed previously.

The Russian Perspective We now turn to the contributions from our Russian colleagues. It will be clear that there are many differences between these contributions and those from the majority of the NATO countries. Exploring the richness of these differences is why we have chosen to call this book a “NATO Russia” dialogue. There are many reasons for these differences. First of all, the classification systems used in Russia for the common psychological disorders are not the same as those used in many Western countries, especially the English speaking world. In fact Russian psychiatric thinking and classification has a very distinguished pedigree, eclipsing our own formulations in the Diagnostic and Statistical Manuals by at least two generations. Likewise, perhaps the greatest Russian scientist of all times, Academician Pavlov, made his presence felt when we came to discuss the problem of how and why people develop chronic and debilitating symptoms after exposure to chemicals at levels which conventional toxicology would suggest harmless (see Chapter 7, Van Der Bergh). The second reason lies in the different political histories of the participant countries, at least in the modern era. Much of the workshop concerned communication and engagement between government and its citizens. We wished for an ideal world in which governments strived to produce rapid, accurate and impartial information in the event of a terrorist incident. Likewise, we wished for a scientifically literate citizenry, but most of all one which trusted its government to be “on the same side”, committed to openness, frankness and transparency. Both of these scenarios are of course mythical. In the United Kingdom communication by government on matters of science is haunted by the spectre of “mad cow disease”. In American there is the Agent Orange saga. Governments have in the past had occasions to be less than open with their citizens, and less than competent in managing public health emergencies. But it is not all one way traffic. Successive governments have been unable to hide their exasperation with citizens as well – the crisis over MMR vaccination in the United Kingdom, in which people seem more willing to allow their children to be infected by agents that definitely do cause disease and even death, whilst avoiding a vaccine which does neither, is at first sight baffling, at least to government. Baruch Fischhoff, who spoke at the meeting and has contributed two chapters to this book, could and did explain this – how lay risk perception is not the same as scientific or statistical risk perception, but one can still sympathise with the difficulties of government when people seem unwilling to listen to, or trust, decent

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scientists whose careers have been spent in protecting the public health, but only too willing to listen to maverick, eccentric and usually misguided scientists who have spent far more time in the TV studio than the laboratory, and whom are far better at writing for the newspapers than the scientific journals. All of these factors are true, and reflect a crisis of confidence in those institutions that we need to trust to defend us against the new terrorism, as political scientist Bill Durodie so elegantly outlines in his dissection of Western responses to terrorism (Chapter 4). But the situation is even more complex in the former Soviet Union. Russian communism, “the God that Failed” as Koestler wrote, did achieve significant social change. But even its most ardent admirers could not claim that a free and democratic press, nor an informed citizenry, were among those achievements. The legacy of communist rule – its hypocrisy and overt manipulation of information, has left a people cynical and disillusioned, with much reason. Communication between government and the people is different when people can recall “Pravda”. All of this is reflected, either spoken or unspoken, in the contributions from our Russian colleagues. Likewise, whilst every contributor constantly referred to the difficulties of co ordination and management of acute crises, the particular legacy of central power in Russia has different problems. There were times when some of those present would have wished for the rigid command and control systems exercised by their Russian colleagues in crisis situations, but there were also times when the disadvantages of these structures were apparent, which is the point made forcefully by Glass when considering what might happen if these centralised emergency management structures were to be overwhelmed by a disaster or catastrophe. We saw some evidence of what Glass is discussing in the ghastly end of the Beslan school siege.

Communication Terrorism is about communication. Without communication there can be no terror, at least other than of those immediately involved. Much attention is being paid, and rightly so, to how terrorists communicate directly with each other, and how they communicate with us. The drawn out torment of videos of hostages in Iraq pleading for their lives before their grizzly executions is an example of the latter. But less attention has been paid to how we communicate with each other about terrorism. Psychological Jamie Pennebaker has made a lifetime study of how people talk to each after disasters in general, and now terrorism in particular (Chapter 16, this volume). People talking to each other in the immediate aftermath of terrorist incidents provides much needed support and reassurance. The conference noted that more attention needed to be given to assisting these normalising processes, and that more needed to be done to safeguard such communications in the immediate aftermath of a terrorist attack. Likewise, it was noted that such communication was an important protection against behavioural panic and disorganisation. The conference also noted en passant the evidence that people talking to mental health professionals, as in so called psychological debriefing or critical incident stress debriefing, did any good, and indeed premature emotional disclosure, especially to strangers or professionals, might actually be harmful (see Chapter 18 and [2,3]). On the other hand, we are now starting to acquire evidence and experience of what treatments do work, especially when focussed not on the majority of people in-


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volved in trauma, most of whom will get better, but on the minority of those who will not (see Shalev, Chapter 17). But what about the authorities talking to the people? The theme of the communication of the risk of terrorism, and of communicating after a terrorist incident, became a leitmotif of the conference, and rightly so. Firstly, because how we prepare populations for the possibility of terrorism is profoundly important in determining our own behaviours in the event of disaster. It may also have crucial political impact on whom we later blame, although that is outside the scope of this volume. Second, if it is indeed the case that, as senior security officials have been saying in Britain and America, it is not “a question of when, but if”, it would be foolhardy to neglect consideration of what is said in the aftermath of an event. Communication matters. The nature of communication has important emotional impacts – people may response to an attack with fear, with rage against the perpetrators, or with rage against their own government for letting it happen, whether justified or not. These emotional consequences themselves affect perception of future risk, and the likelihood of certain behaviours, as Jennifer Lerner and her colleagues demonstrate (Chapter 6). It is not too fanciful to say that the difference between good and bad communication is between a population that responds to terrorism with resilience, courage and a determination to see it through – the Blitz spirit as some contributors termed it – or a population that becomes overwhelmed with anxiety, paralysed with fear, and unable or unwilling to go about its business, thus doing the terrorists’ job for them. We exaggerate, but not by much. The example of Mayor Guiliani in New York who whether by instinct or design managed to mobilise that city’s sense of resilience in the face of disaster is well known. He did so by his behaviour – by speeding to the scene of the disaster he shared the same risks as his citizens, a behaviour that almost cost him his life, but established his courage and credibility [4]. Compare and contrast this with the behaviour of other public figures who are always been moved to a “secure location” at the first sign of trouble. Is it any wonder that in these circumstances people feel less able to tolerate risks or go about their daily business? Actions must match words, and Guiliani’s did that As Aleksanin makes clear (Chapter 8), professionals dealing with emergencies must themselves sometimes accept risk and danger – the same must apply to our leaders as well if they are to provide examples for citizens to follow. If we are to supply examples of responsible bravery, this must start from the top. His words appealed to people’s emotions and sense of shock and pain – as we write in our final chapter on guidelines for communicating the risk of terrorism, public figures have emotions too, and it is not a crime to show them. His words also made it clear what he did and did not know, and established himself rapidly as a source of information that people could trust. The conference also debated the question of not just what should be said, but who should say it. Interesting cross national differences emerged. Powerful civic leaders such as Mayors emerged as important in the USA and Russia, but not in the United Kingdom. Government scientists had less credibility in the UK since the BSE crisis, but were more respected in Scandinavia, and so on. We agreed it was impossible to say who should be the spokesperson, but it was possible to say what qualities this person should have (see Chapter 22).

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They Think it is All Over, and Then... Tom Glass began his presentation by saying one theme of much research about disasters was the fact that afterwards many of those involved often say “well, it could have been worse”. He ascribed this to people being more resilient that we give them credit for, and for the tendency of people to improvise their own solutions when facing adversity. Likewise, we would add the often extraordinary courage and inventiveness shown by emergency workers when really challenged. The conference in general was cautious about some of the apocalyptic “what if” scenarios constructed by some planners concerning CBRN terrorism. We noted that to date terrorism continues to be conventional in its methods, if more indiscriminate and radical in its aims. There is a real danger that we are “scaring ourselves to death” with these scenarios. Likewise, installing more and more elaborate detection systems for less and less likely agents is not only costly, it is also damaging because of the inevitable false alarms, which do not reassure, but only make us more anxious. Some members of the conference also raised fears that these “what if” scenarios did more to reveal to our enemies our own vulnerabilities, and perhaps suggested tactics and opportunities that might not otherwise have occurred to them. So in general the conference, and this volume, concludes that whilst CBRN terrorism provides new threats and challenges, the main threat from global terrorism continues to be conventional. It also concluded that when disasters do strike, especially if man made, there will be death and suffering, often prolonged. But we could also take some comfort from our natural abilities to “muddle through”, our tendencies to react to threats with courage and determination, provided of course that our leaders can provide us with reasons for so doing, and examples of such courage and determination. However, the conference ended on a more ambivalent note. American cultural critic Elaine Showalter spoke about the long term problems that might arise after CBRN terrorism, drawing on the long legacies of Three Mile Island, Chernobyl, the Gulf War Syndrome story and many others [5]. An acute incident may well be managed well but what happens six months later when someone in the affected area develops a cancer, another has a miscarriage, and a third develops strange symptoms. Could this be a lingering legacy of the chemical attack, or the dirty bomb. Official scientists may tell us it is all safe, but there will be the maverick scientist to say otherwise. Rumours and urban legends will flourish. Suspicions will rise. Trust will diminish, and repeated government reassurances will be interpreted as “cover ups”. These problematic long term outcomes are discussed in Chapter 19, and, it is fair to say, whilst we were very much aware of the problem, deciding solutions was more difficult.

References [1] Merridale C. Night of Stone: Death and Memory in Twentieth Century Russia. London: Penguin, 2000. [2] Emmerik A, Kamphuls J, Hulsbosch A, Emmelkamp P. Single session debriefing after psychological trauma: a meta analysis. Lancet 2002; 360: 736–741. [3] Gist R, Devilly G. Post-trauma debriefing: the road too frequently travelled. Lancet 2002; 360: 741–742. [4] Boyatzis R, Bilimoria D, Godwin L, Hopkins M, Lingham T. Effective leadership in extreme crisis. In: Neria Y GR, Marshall R, Susser E, ed. 9/11: Public Health in the Wake of Terrorist Attacks. New York: Cambridge University Press, 2005. [5] Showalter E. Hystories: Hysterical Epidemics and Modern Culture. London: Picador, 1997.

THE BACKGROUND

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Introduction to and Mitigation of Psychological Effects of Weapons of Mass Destruction (WMD)1 Ross H. Pastel a and Elspeth Cameron Ritchie b a USAMRIID, 1425 Porter St, Fort Detrick, MD 21702-5011 b Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20901

1. Introduction The importance of the psychological effects of chemical, biological, radiological/nuclear and high explosive (CBRNE) weapons is increasingly being recognized in the post-9/11 era. CBRNE agents are often referred to as “weapons of mass destruction” or “WMD”. However, with the exception of nuclear weapons and high explosives, most of the WMD do not cause large-scale physical destruction. Perhaps a better term would be weapons of mass disruption, as these weapons can cause mass casualties along with extreme psychosocial effects. Some WMDs have been used as agents of war, but all are likely to be effective agents of terror. This chapter will concentrate on psychological effects of chemical, biological, radiological and nuclear (CBRN) weapons. There are critical characteristics of CBRN exposures that differ from conventional weapons (such as bombs or shootings). For example, only a small amount of a biological weapon may be needed and it can be delivered via the air, water or food supply, or by mail. Many CBRN agents are invisible and odorless; thus leading to uncertainties regarding both what kind and what amount of agent a person has been exposed to. In addition, many of the initial or prodromal symptoms are non-specific which leads directly into the problem of differentiating those with direct exposure from those who were unexposed but fear they were exposed. Not knowing who has been exposed thus becomes a central and very important theme for planners, emergency departments, the public health system, and, of course, for the population at large. For example, the sarin attacks in the Tokyo subway system killed twelve, but led 5000 people to seek medical attention [1]. The anthrax in the mail attacks in 2001 caused 23 cases of anthrax with five fatalities, but over 32,000 people with potential exposure sought prophylactic antibiotics (often on the advice of their employer) [2]. In the event of smallpox or pneumonic plague, the threat of contagion is very real, which brings up issues of quarantine and isolation. The recent SARS (severe acute res1 Disclaimer: the opinions expressed are those of the authors and do not reflect the official opinion of the Uniformed University of the Health Sciences, the Department of the Army, or the Department of Defense.

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R.H. Pastel and E.C. Ritchie / Psychological Effects of Weapons of Mass Destruction

piratory syndrome) epidemic has demonstrated some of the challenges involved with quarantine. In the event of a smallpox outbreak, isolation of patients, tracing and quarantine of contacts, and vaccination – either ring (i.e., contacts and contacts of contacts) or mass vaccination – will be required to halt an epidemic. Many of the CBRN agents can cause grotesque and disfiguring injuries, which increase the psychological impact both on those affected and on those witnessing the event. For many CBRN agents, special equipment may be needed to detect contamination. For those agents requiring wide-spread environmental decontamination, issues of evacuation from the area or even permanent relocation due to long-lasting contamination (e.g., Chernobyl) require attention. The long-term health consequences of exposures to trace amounts of CBRN agents is controversial: there are many uncertainties whether longterm effects might be psychological, psychophysiological or physiological. Reviewing the literature on “Gulf War Illnesses”, the simplest answer is that there was a combination of all of the above [3]. Health risk communication will be important for both acute and long-term risks. Poor knowledge and public communication will increase psychological ill-effects. For example, information about how to protect oneself from immediate attack is currently scanty or contradictory. In the spring of 2003, the US government advised the population to use duct tape and clear plastic sheeting for protecting themselves at home. This announcement was quickly followed by criticism over questions of efficacy and the dangers of suffocation, as well as many jokes. The loss of governmental credibility, with respect to risk communication was, perhaps, the most serious consequence of his episode (see Appendix this volume). For many years, the military has studied the medical effects of CBRN agents. In July 2000, an international conference on the “Operational Impact of Psychological Casualties from Weapons of Mass Destruction” was held, organized by the first author [4]. There have also been a number of recent reviews on the topic [5–8]. Fortunately, although acute and long-term psychological effects after CBRN events may differ in degree from effects seen after natural disasters or high explosives, they seem to exist on a continuum with no apparent unique psychological disorders [9]. However, it has been postulated that psychophysiologic effects will dominate the long term picture [10]. Although there is historical data about the range of psychological effects, less data is available about the best ways to mitigate expected psychological reactions. Unlike the responses to other episodes of mass violence, we do not have enough information to divide our therapeutic responses into early, intermediate and late phases. Therefore, our response is not delineated in a time-sequenced fashion. In addition, CBRN attacks do not always have a clear end of the attack – long-term contamination may lead to a perceived continuing presence and fear of exposure. There may also be a continuing fear of potential long-term health consequences (e.g., radiation exposure). A brief description of CBRN agents and their medical effects begins the chapter. A historical review of psychological effects following CBRN attacks and accidents follows. The acute and long-term psychological effects of these agents is then summarized. The last section has suggestions for mitigation of these psychological effects.


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2. A Brief Summary of Effects of CBRNE Agents 2.1. Chemical weapons Chemical warfare agents (CWA) had their first widespread use in World War I beginning with a German attack with chlorine gas near Ypres, Belgium on 15 April 1915 [60]. The most effective CWA used was sulfur mustard. Chemical agents are reported to have caused one-third of the estimated 5 million casualties of World War I [87]. Fortunately, CWA were not used in World War II. However, they were used again on a large scale in the Iran-Iraq war in the 1980’s, where they reportedly caused at least 45,000 casualties [87]. Five types of CWAs are of most concern: Lung-damaging or pulmonary agents, cyanides, vesicants, nerve agents, and incapacitating agents [60]. Riot-control agents such as tear gas are also chemical agents, but are not considered CWA. Pulmonary agents, such as phosgene and chlorine, are non-persistent gases which produce local pulmonary effects – adult respiratory distress syndrome and pulmonary edema [87]. These agents are toxic industrial chemicals, which are possible terrorist weapons. Cyanides are also nonpersistent gases which can quickly poison cellular metabolism. High exposures cause seizures, and both respiratory and cardiac arrest. Vesicants include sulfur mustard, lewisite, and phosgene oxime and are persistent agents. Vesicants produce delayed effects – blisters (vesicles) – with a latent period of hours following exposure. Depending on exposed areas, the most common effects are on the skin, eyes, and upper respiratory system [60]. Nerve agents (tabun, sarin, soman, and VX) are the most potent CWA. They were invented by the Germans during World War II, but not used until the Iran–Iraq war in the 1980’s. They were also used by Iraq against the Kurdish minority and by a Japanese terrorist cult in the 1990’s. Nerve agents can cause death in minutes by blocking acetylcholinesterase, thus causing excess acetylcholine and a resulting cholinergic crisis. Signs and symptoms vary somewhat after small exposures of vapor vs. small exposures of liquid on skin, but large exposures of vapor or liquids result in sudden loss of consciousness, convulsions, apnea, flaccid paralysis, and copious secretions [60]. 2.2. Biological weapons Biological warfare (BW) is the use of microorganisms or toxins to induce death or disease. Bioterrorism (BT) is the use of biological agents with an ideological motivation (e.g., religious, or political). BW agents (BWA) can be categorized as bacterial agents, viral agents and toxins. BWA differ from CWA in that BWA require an incubation period before they can cause symptoms. Toxins, which are products of living organisms, do not require incubation, but they do have a latent period before they cause symptoms [88]. The Centers of Disease Control (CDC) has differentiated potential biological agents into different categories of concern. Category A agents are of highest concern because of lethality, public fear, and public health requirements. These include the organisms responsible for anthrax, smallpox, plague, tularemia, viral hemorrhagic fevers (e.g., Ebola, Marburg, and Lassa Fever) and botulinum toxin. Typically, BWA initially cause a prodrome with non-specific, flu-like symptoms which can make early diagnosis problematic [89].

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Bacterial agents can be treated with antibiotics, but antidotes to the viral agents and toxins are not available, so supportive care is the only option for treatment. Some BWAs are contagious, meaning that they can be transmitted from person-to-person. Smallpox and pneumonic plague are both contagious through respiratory droplets, while viral hemorrhagic fevers can be transmitted by contact with blood or other body secretions. Licensed vaccines are available for smallpox and anthrax. There has been considerable controversy about the new vaccines however. 2.3. Radiological and nuclear weapons Nuclear weapons can cause death and injury by three mechanisms: blast, thermal and radiation effects [90,91]. Blast and thermal effects are the most prevalent causes of death and injury, but radiation is the most feared effect. Radiological weapons are often referred to as ‘dirty bombs’ or radiation dispersal devices (RDD) and are typically a mix of a radiological source and an explosive. Another type of RDD would be an attack on a nuclear power reactor resulting in a release of radiological material into the environment. In the U.S., the strong containment of nuclear power reactors makes this an unlikely scenario [92]. The acute radiation syndrome (ARS) occurs following exposure to high doses of ionizing radiation. ARS is actually a combination of different clinical syndromes: hematopoietic, gastrointestinal, and a combination of cardiovascular and central nervous system effects. The higher the radiation dose, the shorter the asymptomatic period, and the more intense the initial symptoms. The initial symptoms are non-specific – nausea, vomiting, fatigue, headache and weakness. Radiation is also notorious for causing cancer, perhaps the most feared effect (although actually the contribution of radiation to cancer is relatively small) [93].

3. Historical Examples 3.1. Nuclear and radiological Of all the WMD, nuclear weapons have the greatest destructive impact: they are the quintessential weapons of mass destruction. The atomic weapons dropped on Hiroshima and Nagasaki caused incredible devastation, outbreaks of local fires and large numbers of dead, dying, and injured people [11]. In interviews done after the war, approximately two-thirds described psychological disturbances of intense fear, emotional upset, or depression. Nevertheless there was only a single incident of an apparent mass panic reported at Hiroshima: a large group of frightened people in a park pressed some victims into a river and several died [12]. During the following weeks, survivors continued to witness the sight of severely injured people suffering from burns and blast injuries. In addition, there were outbreaks of acute radiation sickness (ARS). The continued exposures to the devastation and human suffering served as a constant reminder to survivors and reinforced the psychological impact of the original event [11]. Survivors of Hiroshima and Nagasaki were severely stigmatized, especially those with severe burns which resulted in scarring and keloids. Lifton described a ‘Neurasthenic Survivor Syndrome’ characterized by “Persistence of


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symptoms of withdrawal from social life, insomnia, nightmares, chronic depressive and anxiety reactions and far-reaching somatization. . . in addition, fatigue, emotional lability, loss of initiative, and generalized personal, sexual and social maladaptation” [13]. A study of over 7,000 Nagasaki atomic bomb patients done 15 years later showed longterm psychological effects in approximately 7%, with the majority complaining of fatigue, lack of spirit, poor memory and introversion [14]. These symptoms were twice as common in survivors who had shown ARS symptoms and were related to severity of ARS symptoms. The Three Mile Island (TMI) accident in 1979 demonstrated the importance of psychological effects. According to the President’s Commission which studied the accident, the only medical effect documented was mental distress [15]. There were no cases of ARS: the estimated doses for people living within 10 miles of TMI were approximately the dose of an average chest x-ray and much lower than the annual background radiation dose [16]. Populations exhibiting the most distress were TMI workers, families with pre-school-age children, and those living within 5 miles of TMI. Studies of TMI workers reported no long-term effects, only short-term acute effects [16,17]. TMI personnel reported nausea, stomach troubles, headaches, diarrhea, sleep disturbances, and loss of appetite in greater frequency than did control group personnel. (These symptoms are also common in the ARS prodrome, but TMI personnel were not exposed to such doses.) Unlike TMI workers, TMI residents, compared to controls, displayed a significant amount of stress on several measures (performance, self-report measures of anxiety, depression and somatic complaints, physiological measures of urinary norepinephrine, epinephrine, and cortisol, disturbed sleep, and changes in immune system parameters) for up to six years after the accident [18–21]. The TMI symptoms were not the result of exposure to radiation but to perceived radiation threat. Therefore, TMI demonstrates that fear of exposure to WMD can cause significant distress and stress symptoms which can mimic some of the symptoms of actual radiation exposure. Unlike the TMI accident, the Chernobyl accident in 1986 did release significant amounts of radiation. Approximately 135,000 people were evacuated from a 30 km zone in the first two weeks after the accident. Most of these people had to be permanently relocated. In addition, an estimated 600,000 liquidators (i.e., workers involved in the emergency actions on site during the accident and the subsequent cleanup operations) [22]. Acute health effects did occur to liquidators involved in the initial emergency response, including 31 deaths and 140 cases of ARS and other radiation-related acute health effects. An important health effect was widespread psychological distress [22–24]. However, that distress could also have been caused or exacerbated by other factors such as the economic collapse and subsequent breakup of the Soviet Union, evacuation then relocation of communities, distrust in the government, changes in diet (due to contaminated soil), poor nutrition, and other problems [22,24,25]. A study of over 1,400 Latvian liquidators found that 44% had ICD-9 coded mentalpsychosomatic disorders (depression, physiologic malfunction arising from mental factors, or unspecified disorders of the autonomic nervous system) [26]. Due to lack of ICD9 codes, anxiety, post-traumatic stress disorder (PTSD), and sleep disturbances were not diagnosed. A variety of psychoneurological syndromes have been reported as sequelae of Chernobyl in the Russian literature [27–31]. These syndromes are characterized by multiple unexplained physical symptoms (MUPS) including fatigue, sleep and mood disturbances, headaches, impaired memory and concentration, and muscle and/or joint pain.

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These syndromes were reported in both liquidators who had suffered ARS and those who had not [28,30]. No significant correlations were found among physical symptoms, radiation dose and physical examination data [28]. PTSD and PTSD symptoms have been found in two studies [32,33]. An epidemiologic study of over 4,700 Estonian liquidators found an increase in suicide, but no increases in cancer, leukemia, or overall mortality [34]. Suicide accounted for almost 20% of mortality in the liquidator cohort. Reasons for the increased suicide rate are not currently known. Given other studies demonstrating a variety of mental health disorders in Chernobyl liquidators, one could speculate that fear of radiation in these liquidators might cause depression, PTSD, and other disorders which are associated with increased rates of suicide. Interestingly, data from Vietnam veterans with PTSD has demonstrated an increased risk for traumatic deaths, including suicide [35]. The primary toxic agent at Chernobyl appears to be fear, not radiation. 3.2. Biological agents There is emerging data on the potential psychological effects of biological weapons. Smallpox and plague have historically been associated with epidemics and large numbers of fatalities. The most recent smallpox outbreak in a non-endemic country was an outbreak in Yugoslavia in 1972 which caused 175 cases of smallpox with 35 deaths [36]. Containment measures included strict isolation of patients, ring vaccination, prohibition of public meetings, restriction of movement to affected areas, and establishment of checkpoints to check vaccination certificates. A three-week mass vaccination program immunized 18 million out of a total population of nearly 21 million. How the American public would respond to such measures today is unknown. In 1994, there were two outbreaks of plague in India, a bubonic plague outbreak followed one month later by a pneumonic plague outbreak in Surat [37]. There were over 5,000 suspected cases of plague; including 55 deaths [38]. An estimated 400–600,000 people fled Surat, including hospital staff, private medical practitioners, and municipal workers [39–41]. In the city of Delhi, 1200 km from Surat, people used available materials to fashion masks. There was widespread buying and hoarding of tetracycline, which is used to treat plague and is available without prescription in India [40]. The initial government response to the outbreak was denial and officials downplayed the situation. The local press and media helped fuel the anxiety with exaggerated reports [38,41]. In the fall of 2001, the U.S. was shocked by anthrax letters in the mail which led to 23 cases of anthrax [42]. Following September 11, 2001 and prior to the first case of anthrax, there had already been increased purchases of gas masks and ciprofloxacin (“cipro”, used to treat anthrax). After the anthrax mail attacks, there were hundreds of prescriptions for cipro given to people who had no credible exposure [43]. Hospitals reported their already busy emergency rooms were filled with people anxious about anthrax, many demanding treatment. Puzzling long-term effects were seen in the survivors of anthrax. Newspapers reported that survivors suffered symptoms of fatigue, shortness of breath, chest pains, memory problems, nightmares, and rage six–12 months after their illnesses [44,45]. Only one of the inhalational anthrax survivors was well enough to return to work. At this date, no studies have determined whether these symptoms are medical or psychological consequences.


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The acute respiratory distress syndrome may be caused by numerous biological weapons. Other infectious disease outbreaks causing this syndrome have been reported to cause both PTSD and a decreased health-related quality of life (HRQL). For example, the majority of survivors of an outbreak of Legionnaires disease reported fatigue, neurologic symptoms, and neuromuscular symptoms 17 months after diagnosis [46]. HRQL was impaired in 7 of 8 dimensions, and 15% of patients experienced PTSD. Similarly, survivors of acute respiratory distress syndrome have also reported decreased HRQL and PTSD [47,48]. 3.3. Chemical agents World War I chemical warfare agents (CWAs) caused 31% of battle injuries, but only 2% of deaths in U.S. forces [49]. In the initial use of chlorine gas on the Western Front by the Germans in 1915, “A full-blown, blind, contagious panic swept portions of the line” [50]. However, there was no panic farther out on the line where there was little or no gas. In the next six gas attacks over the next two months, there were no mass panics, although protective equipment was rudimentary and not widely available. There were only four other gas panics documented in World War I. The psychological impact of CWA casualties was powerful: “A field hospital full of freshly and badly gassed men is. . . the most horrible and ghastly sight of the war. . . to see a hundred or more men, hale and hearty a few hours before, slowly strangling to death from pulmonary edema, with gradually increasing dyspnea, cyanosis and pallor, making futile efforts to expectorate. . .” [51]. Mustard exposure required long convalescence – French mustard casualties at Ypres in 1917 typically required 45 to 70 days before return to duty [52]. Even perceived CWA exposure could cause symptoms. In one incident following desultory gas shelling, 500 battle-tested troops drifted into medical aid stations over a one week period, suffering from chest pain, fatigue, dyspnea, coughing, husky voice, and indefinite eye symptoms [53]. The divisional gas officer found no evidence of gas inhalation or burning. Three years after World War I, approximately one-half of gassed veterans claimed subjective complaints in medical examinations [52]. When there were no objective findings, no compensation or pensions were paid, nor were these included in statistics of permanent disabilities. There were reports of large numbers of men who had recovered from acute gas-poisoning and had good physical examinations, but suffered from serious sequelae, most particularly of easy fatigability and difficulty breathing on exertion [54]. This condition was variously known as effort syndrome, D.A.H. (disordered action of the heart), and neurocirculatory asthenia. In chronic gas cases, there were often acute attacks of breathlessness at night accompanied by nightmares, and patients usually reported insomnia and unrefreshing sleep [54]. PTSD has been reported in World War II American veterans exposed to mustard agent participating in field trials and chamber tests [55]. Sarin, a nerve agent, was used by a terrorist cult in both Matsumoto City in 1994 and in the Tokyo subway in 1995. Over 5,500 people visited 280 medical facilities following the release of sarin in the Tokyo subway [1]. Of these, 1,046 were admitted to the hospital, 20 were treated in intensive care units, and 12 died (10 in the first 48 hours). No extensive mass panic was reported – victims waited in silence both at the subway station and at hospitals. The perplexing silence may have been a sign of psychic numbness [1]. Most admitted patients were hospitalized for a few days. Some reported sleep distur-

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bances, nightmares, and anxiety. Whether these were due to acute stress disorder or to the nerve agent exposure is not known. One study using a post-traumatic symptom scale one month after the event found that hospitalized patients reported fears when approaching the subway (20%), depressed feelings (18%), difficulty sleeping (16%), physical tension (13%), and emotional lability and irritability (7–9%) [1]. A long-term study of sarin patients who had been hospitalized at St. Luke’s Hospital found that somatic and psychological symptoms continued for 5 years after the incident [56]. PTSD was diagnosed in approximately 2–3% and partial PTSD in approximately 7–8%. There was a high rate of reporting of medically unexplained physical symptoms: eye symptoms, fatigue, muscle stiffness, and headache were all reported by more than 10% of the study population.

4. Psychological Effects – Acute and Long-Term Although mass panic is common in disaster movies and media headlines, the evidence from CBRN events and natural disasters suggests that mass panic is very rare [57,58]. What does seem to be common in CBRN events are large numbers of patients reporting to the emergency room with mild exposure or perceived exposure. These patients are not “worried well.” They are worried – possibly with good reason – but they are not well – they have symptoms which cause distress and pain. We advocate that the term “worriedwell” be dropped because it is pejorative and suggests that nothing is wrong with the patient. These patients are certainly worried, but not yet known to be well. Unfortunately, prodromal symptoms of CBRN weapons are often non-specific symptoms; e.g., headache, difficulty breathing, nausea, dizziness, fatigue, and malaise. These symptoms can also be caused by anxiety or by hyperventilation. However, some of the CBRN agents may produce what seem to be psychological effects, but are actually agent-induced effects [59]. In pulmonary agents, respiratory distress may precede measurable physical signs [60]. Symptomatic ambulatory cases with mild or perceived exposures will present difficulties for CBRN event triage. Ubiquitous, non-specific symptoms can also occur with the perception of exposure to a CBRN agent. Outbreaks of these symptoms are often referred to as mass hysteria, mass psychogenic illness, or mass sociogenic illness. However, these terms have a pejorative connotation and should not be used. A more neutral term has been suggested – outbreaks of multiple unexplained symptoms or OMUS [61]. One review found that the most common symptoms included nausea, vomiting, headache, and dizziness or lightheadedness [62]. Not all outbreaks occur in female school-age children! For example, over 1,000 male military recruits reported at least one symptom following a suspected exposure to a toxin in the dining hall [63]. What can be problematic is when an outbreak of multiple unexplained symptoms (OMUS) co-occurs with a CBRN event. Perhaps the most dramatic example occurred following a radiological contamination incident in Goiania, Brazil in 1987 [64]. Four people died, 20 required hospital care and 50 required medical surveillance. However, over 125,000 people demanded to be screened for radiological contamination – only 249 had any radiological contamination. Interestingly, 5,000 of the first 60,000 people screened had symptoms of vomiting, diarrhea, and/or rashes around the face and neck. Although consistent with radiation sickness symptoms, none were contaminated.


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The available data suggests that there will be many more patients presenting with mild or psychological symptoms than will be presenting with moderate or severe injury/illness. Unfortunately, when talking with various experts, most disaster exercises have few psychological casualties and what few casualties they have are typically ‘psychotic’, not the expected type of casualty. Furthermore, experience from various disasters, demonstrates that the ambulatory patients show up at the hospital first – before the severely injured can be transported [65]. CBRN victims may present with ill-defined, chronic fatigue-like syndromes with multiple unexplained physical symptoms (MUPS), such as was seen after the first Persian Gulf War in 1991. A full review of Gulf War Illness is outside the scope of this chapter, but may be found elsewhere [3]. Similar syndromes have appeared in veterans following many wars or following infectious diseases, CWA exposures, and nuclear/radiological exposures [14,18,26–28,44,49,54,56,66,67]. These may be stress-related somatization disorders, but at this point, there are no definitive studies. In natural disasters and terrorist attacks with conventional weapons, PTSD, depression, generalized anxiety disorder, and substance/alcohol abuse are commonly seen [68– 70]. We can probably expect similar results from CBRN agents. For example, PTSD has recently been recognized in people recovering from sepsis and acute respiratory distress syndromes [46,48]. PTSD and PTSD-like syndromes were seen following Chernobyl and the sarin attacks in Tokyo [1,25,56,71].

5. Mitigation of Effects 5.1. Preparation in advance Planning before a CBRN event occurs should help prevent and/or mitigate both medical and psychological effects. This should be done in many forms: education of the public, table-top exercises, disaster drills, practice performing tasks in protective equipment, and full scale “mass casualty” exercises [72]. The mass casualty exercises need to be realistic, and they need to role play with large numbers of minimally injured and traumatic stress casualties [73]. The difficulty will be to alert the public to the risks, but not unduly alarm them. Planning and disaster drills should improve the resilience of the public. Accurate information should be released on the effects of the different CBRN agents. Fortunately the Federal and state governments are now implementing disaster planning on a wide scale. In planning for a large-scale disaster, there are numerous scenarios to consider. Is this a chemical or biological or radiological incident? Is it an act of war, terrorism, or an industrial accident? Is there warning, or is it unexpected? Where does it take place? Who is in charge? In all cases, there will be many agencies responding to the attack, as in any disaster (see also Chapter 9 for similarities with Russia). Jurisdictional issues will be paramount. As much as possible, these should be thought through in advance, on the local, state and federal level. For example, in the National Capital Area, deemed a high threat target, there will be the local governments of Northern Virginia, the District of Columbia, and Maryland, plus numerous federal agencies, including the military and the Department of Homeland Security.

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Emergency departments need to be prepared to handle large numbers of people, who are very concerned about exposure. Rather than dismissing concerned citizens by using the pejorative term “worried well”, cases must be taken seriously. A triage area outside the emergency room should be set up, so that many can be screened quickly but thoroughly. Care should also be paid to the concerns of the health care workers. Risks of secondary contagion from chemical agents or infection by biological agents have to be planned for – or else, many health care workers may not show up for work. A number of studies have also demonstrated that victims of a CBRN event consist of more than those on-site during the event. Rescue workers, first responders, healthcare providers, body handlers are also at risk, as are those who lost family or friends to the event [74–76]. The SARS epidemic has demonstrated potential vulnerabilities in our assumption that the health care system is capable of a comprehensive response. The federal government on 10 February 2003 began to issue guidelines for the general public to prepare for a chemical or biological attack. These contained common-sense recommendations, such as, a supply of water, food, flashlights and radios with extra batteries, and mechanical can openers. They also recommended purchasing a roll of plastic, duct tape and scissors for sealing off a room in the home from chemical attacks. This latter recommendation is more problematic, because of the risk of suffocation in complete sealed rooms as was seen in the Scud missile attacks on Israel in 1991 [65]. Training of medical and mental health providers and other associated helping agencies is critical, as has been stressed in other areas of this textbook. Further issues for training of mental health care providers include: the identification of the medical and psychological effects of the different CBRN agents, the differentiation of medical from psychological effects, recognition that infected/injured patients will also suffer psychological consequences and require social support, desensitization of claustrophobia from the protective gear, and other issues as described elsewhere [7,8]. 5.2. Protective equipment issues The protective gear to protect against chemical and biological weapons varies widely, from a simple facemask, to the Mission Oriented Protective Posture (MOPP) gear used by the military, to the self-contained suits used by CDC and HAZMAT personnel. In the past, it was thought that issues of wearing the protective gear were limited to military personnel and first responders trained in use of the equipment. However, increasingly the civilian population may be asked to wear some sort of protective gear. Command and control is an issue in any chaotic situation. In a situation where protective gear is worn, the protective gear will obscure recognition of faces and may garble communication. Therefore labels on the outside of the suits should clearly identify the wearer, and potential communication difficulties should be anticipated. For those who have not worn protective equipment, a brief description of the alienating effects of that equipment may be useful. In the military setting, those who wear the MOPP gear occasionally develop symptoms of claustrophobia, which has been termed “gas mask phobia” [77,78]. This is characterized by feelings of anxiety or panic, which may lead to hyperventilation. In turn, the hyperventilation and anxiety leads to the eyepieces clouding up, and to difficulty breathing, which further contributes to anxiety. In training exercises, occasionally the mask is pulled off, which gives immediate relief. However in the context of a chemical attack, that option may cause death.


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Aside from the psychological effects, the equipment is hot and clumsy – even though lighter, improved equipment has been developed. Most equipment allows one to drink through a water bottle, but eating and elimination of body wastes remains problematic. The thermal burden may contribute to the psychological effects described above. “Gas mask phobia” may be treated like other phobias, with the mainstay of treatment being relaxation and desensitization. In practice, that means initially wearing the equipment in quiet situations for short periods of time, and building up to longer periods with more intense activity. Emphasis should be given on activities that replicate the actual duties that a person would perform in the event of an attack. This may include either strenuous activity or working on a computer. Practice of basic activities of daily living, such as eating, drinking and going to the bathroom, should also be practiced. Firefighters and other first responders who routinely train in personal protective equipment are probably self-selected to tolerate the equipment. However, those applicants who are initially unable to tolerate the protective mask should be given a trial of the techniques described above. 5.3. Risk perception and health risk communication In a CBRN event, public health authorities will attempt to calculate the extent of the threat, and doubtless, information will be released via the media. However, it is likely that the extent of the danger will not be known immediately. Typically, initial information is incomplete, fragmented, and sometimes contradictory. As many contributors to this book note, health risk communication will be essential (see chapters 6, 18 and 22). Basic principles of health communication, such as having a consistent message delivered by a knowledgeable and credible official, listening and responding to the concerns of the public, and avoiding the appearance of defensiveness or concealment, should be followed [79]. In the recent past, including 9/11, the anthrax attacks, and the sniper events in the Washington DC area, the value of daily or twice-daily scheduled briefings with the media and the public cannot be understated – even if there is no new information to disseminate. Mayor Giuliani of New York City was extremely effective following the events of September 11. After any toxic accident, there is anxiety about health effects of any toxic release. Such anxieties will be multiplied in the aftermath of a CBRN event. Following 9/11 and the anthrax attacks, the news media was full of devastating descriptions of the results of a potential smallpox attack, and suggested that in the event of anthrax, “Your next breath may kill you.” These kinds of “scare-tactic” information are not helpful – instead the public should be provided with accurate hazard communication and workable solutions, especially with measures that can be taken to protect one’s self and family. According to one approach, risk equals hazard plus outrage [79]. Hazard is the scientifically-based risk-assessment, but outrage is made up of non-quantifiable factors related to the public’s concern and perception of the event. CDC has developed a course on “Emergency Risk Communication Training” which contains more in-depth information on the topic than we have room for here. For more information visit their web site at: http://www.cdc.gov/cdcynergy/emergency/. Outrage following a WMD attack will significantly influence both acute and long-term psychological effects.

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5.4. Triage and issues of differential diagnosis When Israel was attacked with scud missiles during the first Gulf War in 1991, large numbers of people reported to the emergency room for treatment [65,80]. Studies reported that approximately 70–80% of the patients in the early attacks were for stress-related symptoms. Unfortunately, emergency medicine physicians do not spend much time in residency learning how to evaluate psychological casualties [81]. Only recently has there been inclusion of neuropsychiatric casualties in triage [75,82,83]. It will be important for mental health care providers to become better integrated with emergency rooms. An important lesson learned from the Israeli experience is the importance of a separate stress center at hospitals, so that psychological casualties can be removed from the emergency room and taken to a less stressful environment [65,84]. Eleven Israeli civilians who were never in danger of a SCUD missile died because of fear/panic – four by heart attacks, and seven by suffocation (either putting on their gas masks improperly or completely sealing off their room). Initial treatment of psychological casualties may have profound consequences for long-term effects. Military experience dating from World War I demonstrated that “shell shock” casualties needed to be treated near the battle front and be treated when they initially presented with symptoms, rather than after the symptoms had become ingrained [53]. An important part of treatment was the positive expectancy of the staff that the patient would get better, that he was suffering a normal response to an abnormal stimulus. Military experience since then has demonstrated the effectiveness of this treatment, which has been given the acronym PIES – proximity, immediacy, expectancy, and simplicity in reducing PTSD and enhancing the return of soldiers to duty [85,86].

6. Conclusion The use of CBRN weapons may result in mass disruption. There will be a complex of effects which will include acute psychological casualties, long-term psychological casualties, and large-scale psychosocial consequences such as economic disruption, evacuation and/or relocation of portions of the population. The psychological effects will not be unique, but will be similar to those seen after natural and technological disasters, and attacks with conventional weapons. There will likely also be an increase in ill-defined, chronic-fatigue-like syndromes with multiple unexplained physical symptoms. Many of these effects can be prevented or mitigated by proper planning and practice prior to a CBRN event. Mental health care providers will need to become better integrated with disaster response plans and emergency rooms. Early recognition of psychological casualties with prompt supportive treatment in an area separate from medical treatment may be very useful. Health risk communication will be critical.

References [1] Asukai N, Maekawa K. Psychological and physical health effects of the 1995 sarin attack in the Tokyo subway system. In: Havenaar JM, Cwikel JG, Bromet EJ, editors. Toxic Turmoil. Psychological and Societal Consequences of Ecological Disasters. New York City, NY: Kluwer Academic/Plenum Publishers, 2002: 149–162.


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Emergency, Disaster, and Catastrophe: A Typology with Implications for Terrorism Response Thomas A. Glass Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe Street, Baltimore, MD 21205

1. Introduction The central theme of this chapter is that previous research and theory in the sociological study of natural and technological disasters can inform present policy and research in the area of terrorism (and bioterrorism more specifically) in ways that have yet to be fully appreciated. For the last five decades, the social scientific study of disasters has amassed a large number of case studies, refined a set of useful concepts and theories, and dispelled important myths about the way social groups respond to tragic and lifethreatening circumstances. A better understanding of how the public responds to disasters can inform preparedness and mitigation efforts in the area of terrorism. The dominant theme of the sociological study of disasters has been the observation that social response is less chaotic, less panicked, and more patterned and rule-governed than conventional wisdom has it. However, these insights have been less well articulated and explicated in the area of bioterrorism to date. Therefore, the main goals of this chapter are to provide this explication by: 1) Describing the results of a comparative study of 10 natural and technological disasters done by the author and a team of investigators at Texas A&M University; 2) Propose a typology of mass casualty events (MCEs) in order to formalize a distinction between disasters, emergencies and catastrophes; 3) Develop and explicate the core theme that despite the tendency of planners to think about preparation for a CBW attack in solely professional terms, it would be a terrible mistake to ignore or underestimate the possible role public will likely play in a large scale event; 4) Unpack the implications of this line of research for bioterrorism planning, policy and research.

2. Comparative Study of Mass Casualty Events (MCEs) Between 1989 and 1994, our group, based at Texas A&M University in the United States, initiated a multidisciplinary and comparative study of natural and technological disas-

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Th.A. Glass / Emergency, Disaster, and Catastrophe

ters funded by the National Science Foundation. This was in response, in part, to considerable interest in disaster research after the United Nation’s decade on disasters. Our goal was to study a range of events comparatively, in order to identify general patterns in response to situations that produce large numbers of casualties, for which some deaths and injuries are assumed to be preventable. This was among the first studies of its kind to be comparative across multiple events, and which brought together engineers, social scientists, epidemiologists and landscape architects. The epidemiologic objective of this project was to understand how deaths and injuries occurred, and what factors mitigated for and against fatal outcomes. Our team developed a quick response field methodology, based in part on over 30 years of study by investigators at the Disaster Research Center at University of Delaware. We deployed a multidisciplinary team to each of 10 MCE’s within 72 hours. Massive amounts of data were collected by our team including building plans, population surveys, press coverage, hospital and emergency medical system data, extensive interviews of professional and non-professional persons involved, and death certificates. The overall goal of the study was to examine factors related to survivability. This was in response to the observation that fatalities and injuries are almost always lower than expected and fewer than initially estimated. The question was: why is this so? What factors are associated with risk of death and injury, and, perhaps more importantly, what factors are associated with protection against these risks? 2.1. MCE’S studied The ten MCE events examined are described in brief detail in Table 1. They included both large and small events, both natural and technological calamity, and “single-site” and “multi-site” events. Table 1 summarizes the casualty figures. In all the events studied, the common refrain from those who examined the epidemiological outcomes was “It’s a miracle that more people weren’t killed.” For example, on August 24, 1992, Hurricane Andrew brought sustained winds of over 140 miles per hour to southern Florida. The best estimates suggest that at least 10,000 residents of Homestead Florida (a community that was especially hard hit) remained during the category five hurricane. Despite almost inestimable wind speeds, and the destruction of approximately 56,000 family dwelling units, Table 1. Summary information on MCE’s studied Location

Event∗

1. Loma Prieta, CA, USA 2. Lugoff, SC, USA 3. LaGuardia Airport, NY, USA 4. Brenham, TX, USA 5. Guadalajara, Mexico 6. Dade Co., FL, USA 7. World Trade Center, NY, USA 8. Tulsa OK, USA 9. Mobile, AL, USA 10. Northridge, CA, USA ∗ “disasters” vs. “emergencies”.

Date

Deaths

Number of injures

Earthquake Train derailment Plane crash Natural gas explosion Underground gas explosion

Oct. 1989 Mar. 1991 Mar. 1992 Apr. 1992 Apr. 1992

62 8 27 3 200+

3757 63 24 18 1400+

Hurricane Andrew Bomb explosion and fire Tornado Train derailment Earthquake

Aug. 1992 Feb. 1993 Apr. 1993 Sep. 1993 Jan. 1994

34 6 7 47 58

1400+ 1042 143 181 9200+


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along with significant damage to the response infrastructure, only 34 were killed [1]. The critical finding in each of these events was that untrained citizen, victims at the immediate scene, responded to life-threatening circumstances with extraordinary resourcefulness and competence. Importantly, these data also revealed that victims respond collectively, by forming emergent social groups, that avoid death and injury beyond expectation. The explication of these findings and their implications for terrorism response will be the subject of the remainder of this chapter. Other results and conclusions from this study have been published previously [2–6].

3. What Is a Disaster? Among the most important findings of this study, was the realization that the term disaster is problematic and in need of greater clarity of definition. In common language, we have become accustomed to hearing people use the word disaster to refer to everything from a dinner party that goes badly, to an outbreak of terrible disease in a dozen people (e.g., anthrax, U.S.). In the course of our study, our group developed a typology of mass casualty events based on the relative magnitude of two fundamental parameters: a) the demand characteristics of the event (numbers of victims in need or in potential need of extrication, rescue, shelter, and medical intervention), and b) the response capacity available in the immediate environment of the event (including both formal and informal sources of response capacity). This typology is depicted in Fig. 1. The figure posits three qualitatively different types of MCEs: emergencies, disasters and catastrophes. The fundamental insight, drawn from our own studies, and from previous disaster sociology, is that relative scale is of critical importance. That is, a disaster can be more precisely defined as an MCE that generates demands (casualties and damage) in excess of the locally available response capacity. This implies that a small MCE that occurs in a rural or remote area with few formal response resources, can become a disaster, while

Figure 1. Typology of MCEs, making distinctions between disasters, emergencies, and catastrophes.

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a large MCE (in absolute terms) in a metropolitan city equipped with vast professional and non-professional resources, may not be thought of usefully as a disaster at all. For example, we studied the derailment of the Amtrak sunset limited train in Lugoff, South Carolina. Although this event produced only 64 serious injuries and 8 deaths, we classify it as a disaster because the response capacity was exceeded by the demands. The event itself occurred in a swamp, several miles from the nearest town. The derailment occurred at four o’clock am near a in a small town with a small volunteer fire department. Given the needs of those injured in the dark, local resources were quickly overwhelmed. Alternatively, we also studied the crash of U.S. Air flight 405 on a runway at LaGuardia Airport in New York City in March of 1992. Of the 51 passengers on board, 27 died and 24 were injured after the plane flipped off the runway and into Flushing bay. Ad hoc civilian responders on the plane managed to remove injured passengers from fuelcovered mirky water. In contrast to the circumstances surrounding the Lugoff crash, the US air crash in New York City produced a massive professional response. The EMS and hospital capacity was hardly dented by the demands. This event, in our typology is better classified an emergency. A third relevant example is the Earthquake that struck Kobe Japan in January of 1995 (although well-documented, it was not among the events our group studied). Kobe represents the rare circumstances when the demand characteristics of the event dramatically exceed the response capacity of the formal response system, coupled with substantial direct or indirect damage to the infrastructure upon which that response system depends. In the immediate aftermath of the Kobe (or Great Hanshin) earthquake, roads, bridges, and communications were completely knocked out, hospitals were turned to rubble, firefighters lacked water to battle the 300 fires that broke out due to disruption of the water supply. Tragically, Kobe generated 6,279 deaths, 90% occurred during building collapse, 35,000 injured, and 300,000 lost their homes. In short, the formal response system was massively disrupted. In the first 24 hours, no patients were transported to the local hospitals [7]. Yet despite this, over 1800 persons were extricated from collapsed structures and automobiles and 80% survived despite the lack of a hospital [8]. This points to the importance of non-professional (or informal) response capacity. Kobe is an example of an event that due to the scale of disparity between demands and resources, constitutes a catastrophe. As depicted in Fig. 1 the relationship between demands and resources may not be strictly linear. It has not been possible in the study that we completed to do a comprehensive analysis of the precise threshold points at which an emergency becomes a disaster, or a disaster becomes a catastrophe. We have come to believe however that this typology represents qualitatively different phenomenon with important implications for planning and response. This is the topic of the next section. 3.1. Relevance to terrorism? The two key points made thus far have been: emergencies are qualitatively different from disasters, and that whether an event becomes a disaster depends on the relative scale of resources to demands. To extend these points to a WMD scenario, an event involving 5 thousand victims in New York’s Manhattan may not require the same response strategies as an event involving 500 cases in Manhattan, Kansas (population X). In the U.S., there is a clear preference for thinking in terms of emergencies (albeit large scale ones) in which


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formal response capacity (hospitals, doctors, nurses, police, EMS) will be sufficient, if severely taxed, to mount a response that results in a minimal reduction in the standard of care afforded to those who are injured. However, beyond the horizon of events that are no larger than the break-even point, where professional responses are adequate, the question becomes: what happens when all the hospitals, clinics, pharmacies, first-aid tents become flooded beyond capacity? What happens when demands exceed that threshold? We rarely entertain this as a possibility, both because these kinds of events are rare and because we tend to presume that available professional capacity is highly elastic. This should not prevent us from thinking about larger scale events where life and death may hang in the balance for large numbers of civilians and for which highly professionalized models are less than adequate. What makes disasters so interesting to study is that from a sociologic approach, human behavior is general highly patterned and structured as a result of the “take-forgranted” nature of everyday life. Sudden disasters (such as an earthquake) cause a rapid dislocation in the integrity of the take-for-granted world of everyday life. By definition, this dislocation is usually on a large or massive scale and by definition, groups and individuals have to create new ways of coping. By definition, what makes a disaster disastrous is that the resources available to respond in the usual taken-for-granted are insufficient for the scale of the crisis. Disasters have this all encompassing quality that transforms and upends routine life sometimes in the blink of an eye. Based on several decades of research, social scientists have come to understand the nature of what happens at the intersection of victim behavior, health system response and the environment as emergent collective behavior. This concept is a rubric, it is a powerful organizing tool and heuristic device. 3.2. A thought experiment The essential argument is that disasters are qualitatively different from emergencies in ways that are quite significant in terms of planning and response. Consider the following simple thought experiment. If a gas attack occurred in the underground below Trafalgar square at this very moment, generating 100 critically injured Londoners, would emergency medical workers arrive quickly and mobilize sufficient resources to respond effectively to the needs of the injured? Would law enforcement be able to establish a secure perimeter and begin an investigation into the identity of the culprit? Would London’s hospital system be able find 100 empty beds to treat victims as they arrived? Would doctors and nurses be able to offer all 100 injured patients state-of-the art care without significant compromise? Could all this be done right now without planning or drilling beyond what has been done so far? Would the number of preventable deaths most likely be kept low? The answer to all these questions is most likely yes. What role would the lay public play in the response: that of victim or bystander. In contrast, what if a dirty bomb in a suitcase exploded in Trafalgar square right now and there were 10,000 seriously injured persons? Would the answer to the above questions still be yes? What is the difference between 100 and 10,000 casualties (other than 9,900 injured persons)? Beyond the obvious differences, previous research suggests that the 100 victim case (a clear emergency in resource-rich London) is qualitatively distinct from the 10,000 victim case. The differences are described in Table 2 below.

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Th.A. Glass / Emergency, Disaster, and Catastrophe Table 2. Characteristics of emergencies vs. disasters Emergencies

Disasters

Demand Resource Ratio

Demands Response capacity

Demands Response capacity

Event perimeter First responders Ideal management model Organizations Preventable death

Well-defined Professionals Command & control Autonomous None to few

Diffuse or none Professionals & Nonprofessionals Emergent resource coordination Convergence Few to large numbers

Crucial mode of care Use of triage∗ Panic

Trauma NO Unusual

Primary care YES Rarer

∗ Triage is used in this context to refer not to the general practice of selecting patients for order of treatment based on urgency of need, but in the more formal, military usage, meaning choosing to withhold care from patients unlikely to survive or the extreme rationing of care under conditions of a shortage of care.

The defining characteristic of a disaster is the relative balance of resources to demands. The other qualitative differences listed in table two arise principally from this. In an emergency, professional responders (fire, police, military, EMS, etc.) seek to establish a fixed event perimeter, often demarcated by the familiar yellow plastic tape. The yellow perimeter establishes the edge of the event itself, but also establishes a dividing line between professionals and the lay public, who are assumed to play no significant role and who are kept on the outside of the perimeter (unless they are victims). In an emergency, the event boundaries are normally easily established and well-defined. Inside the event boundary, professionals conduct search and rescue operations, coordinated from command and control centers located at the event periphery (but inside the yellow tape). Emergency managers tend to assume that all events will be perimeterizable, and hence cordoning the edges of the event is a standard aspect of “disaster drills”. However, in the real world, disasters are distinct in that the perimeter is almost always porous or non-existent. This means that ordinary citizens, who are or the scene, are directly involved in response efforts. Response efforts in a disaster depart from the protocols and procedures of emergencies, due in part to the inherently diffuse or non-existent boundaries of the event. Response to victims tends to emerge as a blend of professional and non-professional action. For example, in the Kobe earthquake, only ¼ of live victim extrications were accomplished by fire, EMS or national-defense forces in 1995 [8]. Due in part to the absence of a defined perimeter, the most common method of victim transport was the private family car, with ambulances transporting only 26% of victims [9]. In our own study, we recorded evidence of emergent patterns of cooperation and mutual aid between civilians, military, and professional responders in the sewer explosions in Guadalajara Mexico in April of 1992. In that event, groups of citizens with no formal training formed search and rescue teams. They used car jacks to lift rubble, and used garden hoses to siphon air to those who were entrapped. This illustrates our third qualitative difference: in disasters, a mix of professionals and non-professionals are the first-responders to the event. In emergency situations, logistical and command and control operations ensure that professional first responders are quickly mobilized at the scene. In disasters, especially ones that are multifocal in nature, professional responders generally have significantly longer response times. In many of the events we studied, disaster conditions cause disruptions in communication, traffic, and in those systems designed to function best in single-location emergencies. During


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hurricane Andrew for example, the Dade County Fire Department’s disaster response team, which has responded to disasters on the other side of the globe, was not able to respond to an event that occurred in their own jurisdiction. In the U.S., the 9-1-1 system is a good example. During a disaster, the 911 telephone response system becomes quickly flooded with emergency calls. Beyond a certain threshold, the systems ability to maintain protocol is exceeded. In an emergency, a command and control model of event management works well. Adapted from the control of forest fires, the Incident Command System has been the key strategy for emergency response in the United States. In the context of events with a defined perimeter and sufficient professional response capacity, the ICS is especially effective. However, in a disaster context, a single command center with a single incident commander is seldom effective or practical. More importantly, in the disaster context, what is needed more than a vertically hierarchical command and control model, is an emergent systems coordination model, which allows teams using different communication systems, with no or little previous experience working together, and with various levels of knowledge of the local situation to work together in a complex and dynamic environment. Additionally, the ICS is not an effective system for coordinating civilian participants in the response effort, despite substantial evidence that civilians play a critical role in search and rescue, victim extrication, and first aid in disasters. In the U.S., alternatives to a rigid, military style command and control model of disaster planning have yet to be envisioned. As one example, the recommendations of the CDC Strategic Planning Workgroup of preparedness and response for biological and Chemical terrorism provides great detail on the need for professional training, information systems, and infrastructure building, and provides no mention of the role of the civilian population or in the need to coordinate lay and professional first responders [10]. Several examples of alternative approaches can be found in countries that have more experience with large-scale MCEs including Sweden’s “Total Defense” strategy [11] as well as the “community information centers” found in Israel [12]. In most emergencies, there are few or no preventable deaths; the standard of care is maintained even under system stress conditions, and there is no real triage. In a disaster however, because the response capacity is exceeded, the number of preventable deaths can be substantial. 3.3. Summary Among the implications of this distinction is the basic idea that patterns and procedures cannot be generalized from emergencies to disaster situations. For example, numerous American commentators and policy makers including Margaret Hamburg [16], Eric Noji [17], and others, have written articles about lessons learned from recent emergencies and their relevance for disaster response. The events most often used as templates or blueprints for disaster preparedness include the 1999 outbreak of West Nile Virus in New York (62 cases and 7 deaths), the Washington D.C. area sniper case (13 shootings, 10 deaths), the anthrax attacks of 2001 (22 cases, 5 deaths), or the 2002–2003 SARS outbreak in the U.S. (418 total suspect or probable cases [18]). Using emergencies such as these (which admittedly have important lessons to teach and are doubtless of high public opinion visibility and impact) may provide an insufficient basis for designing response patterns for disasters. Next, the implications of these arguments are drawn out more extensively for terrorism preparedness.

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4. Implications for Terrorism Preparedness 4.1. Implication #1: The civilian public will play a critical role in a disaster Mistrust of the public’s ability to participate effectively in MCE response is widespread. In the United States, disaster planning has tended to emphasize centralized, technology intensive, professionalized response models. In turn, emergency management professionals tend to treat the public as an unwanted nuisance, as panic prone, and as irrelevant to effective response. This is appropriate for emergencies, but not disasters where by definition, formal response systems are overwhelmed and unable to provide adequate response without non-professional assistance. Mutual aid from distant professional agencies is, of course, a component of a complex response, however, the significance of immediate victim/bystander response has been underappreciated and overlooked. Overall, the evidence suggests that victims tend to respond effectively and creatively. In our research, we observed in almost every event, that victims and bystanders tend to form spontaneous groups with roles, rules, leaders and a division of labor. This emergent collective behavior makes it possible for ordinary citizens to do extraordinary things. The Amtrak Sunset Limited derailed and crashed into a bridge near Mobile, Alabama on Sept 22 1993 with 220 passengers and 18 crew members aboard. It was the worst train crash in Amtrak history with 47 fatalities, and over 180 passengers and crew injured. The train crashed at 2:58 in the morning. EMS did not arrive for 1.5 hours and the first patient was not transported until 6:15 AM. All those who died expired within moments. We estimated that 14 additional people would have died if it had not been for other passengers and crew, along with one nurse who was on the train. By the time EMS was able to find the train in the darkness and fog, passengers and victims had been waiting for well over an hour. In most cases, the role of ordinary citizens is under appreciated because the news media arrives with (or because of) formal first-response groups. However, in disasters, the majority of those who will be saved, have been saved prior to the arrival of professionals. In disaster epidemiology, experts often refer to “the golden 24 hours”, or the time when life-saving rescue must arrive before the critically injured are no longer alive or salvageable. Our data show that the vast majority of fatalities in disasters occur instantaneously, or within twenty minutes, not hours. Moreover, the reactions and behaviors of ordinary citizens, who happen by chance to be in the immediate vicinity, and who take actions that have life-and-death consequences for those around them, are a critical and systematically ignored aspect of disaster response. 4.2. Implication #2: Don’t panic about panic In all the events that our team studied, we were struck by the frequency with which victims and responders we interviewed commented on the absence of panic, complaining or irrational behavior. Most described an “eerie feeling of calm” during life and death moments. Panic is a staple of disaster movies, but is quite rare in disasters. It is clear from our research that ordinary citizens are capable of avoiding deadly harm both individually and collectively through astonishing action. Humans may well be evolutionarily selected to respond adaptively, rather than with panic in those situations. There are of course, well documented exceptions, events where panic (defined as irrational flight behavior) is seen. Examples include indoor fires such as the Coconut Grove nightclub fire in Boston in 1942 in which 491 people were killed [19], as well as football stadium “riots”.


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Although panic is rare, it is not, as some have argued, un-studyable. E.L. Quarantelli, the leading sociologist in this area and founder of the U.S. Disaster Research Center, studied 150 disasters over 50 years and concluded that panic is “extremely rare and almost nonexistent in most disasters” [20,21]. Panic behavior is often portrayed by the media as antisocial behavior, an irrational and ineffective means of escape or collective response. The sociological literature demonstrates that behavior that is described as panic by the press (who have a vested interest in portraying situations as irrational and brutish) is actually adaptive – emergent, not always laudable, but often quite adaptive. Discussions of panic in disasters often lead to the question of looting. Looting is quite common in civil disturbances, but extremely rare in natural disasters. This is because in the latter, powerful norms emerge that protect the idea of private property. At the same time, norms emerge also to support the notion that some property becomes community property when the common good is at stake. In the Guadalajara sewer explosions for example, groups of citizens “broke” into cars and shops to retrieve car jacks to move rubble. This was not looting, but rather a reflection of an emergent norm about how property could be appropriated for collective service. Looting is a response to dissensus and conflict arising from particular social conditions. More often than not, serious scholarship has shown that social response to disasters is based on consensus, rather than dissensus, on cooperation rather than conflict, and on voluntarism that most often goes beyond the call of duty [3,22–26]. Moreover, despite widespread expectations about panic, the most common emergent norm in disasters is altruism. The one event studied by our group where we had expected to see wide spread panic was the first World Trade Center bombing in New York City in February of 1993. With nearly 10,000 people trapped in a vertical column waiting to evacuate the building, all the emergency lighting and public address systems failed (along with elevators); this should have been an ideal mix of ingredients for panic. Hundreds waited as long as six hours slowly descending smoke filled stairwells in the dark. As part of our study, we conducted a random sample of 415 people who were in those stairwells. Our data demonstrated that panic was unusual, and that people were mainly cooperative and calm [5]. The press reported differently but mostly because they interviewed people fleeing the buildings and ignored people who said there was no panic. 4.3. Panic and bioterrorism In regards to the threat of bioterrorism, the question of panic becomes more complex; the lessons of natural disasters clearly have limits. In the case of an intentional outbreak of infectious disease, the problem of emergent norm formation is complicated by the presence of a potentially hidden and contagious threat that cannot be contained. What norms would emerge? How would vaccine stock piles be regarded by organized and spontaneous groups? Would the public trust or reject efforts to enforce quarantine, to institute infection control measures, and ration available treatments? The answers to these questions are not known. One could imagine that the circumstances for panic or other antisocial collective responses could exist. However, historical accounts of the influenza pandemic of 1918, fail to bear this out [27,28]. It is often forgotten that the Great Spanish flu pandemic, which killed over 500,000 Americans, was, according to Alfred Crosby, widely believed to be a biological weapons release – that the Germans had unleashed a new kind of stealth weapon (Bayer aspirin) [27]. Despite those fears, communities across

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America and throughout the world demonstrated remarkable resilience, resourcefulness, and altruism. The lessons of 1918 however have been lost to the extent that we still lack planning for an outbreak scenario in which the hospitals are filled to capacity, and the outbreak is not yet contained. For this reason, and based on the results of our research, models such as the ‘shielding’ model, which relies on a decentralized, home-based approach to disease surveillance and control should be given stronger funding and support, in addition to current attempts to build a purely hospital/clinic based response capacity (for discussions of shielding, see [29–31]). One thing that is clear is that the term ‘panic’ is used indiscriminately and imprecisely in ways that cloud rather than clarify. For example, after the 2003 U.S. anthrax attack, numerous stories appeared in the press about “panic” buying of antibiotics and gas masks. This hardly amounts to the sort of wholesale abandonment of social order that is implied by the term panic. More to the point, the best survey of post-anthrax behaviors, conducted by Harvard University and Robert Wood Johnson in the three most impacted cities (October 2001), found that only 1% had “purchased a gas mask” and only 5% had gotten an “antibiotic prescription” [32]. Moreover, these behaviors were a symptom of uncertainty, and were medically unwise, but do not constitute evidence of widespread panic. That same survey showed that 44% of the residents of the affected cities reported that they did not trust the secretary of Health and Human Services (T. Thompson), who’s handling of the anthrax crisis was described by John Schwartz of the New York Times as “spin control” rather than sound public health [33]. Overall the lesson is that when people have preexisting social relationships in disasters, then panic is overall quite unusual. This is a lesson that should be considered in disaster preparation.

5. Summary and Conclusions In his recent book Our Final Hour: A Scientists Warning: How Terror, Error and Environmental Disaster Threaten Humankind’s Future in this Century – on Earth and Beyond, Britain’s Astronomer Royal, the Cambridge University Cosmologist Martin Rees says the human species has no better than a 50–50 chance of surviving the 21st century. He has made a 1,000 dollar bet that a biological weapon attack or an error in a lab will kill 1 million before 2020 [34]. Yet, planning and preparation for biological weapons continues to be based on small, contained emergencies. Absent are the plans and preparations for events of super magnitude. The greatest opportunity to invest in strategies that will minimize preventable deaths, however, lies in thinking about and planning for events of this scale. This chapter has attempted to bring needed scrutiny to the problem of how disasters should be defined and how they differ from emergencies and catastrophes. In conclusion, based on this distinction, as well as a large body of sociological research, the following tentative speculations may be useful in guiding policy makers and researchers struggling to plan for the kind of massive event that Rees warns about: 1) During a disaster or catastrophe, victims will circumvent normal routing mechanisms into the hospital and will self-transport, self-triage and to some extent, may self treat. In the 1995 Sarin Gas attack in Japan, for example, 688 people were transported to hospital by emergency medical and fire department authorities. More than 4,000 people found their own way to hospitals and doctors using taxis, private cars, or on foot.


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2) Hospitals will likely be heavily stressed because the least injured persons will rush to hospital seeking advice and treatment and will clog emergency departments. This will be followed by the press, family members of the injured or infected, and the convergence of all manner of medical personnel. This will, regrettably, create an ideal Petri dish for the transmission of infectious agents. 3) People will form emergent and spontaneous groups. These groups will not be under the direct control of any national agency. The behavior of these groups may make the largest difference in terms of ultimate outcomes. Failure to involve these groups through open and candid release of information, and a sense of collective responsibility will increase the likelihood that destructive social responses emerge. It is critical to develop strategies to pre-engineer the “Blitz spirit” by building trust and local civilian response capacity. Society itself is comprised of interconnected networks of social actors across organizations. This dense network represents an ideal scaffolding for building a civilian based infrastructure that can be harnessed in the event of bioweapon release, pandemic flu, or other emerging infectious threats. 4) The questions around panic and civil unrest after a biological weapons attack depend on what sort of collective definition of the situation emerges. Will norms of mutual dependence and collective resolve emerge and flourish? Will a spirit of esprit d’corps prevail as happened during the Blitz in Britain during World War II? (for an excellent discussion of civilian resilience during the Blitz, see [35]), or as occurred in New York after September 11, or will latent fractures within the social fabric rip open pitting groups against one another in competition for scarce resources? One might postulate that a consensus crisis is more likely as long as the perpetrators are socially external, and as long as information dissemination perceived to be accurate, timely, and free of spin control, and that resource distribution is perceived to be equitable. Finally, the main message of this chapter has been that disasters and emergencies are different classes of events and require different strategies. Qualitative changes occur during crisis situations that exceed the normal range. The surprise: despite what we see in disaster movies, disasters are not, for the most, part chaotic. Instead rules, roles and disaster specific norms of behavior emerge as the event itself collides with the groups and systems it effects. Learning from the lessons of past disasters may have considerable value in improving our preparations for large scale events in the future.

References [1] Anonymous. Preliminary report: medical examiner reports of deaths associated with Hurricane Andrew – Florida, August 1992. MMWR – Morbidity & Mortality Weekly Report 1992; 441 (35): 641–644. [2] Aguirre BE, et al., The Social Organization of Search and Rescue: Evidence from the Guadalajara Gasoline Explosion. International Journal of Mass Emergencies and Disasters 1995; 13 (1): 67–92. [3] Glass TA. Understanding public response to disasters. Public Health Rep 2001; 116 (Suppl 2): 69–73. [4] Glass TA, Schoch-Spana M. Bioterrorism and the people: how to vaccinate a city against panic. Clin Infect Dis 2002; 34 (2): 217–223. [5] Aguirre BE, Wenger D, Vigo G. A test of the emergent norm theory of collective behavior. Sociological Forum 1998; 13 (2): 301–320. [6] Wenger DE, Aguirre B, Vigo G. Evacuation under conditions of uncertainty: The World Trade Center Evacuation of February 26, 1993. In: International Sociological Association (ISA), 1994: ???

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[7] Nagasawa Y. Earthquake damages to hospitals and clinics in Kobe, Japan. Jpn Hosp 1996; 15: 77–82. [8] Tanaka K. The Kobe earthquake: the system response. A disaster report from Japan. Eur J Emerg Med 1996; 3 (4): 263–269. [9] Tanaka H, et al., Overview of evacuation and transport of patients following the 1995 Hanshin-Awaji earthquake. J Emerg Med 1998; 16 (3): 439–444. [10] Biological and chemical terrorism: strategic plan for preparedness and response. Recommendations of the CDC Strategic Planning Workgroup. MMWR Morb Mortal Wkly Rep 2000; 49 (RR-4): 1–14. [11] Kulling PE, Holst JE. Educational and training systems in Sweden for prehospital response to acts of terrorism. Prehospital Disaster Med 2003; 18 (3): 184–188. [12] Sachs Z, et al., Community coordination and information centers during the Persian Gulf war. Isr J Med Sci 1991; 27 (11–12): 696–700. [13] McNabb SJ, et al., Hurricane Andrew-related injuries and illnesses, Louisiana, 1992. Southern Medical Journal 1995; 88 (6): 615–618. [14] Cushman JG, Pachter HL, Beaton HL. Two New York City hospitals’ surgical response to the September 11, 2001, terrorist attack in New York City. J Trauma 2003; 54 (1): 147–154; discussion 154–155. [15] Bremer R. Policy development in disaster preparedness and management: lessons learned from the January 2001 earthquake in Gujarat, India. Prehospital Disaster Med 2003; 18 (4): 372–384. [16] Hamburg MA. Bioterrorism: a challenge to public health and medicine. J Public Health Manag Pract 2000; 6 (4): 38–44. [17] Noji EK. Introduction: consequences of terrorism. Prehospital Disaster Med 2003; 18 (3): 163–164. [18] Update: severe acute respiratory syndrome – worldwide and United States, 2003. MMWR Morb Mortal Wkly Rep 2003; 52 (28): 664–665. [19] Saffle JR. The 1942 fire at Boston’s Cocoanut Grove nightclub. American Journal of Surgery 1993; 166 (6): 581–591. [20] Dynes RR, Tierney KJ, Fritz C. The emergence and importance of social organization: the contributions of E. L. Quarantelli, in: R.R. Dynes and K.J. Tierney, editors. Disasters, Collective Behavior and Social Organization, 1994, Newark, DE: University of Delaware Press, 1–17. [21] Quarantelli EL. The sociology of panic, in: N. Smelser, P.B. Baltes, editors. International Encyclopedia of the Social and Behavioral Sciences, New York: Pergamon, 2001: 11020–11023. [22] Benedetto R. Poll finds anthrax fear but no panic, in: USA TODAY, 2001, p. A-4. [23] Crocq L. Individual and collective behaviors in earthquakes, fire, and man-made disasters. Psichiatria Ed Ecologia 2001; 37–46. [24] Dynes RR, Tierney KJ, eds. Disasters, Collective Behavior and Social Organization. Newark, DE, University of Delaware Press, 1994: 378. [25] Johnson NR. Panic and the breakdown of social order: popular myth, social theory, and empirical evidence. Sociological Focus 1987; 20 (3): 171–183. [26] McPhail C, Johnson NR. The myth of the madding crowd. Social Forces 1992; 71 (1): 238. [27] Crosby AW. America’s Forgotten Pandemic: the Influenza of 1918. 1989, Cambridge, MA: Cambridge University Press. [28] Schoch-Spana M. Implications of pandemic influenza for bioterrorism response. Clinical Infectious Diseases 2000; 31: 1409–1413. [29] Everly GS, Jr. Responding to bioterrorism and psychological toxicity: an introduction to the concept of shielding. Int J Emerg Ment Health 2002; 4 (4): 231–233. [30] Prior SD, Rowan F, Saathoff G. Foundations of shielding. Int J Emerg Ment Health 2002; 4 (4): 235–238. [31] Saathoff G, Everly GS, Jr. Psychological challenges of bioterror: containing contagion. Int J Emerg Ment Health 2002; 4 (4): 245–252. [32] Blendon RJ, et al., Harvard School of Public Health/Robert Wood Johnson Foundation Survey Project on Americans’ Response to Biological Terrorism, Study 2: National and Three Metropolitan Areas Affected by Anthrax. Boston, MA: Harvard School of Public Health, 2001. [33] Schwartz J. Efforts to Calm the Nation’s Fears Spin Out of Control, in: New York Times, 2001: New York, NY. [34] Rees MJ. Our Final Hour: A Scientist’s Warning: How Terror, Error, and Environmental Disaster Threaten Humankind’s Future In This Century – On Earth and Beyond. New York, NY: Basic Books, 2003. [35] Jones E, et al., Civilian morale during World War Two: responses to air-raids re-examined. J Social History, forthcoming.


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Cultural Precursors and Psychological Consequences of Contemporary Western Responses to Acts of Terror Bill Durodié Senior Lecturer in Risk and Security, Resilience Centre, Cranfield University, Defence Academy of the United Kingdom, Shrivenham, Swindon SN6 8LA

Introduction This article explores what the response to the terrorist attacks of September 11th 2001 teaches us about Western society today. There has been a wealth of research examining the purported cultural background and psychology of the perpetrators of those events [1]. That focus has two main rationales; to identify and deal with potential terrorists, and to begin to tackle what are considered to be the ‘root causes’ of terrorism – usually held to stem from poverty and disaffection across the Third World [2]. These approaches offer a somewhat predictable and reassuring explanation of events. They locate the problem of terrorism elsewhere – in the minds, actions and cultures of others. At best, those posing a threat are understood to be reacting in an adverse way to what are held to have been the injustices committed against their forebears during an earlier age of imperial domination. Here, I wish to consider the extent to which some of the issues may be far closer to home, and more contemporary, than we like to envisage. In part, this is due to the particular way in which Western societies perceive and deal with anything that involves risk nowadays [3]. If anything, the actual threats posed could be conceived of as weaker today than those presented throughout most of the Cold War, yet society appears to react as if they were stronger. Why is this? And what does this tell us about ourselves? A focus on our increasingly exaggerated perceptions of risk and the adverse consequences this brings, both to the people of the Third World and for Western societies, is a missing element to our analysis of terrorism that we ignore at our peril. Ultimately, if our responses are shaped, in part at least, through the prism of our own domestic fears and insecurities, then the actions taken will prove limited or ineffective, and may serve to confuse matters more. A mystifying mythology is created, which in its turn demands totemic gestures to reassure the public. This process, readily becomes a self-fulfilling fantasy which – far from assuaging our concerns – will only drive them further. Inverting Questions Just as there are two sides to every coin, so occasionally we need to invert the questions we ask of society if we are to obtain a more balanced and productive take on issues.

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B. Durodié / Contemporary Western Responses to Acts of Terror

For example, the recent fashion to re-examine Samuel Huntington’s work on, ‘The Clash of Civilisations’ [4], in the light of 9/11, would do well to be moderated with an equally vigorous examination as to the possibility of a clash within civilisation, rather than between differing cultures. This would need to address the radicalisation of Muslims within western societies, but more importantly, for those wanting to get to the real roots of this phenomenon, to assess and analyse the largely Western origins of anti-Western ideas. In this vein, rather than recording so-called anti-American sentiment across the world today [5], we would do well to examine how such attitudes have developed closer to home. After all, more anti-capitalist protestors come from Seattle than from Gaza. The rejection of once core social values, such as ambition, success and development, and their representation as arrogant, selfish and dangerous, reaches its apogee in relation to the US – the most advanced capitalist nation. This rejection is reflected in a growing selfloathing evident in American culture and that of other Western societies, as expressed for instance in Oscar-winning Michael Moore’s best-seller ‘Stupid White Men’ [6]. Another assumption worth exploring in a more rounded way, is that of the need to understand why it is that a small proportion of Asian youth appear to be attracted to fringe Islamist organisations. It may prove more productive to ask, why it is that a small element of Asian youth, and quite a few others beside, fail to find any sense of solidarity or purpose within Western society [7]. Surely, it is an indictment of our own culture that its lack of direction and dynamism, fails to attract and inspire ambitious young people? It is not the magnetism of those who supposedly seek to restore a twelfth-century caliphate in the twenty-first century that should concern us. Rather, it is a failing of our own society that it does not project clearly a vision of its own future to argue against those who would have us live in the past. It fails thereby, to command loyalty, or to impart any sense of mission or meaning. Instead of examining the presumed culture and psychology of those who perpetrate acts of terror, this article focuses upon those selfsame factors in relation to our societies and to ourselves. To what extent are we truly facing a new phenomenon, encompassing new technologies with unforeseen consequences? Or, is it we who have changed – including our individual attitudes to danger, the coherence of our institutions and our sense of social solidarity and resilience?

Diminished Selves The extent to which, once core, social affiliations and bonds have been eroded without replacement over recent decades is striking. We should be alert to the possibility of this producing some unexpected consequences. At the formal level, people in advanced Western societies are increasingly unlikely to participate in the political process. Nor are they as likely to be active – or even passive – members of political parties or trade unions in the same way that their forebears were. There is, of course, more to democracy than merely casting your vote, but even when people do vote, it is often on a negative basis – against an incumbent – rather than for their replacement. These trends are also most marked amongst the young. At the informal level, some changes are even more notable. Many have commented on the growing pressures faced by communities, neighbourhoods and families. In ‘Bowl-


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ing Alone’, the US academic Robert Putnam pointed to the demise of informal clubs and associations [8]. Meeting with friends occurs less frequently than previously, too. This loss of, what has sometimes been coined, social capital, has occurred within a remarkably short period of time. A generation ago it was quite normal to send children to school on their own, assuming that other adults would act in loco parentis – chastising them if they misbehaved, and helping them if they were in need. Today, across many urban areas, this can no longer be assumed to hold. None of us ever signed a contract saying that we would look after other people’s children. It was simply an unstated and self-evident social good. Sadly, this erosion of communal bonds has, in its turn, made the job of parenting harder still [9]. So, as well as being liberated by the erosion of traditional rules and structures over recent decades, we should note that, without anything to replace these, we have also become more isolated from one another and less effective in consequence. Far from this erosion of old community values necessarily giving rise to a new, confident individualism, what we have seen is the emergence of a disconnecting process of individuation. In the past, social networks and norms may have imposed arbitrary or authoritarian structures and rules upon people, but they also provided meaning, conferred identity, and facilitated basic processes, without which we have become greatly diminished as individuals [10]. Being less connected has also left people less corrected. It has allowed their subjective impressions of reality to go unchecked, unmediated or unmoderated through membership of a wider group or association. In the past, when confronting difficulties, people would, through their social networks, have been encouraged to view things more objectively, or at least from a different perspective. They could also have envisaged a collective solution to their problems. Nowadays, personal obsessions readily grow into allconsuming worldviews that are rarely open to reasoned interrogation or resolution. We may be more aware than previous generations, but we are also easier to scare, as we are increasingly alone in facing life’s challenges. Notably, it is this erosion of informal social bonds that has led to their having to be replaced by more formal processes of blaming and claiming [11]. Thus, a narrowly self-oriented personality and culture has emerged alongside a growing sense of isolation and insecurity. In some ways, we have replaced a culture of unthinking deference by one of unnecessary fear. It seems that confident individuals need a coherent society to fall back on, just as much as a coherent society requires confident individuals to build from.

Risk Aversion Above-all though, this process of individuation has encouraged an exaggeration of the threats and challenges posed by everyday life. This has manifested itself as a growing obsession with, and aversion towards, all-manner of risks, both new and old. Risk has become a dominant prism for viewing the world today, as evidenced by the number of courses, conferences and journals now devoted to the concept. This outlook emerged gradually, but was catapulted to prominence through the break-up of the Cold War order, coinciding with the publication of the German sociologist, Ulrich Beck’s book, Risk Society [12].

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The Aids-awareness campaigns of the 1980s were an early indicator of changing perceptions of risk. In the UK, these became much clearer in the debacle over bovine spongiform encephalopathy (or BSE), more commonly referred to as ‘mad cow disease’ [13]. Since that time there have been a steady stream of risk-related issues impinging upon public consciousness. These have included campaigns against the presumed adverse consequences of introducing genetically modified organisms into the environment, and concerns over the use of mobile phones held to have possible effects on the brain through so-called non-thermal radiation [14]. More recently the MMR (measles-mumps-rubella) triple-vaccine, was accused by some, despite a lack of confirming evidence, to be linked to autism in infants [15]. Nor was it just scientific and technological risk-related matters that came to prominence. Age-old activities and problems have also been reinterpreted and reorganised around a heightened consciousness of risk. Bullying in schools, sun-bathing, child abduction, untrustworthy GPs, and the very food we eat, have all, at one time or another, formed part of a growing panoply of issues one can point to, of fears raised over recent years. Risk management as a discipline has therefore become a major discourse and organising activity, in both the public and the private sector [16]. Risk managers sit on the board of major companies [17]. Even relationships are now increasingly viewed through the distorting and stultifying prism of risk. Despite concerns raised as to the broader implications and consequences of this, there is an almost unstoppable trend to reinterpret all issues – whether personal, social or scientific – in this way. But, rather than the world changing any faster today than in the past, or becoming a more dangerous, unforeseeable or complex place, it may be our diminished, and more isolated, sense of self that has altered our confidence in dealing with change and the problems it gives rise to [18]. More on our own, and self-absorbed than previous generations, with an exaggerated sense of threat, it has become normal for people to look for, and expect, professional support in dealing with what would once have been considered to be everyday difficulties. An all-regulating, blame-attaching response to problems and issues ensues that has, in its turn, helped shape a new, more limited, political framework and agenda for a period largely devoid of any broader social vision. In part, this is because a more positive, social and cultural orientation towards change declined over the course of the twentieth century. Radicals who would once have promoted science and technology as a means for challenging vested authority and power, came to associate these with post-war American militarism [19]. Combined with the political defeat and exhaustion of the left, best symbolised internationally by the end of the Cold War, this helped foment a more conservative outlook. In their turn, the old right, briefly triumphal about these developments, soon fell out with one another. The only force to have held them together was the threat posed to their interests by the Soviet bloc externally, and organised labour internally. The convergence of left and right reflects the absence of any broader sense of mission or agreed direction for society. The management of risk fulfills the need for a new organising principle. Politicians, concerned as to their legitimacy have then sought to repackage themselves as societal risk managers. They have also increasingly pursued the centre ground, seeking technical, rather than political, means to enhance turnout in elections. But the demise of any polarised or principled political debate also fed declining interest and engagement in the public sphere. More limited aspirations – to promote voting by


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anyone, for anyone, and to micro-manage the economy, focusing particularly upon privatised concerns such as education and health – have not inspired a new generation of voters. Attempts to include the public more in certain decision-making processes by various means have merely reflected and reinforced declining electoral participation rates [20]. What’s more, whilst a nervous and atomised public is held to expect greater regulation of risk by the authorities in order to feel protected, there is no way of ever satiating this assumed demand. Rather, the failure to do so, appears to confirm a growing sense of human limitations and low expectations. It also feeds suspicion of the very authorities – political, corporate and scientific – that would need to be trusted in order to transcend contemporary difficulties, as well as further undermining social bonds. Increasingly, through these processes, people have learnt and been encouraged to assume the worst or presume a cover-up, even before any crisis has truly emerged.

Cultural Asymmetry It is within this broader cultural context that we need to situate the events of September 11th 2001. Far from being the trigger to a period of insecurity and policy change, these events were a catalyst for wide-ranging trends that lay just beneath the surface of Western society. For the first time, 9/11 allowed Americans en masse to view and perceive of themselves as victims on the world stage. They hardly needed much encouragement. Victims – people who are known by what happens to them – as opposed to heroes – people who are known for what they do – are a key reference point of our times. The fact that the attacks were unprecedented in scale and occurred in the US simply allowed the domestic soul-searching to begin. We should be clear that the real driver for this was the growing sense and exaggeration of risk, caused and accentuated by the individuation of society deriving from a concomitant loss of confidence and purpose. Notably, there has been a shift in conceptualisations of risk in recent years that parallels the demise of active participation in the political sphere. The classical notion of risk comprised an active formulation of ‘taking a risk’, that envisaged positive, as well as possibly negative, outcomes. Contemporary use however, focuses more on the notion of ‘being at risk’, a largely passive viewpoint that externalises threat as somehow being inherently and inevitably out there [21]. This historical shift however, retains an important cultural dimension. Accordingly, there are some who retain an understanding of risk-as-opportunity rather than becoming transfixed by risk-as-threat. It was this cultural asymmetry towards risk-taking, far more than the resource asymmetries other commentators have focused on, that was crucial in facilitating the events of 9/11. In another age, individuals armed with box-cutters might not have been able to achieve what they did. If we are to prevent similar incidents from happening again, we need to become conscious of quite how much we have changed as individuals and as a society over the short period since the end of the Cold War. These changes increasingly play a determining role in world affairs. Some commentators have described this shift as the advent of what they call an ‘age of anxiety’, or ‘culture of fear’. This culture stems from and further encourages a focus on the personal and private over the political and public. Indeed, political life increasingly focuses on personal issues as a consequence. This narrow, privatised introspection emphasises feelings over facts and image over insight, leading to the advent of what

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has also been labeled the ‘therapeutic society’ [22]. Any sense of a collective good, or the need to maintain one’s composure, has been replaced by an increasingly narrow and self-obsessed emotionalism that pours itself out because it fails to perceive any common good worth believing in – still less fighting for. Accordingly, those who do believe in something – no matter what – appear as fanatics to contemporary sensibilities and are labeled ‘fundamentalist’. Ironically, their sense of the possibility and need for social solidarity and sacrifice – irrespective of their limited aims – are important elements of resilience we would do well to learn from, rather than seek to eliminate. What’s more, getting obsessed with – or seeking to moderate – the passions and aspirations of others, evades the urgent need to resurrect our own beliefs and capabilities. Another measure of how much it is we who have changed, can be found by examining the literature on human responses in disasters going back over fifty years. In the past, it was generally assumed that people and systems were fairly resilient and could cope. With few exceptions this was found to be true [23]. Today, experts tend to assume that individuals and institutions can not manage without professional support in a crisis. Accordingly, it is now presumed that humanity and society are always vulnerable and in need of long-term, if not life-long assistance. For nearly fifty years the Western allies stood face to face against an enemy known to have a formidable nuclear arsenal, stocks of, capabilities in, and a significant research programme into, chemical and biological weapons. Yet now, in an age when concepts of belief, truth and sacrifice have been so eroded that they no longer hold any purchase, and when confronted by those who are prepared to commit suicide for their cause, we move to reorganise the world as if we had never faced a greater threat. Surely this tells us more about ourselves than about the enemies we face?

Psychosocial Impacts September the 11th 2001 is testimony to the remarkable strength and widespread prevalence of human resilience. As in most disasters, the orderly evacuation of the World Trade Centre reflected a tendency toward spontaneous, rational, and co-operative behaviour [24]. Yet, the political presumption of social vulnerability and concomitant need for professional support was not long in the offing. Indeed, the dust had hardly settled from the twin towers when a veritable army of counselors, psychologists and other assorted therapists descended on New York to offer their help. Unsurprisingly, according to their own methods and determinations, these experts found an elevated incidence of post-traumatic stress disorder (PTSD) – a term not even listed in psychiatric diagnostic manuals until the 1980s. They also assessed significant rates of depression across the entire population [25]. This was even among those who had only been ‘exposed’ to these events through the medium of television. In this regards, it is worth noting that the very act of searching for, and highlighting, this supposed evidence, itself derives from and ultimately reinforces a culture that effectively encourages people to label themselves as being ill. As Tel-Aviv based psychiatrist, Professor Avi Bleich, has indicated, the reported incidence of trauma appears peculiarly elevated. This is especially so when contrasted to the significantly lower levels amongst an Israeli population who have suffered terrorist


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attacks on an almost daily basis, over a protracted period [26]. All this reinforces the points made as to the determining role of cultural and historical factors in shaping our presumption of vulnerability. But the notion of frail individuals still prevails, shaping both policy and attitudes. Hence, even the Fire Department of New York – who’s firefighters on September the 11th 2001 had been the heroes of the hour – subsequently reinvented themselves according to the dominant social outlook, as forgotten victims in need of support and compensation. By the time the anthrax attacks occurred, Americans had become focused on security issues in general, and their own insecurity in particular. Hence, despite targeting politicians and the media, these incidents led to an unprecedented response right across society. This was manifest by the number of people who handled their mail, quite literally, with gloves, as well as in the demands for ciprofloxacin that inundated doctors across America, from those keen to have what was held to be necessary to treat themselves in the highly unlikely eventuality of being exposed. In the first two weeks of October 2001 alone, there were some 2,300 false anthrax alerts across the United States. A number of these incidents led to cases of what is described in the psychiatric literature as mass psychogenic illness, or in more popular terms, people quite literally worrying themselves sick. One notable case occurred on the Maryland subway where 35 people had to be hospitalised after developing real symptoms including drowsiness, irritability, nausea and vomiting, subsequent to their concerns being alerted to the smell of a strange substance, which later turned out to be window cleaning fluid [27]. Many other similar incidents occured. This was not that first time that mass psychogenic illness or something similar has been observed in populations. It is worth reminding ourselves that due to their fears, combined with a lack of knowledge as to how to use the equipment they had been provided with, a small number of Israelis suffocated themselves to death on their own gas masks during the first Gulf War. The figure was more than had died from being hit by one of Saddam Hussein’s Scud missiles [28]. And, whilst they eventually habituated themselves to the new circumstances, this same population also suffered from an increased incidence of coronary problems in the early days of that conflict. Whether based on a real threat or not, such responses can pose real strains upon society and its resources in an emergency. An incident in Goiana, in North-East Brazil, in 1987, where an inappropriately discarded hospital Cæsium source was stolen by youths is particularly apposite in this regards. Once the incident became known, it led to 100,000 people presenting themselves to the authorities for examination and treatment. Emergency workers had to commandeer a football pitch to sort out the worried-well from the truly exposed, who numbered in the end no more than 244, of which only 54 merited treatment. The point is that people’s concerns, genuine or otherwise, are shaped by the purposes and beliefs of their society and more particularly, those of their social and political leaders. This can have a real impact on the demand for resources and hence the ability of the authorities to cope with any particular incident. By the time an emergency actually occurs, it is too late to change such outlooks. Hence, whilst the numerous training exercises we now witness may serve some limited purpose for the authorities, they will have little impact upon social resilience itself.

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Driving Concerns The actions of political leaders and emergency responders at critical times, especially in the initial stages of any incident, send out important signals to the rest of society as to how they are expected to behave. This can drive public concerns rather than assuaging them. Ambulance personnel, for instance, are trained in an emergency, to calm trauma victims down irrespective of the state of their injuries by downplaying the latter, as such actions save lives. Contemporary culture however, is suspicious of expertise and demands a degree of openness and transparency that increasingly precludes the application of such professional judgment. Few have questioned whether sending people in full chemical and biological weapons suits to handle the numerous incidents of white powder scares that occurred in the aftermath of the anthrax cases, was necessarily the most appropriate action to take. And, in a similar vein, questions could be asked as to the UK government’s decision to place armed police outside mainline railway stations in London in the aftermath of September the 11th , or tanks and troops outside Heathrow airport subsequent to an alleged tip-off as to the possibility of a surface-to-air missile attack. Some commentators have suggested that, far from reassuring the public, such steps are counter-productive and project an image of a society that appears to have lost control, or any sense of perspective and proportion. More recent episodes, concerning the systematic cancellation of flights to Washington DC from London and the release of information surrounding the supposed foiling of a plot to use the little-known chemical osmium tetroxide in an explosive device seem to confirm this trend. This points to a growing confusion, or erosion of the divide, between what ought to remain private intelligence, and what is worth putting into the public domain, based upon an assessment of people’s abilities to take effective action based on the information provided. The British Prime Minister, Tony Blair, countenanced against taking action ‘on the basis of a general warning’, in a speech delivered on the 11th of November 2002 at the Banqueting House in London [29]. He indicated that this could lead to ‘doing their [the terrorists’] job for them’. Yet, the authorities perceive themselves as being under a great deal of pressure to be seen to be acting. Whether their perceptions of the public mood are accurate, or the actions they take are truly effective, remains to be determined. Phrases such as ‘alert, not alarmed’, together with the assumption that a terrorist attack is a matter of ‘when, not if’, or indeed that an attack is ‘inevitable’, are about as general and unspecific as it gets. Such rhetoric presumes itself to be challenging an assumed complacency towards the issue of terrorism, and is presented as, resolute and robust. But the generalised sense of ‘being at risk’ or ‘vulnerable’ that they project reveals an almost resigned air of fatalism towards future events. The use of language to prepare, or alert, the public, also smacks of blame-avoidance rather than determined resolve. It exaggerates the significance of terrorism to society and, in effect, encourages all-manner of potential terrorists, as well as hoaxers, loners and cranks to have a go. It also ignores the understanding the public do have, that determined individuals will always be able to get through, no matter how many technical barriers have been erected against them doing so. Continuously issuing warnings or information that turn out to be factually incorrect, out of date, or too vague to act upon has a number of consequences.


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First, it can literally make people ill. This need not be as dramatic in form as instances of mass psychogenic illness, but it has helped to foment a vaguer underlying anxiety about life and a gradual, passive disengagement from it, that could be tremendously disabling for those seeking to build up social resilience. This is reflected in the large number of surveys that – irrespective of their self-reported basis and the changing basis for assessment – point to increasing levels of stress, depression and trauma, in the aftermath of various incidents. Second, the more likely scenario is that over a period of time, people grow used to ignoring such statements. Again, this could clearly have dramatic consequences. Recent polls suggest that on the whole people are going about their everyday lives ignoring the threat of terror in a pragmatic and resolute fashion. However, this insouciance is likely to be more representative of a growing, broader cynicism and mistrust of authority that now prevails throughout western societies, rather than reflecting any deeply felt inner commitment or resolve. Third, constant warnings readily lead to a self-fulfilling demand for the authorities to do something – distracting them and us from real risks, and diverting social resources accordingly. Amongst other problems, this generates a situation best characterised as information overload. The demand for the public to be vigilant and report any unusual activity, combined with the task of existing and new agencies to sift through these vast amounts of potential intelligence material, clogs up the system, triggering paralysis by analysis, and failing to identify and act upon more plausible threats and risks. Banks, now required to report any ‘suspicious’ transaction to identify possible instances of money-laundering, report a similar trend towards not being able to see the wood for the trees. Sadly, as no serious local authority can afford not to have revised its emergency plans and procedures in the light of these developments, it almost seems that if they do not assess themselves as potentially being on a terrorist hit-list then they can not be taking their responsibilities seriously. A climate has been created whereby whatever measures the government, security and emergency services take, there is an insatiable appetite for more and demands emerging from all quarters, both public and private, to the effect that not enough is being done. The problem is, that many of the measures being put in place are totemic gestures, rather than rational strategies. It is also worth noting the significant element of commercial interests in such matters. Security is big business and indeed, due to our exaggerated sense of insecurity, one of the fastest growing sectors today. Accordingly, there are numerous risk and security consultants, as well as scientists and engineers, of varying abilities and distinctions, who have a financial interest in maintaining both social and individual concern in these matters. These have encouraged companies to develop so-called ‘business continuity strategies’ of dubious worth, focusing particularly on the integrity of their information systems, and the presumed cost of not doing so. All this has led to an inevitable, if perverse, rise of a certain degree of wishfulfillment. One senior executive recently remarked to me that the supply side for respirators or gas-masks was all ready and waiting, what he needed now was for the demand to be ‘stimulated’.

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What if? As all issues are now examined through the prism of risk, there is a growing cultural proclivity to err on the side of caution. This emphasises the negative aspects of particular situations, assuming far-fetched scenarios and acting as if these were true. Extrapolating from worst case evidence, or even uncorroborated data, has become the norm. This has led to a distinctive shift over recent years from asking scientific ‘What is?’ type questions that call for specific evidence, to asking more speculative or anticipatory ‘What if?’ type questions. The latter appeals to a more general, emotionally-driven response. But once we start focusing upon ‘What if?’, an inexorable logic develops. For instance, once we have asked the question ‘What if there were groups or individuals out there who might want to use a biological agent against us?’, then we are led through a convoluted series of further presumptions, ‘What if they had access to such an agent?’, ‘What if they were willing, and capable, of deploying it?’, and so on. Despite the absence of evidence, and the numerous cumulative assumptions, there is little choice, lest they be accused of complacency, but for the authorities to begin to prepare our capacity to cope with such an attack. Thus it was, that smallpox, a disease recognised by the World Health Organisation as having been eradicated in the 1970s, has come back to the fore. Despite the two known repositories of the virus, in the United States and the former Soviet Union, having had no reported breaches of security it was possible to speculate otherwise. In fact, smallpox would not pose particularly great problems, but vaccines were demanded so that public health agencies could establish a protective ring around any incident, just in case. But, the ‘What if’s?’ did not stop there. After all, ‘What if those dispersing the agent had made a point of doing so in a variety of places including airports to ensure effective worldwide dispersal?’. Then, clearly vaccine stocks needed to be sufficient to cover entire populations. In time, we would need to begin a process of actually inoculating first responders and then, in the interest of access and transparency, making the vaccine available to any other person who may wish to have it. Unsurprisingly, what started as a speculative discourse and set of scenarios on one side of the Atlantic, spread like a real disease across to the other side. Other nations followed suit. The next logical step is to ask the same questions with respect to the many other viruses and micro-organisms that could be identified as posing equivalent or significant risks, such as ebola, tularemia, Lassa fever, Marburg fever, e-coli and botulinum, to name but a few. Once the ‘What if?’ questions have started, it is quite literally like knocking over a line of dominoes, except that each step can cost millions, as well as inflicting a tremendous social cost on entire populations who effectively grow accustomed to living in fear. Interestingly, the fear of bioterrorism has tremendous purchase over contemporary society because it also acts as a powerful metaphor for élite concerns as to the corrosion of society from within [30]. Rather than analysing such issues at face value, or in their own terms, as a recent report by the Royal Society did in relation to chemical and biological agents [31], a broader historical and cultural perspective is required to understand why individuals and societies feel so vulnerable to what remain largely speculative scenarios.


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Institutional Distractions Speculation dominates the news after every high-profile arrest or incident. But rather than blaming the media for this, as many are prone to doing – thereby feeding a regulatory response – we would do well to examine the actions and statements of other key public institutions and individuals, ahead of such crises. For instance, after the supposed discovery of the Category B agent ricin, in a flat in north London, the Financial Times reported an official as saying; ‘There is a very serious threat out there still that chemicals that have not been found may be used by people who have not yet been identified’ [32]. This statement of the obvious remains true whether there is a war on terror or not. But, under a banner headline stating; ‘Chemical weapons factory discovered in a London flat’, it helped set the tone of the debate. Yet, whilst the media are guilty of uncritical reporting, thereby enhancing social presumptions, we should be clear that they alone do not set the tone. This latter rather reflects élite fears and the broader cultural perspective that inclines towards believing the worst. Ironically, as more discretely reported in the Sunday Times at a later date, this particular story transpired to be largely false [33]. Analyses by scientists from the UK government’s chemical weapons establishment at Porton Down, found no evidence of ricin manufacture. Yet this aspect of the story was never officially reported or retracted by the authorities and so the assumption amongst the public that it was true, has remained. Presumably, it was felt to be a useful vehicle for keeping the public vigilant. The media both reflect our cautionary climate and, in certain instances, help to amplify it. But it is nervous politicians and officials who are the real drivers as – lacking any vision of their own – they are unable to separate themselves effectively from the broader culture. In the UK for instance, the newly-established Health Protection Agency has issued numerous public health advisories through its ‘cascade system’, to facilitate GPs in the presumed, anticipated task of having to identify the first signs of a chemical or biological attack. This focus not only diverts resources from where they could best be used within the health service, it effectively helps to establish the context and content for future discussion. Worse, the failure to use specific expertise and to assess the real threat posed appropriately, distracts us from the real risks we continue to face, both from terrorism and from other everyday life. As has continuously been demonstrated, real terrorists prefer to use more reliable weapons such as high-explosives and car bombs. Leading scientists continue to identify nature as by far a greater threat to humanity than presumed acts of biological terrorism – although this danger too is prone to being exaggerated. There is little recognition given to the fact that advanced economies are better placed to deal with the consequences and contain the potential of such incidents. Rather, contemporary obsessions prevail, as can be seen by examining new funding priorities and programmes, which dictate an unwarranted distortion of social resources and research priorities towards so-called ‘weapons of mass destruction’.

Psychiatry Lessons Overall, governments have sought to assuage public concerns through the provision of what they consider to be appropriate and accurate information. Ironically, this approach,

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advocated by the new gurus of risk management and communication may serve to make matters worse by feeding the insatiable appetite for fear. It is widely contradicted by a wealth of literature emerging from the field of psychiatry that suggests the provision of information alone – outside an understanding of context and the sense of one’s ability to shape this – can be a potentially futile and counterproductive exercise. It is not so straightforward to reassure anxious people. Even when concerns are correctly identified and targeted, the evidence suggests that – whilst the more extreme manifestation of symptoms may abate temporarily – without tackling the deeper underlying concepts behind them, problems can soon reemerge, manifesting themselves in an exaggerated form [34]. The bottom line is the need to challenge people’s core beliefs about a situation head on. But increasingly over recent years, we have become unwilling to do so. As a society we prioritise consensus-seeking over confrontation. The latter appears too dismissive, or judgmental, to contemporary sensitivities. What’s more, this is not a task that can be achieved by individual psychiatrists or therapists, even in the rare instances where these are not affected by the prevailing norms and values. If the surrounding culture continues to provide signals and messages reinforcing concerns, then the expert is likely to be ignored or questioned anyway. The best that can be achieved in such circumstances is to habituate people to the world they now live in, by encouraging an acceptance of uncertainty. But doing so serves to confirm the dominant social script establishing concern about terrorism. The real task would be to remind people that there is far more to life than terrorism. This has not been addressed by the authorities so far. It requires a focus on ends well beyond dealing with immediate problems. This is a political task that far from distracting us from contemporary issues, should inform the very solutions we seek to put in place. By taking a broader, longer-term view, we would become more conscious of the extent to which trauma itself is a social and historical construct. The widely used terminology of post-traumatic stress disorder did not emerge into professional circles until the mid-1980s. At the time, this was to explain the particular problems faced by certain Vietnam veterans in the US. These suffered not so much from their defeat in South-East Asia, as from rejection by their own communities upon their return home. Shunned as pariahs and labeled psychopaths, the PTSD category eventually offered moral exculpation and access to compensation. But whereas older conditions such as ‘shell shock’ and ‘battle fatigue’ had been held to be specific, relating to a soldier’s background and psyche, the new diagnosis was applied more generally – assumed to derive from the fundamentally traumatising experience of war. Originally framed as applying only to extreme events, PTSD spread rapidly like a disease, to encompass relatively common happenings such as accidents, muggings, verbal or sexual harassment, and even workplace disputes. It finally entered the official Diagnostic and Statistical Manual of Mental Disorders in 1980 and aid agencies now commonly assume whole populations to suffer from it in advance of detailed analysis. Ironically, most veterans diagnosed with PTSD have had no combat experience, pointing to a self-justifying reconstruction of current problems through a narrative of past trauma. Research also suggests that PTSD is more serious and more common among international relief and development personnel, than for the locals they seek to support [35]. These facts indicate the category to be culturally constructed and its causes


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amplified through our particular Western obsession with risk and stress, often in pursuit of remediation or recognition. Studies of those exposed to a range of natural and manmade disasters consistently show that beliefs held prior to an event coupled with one’s understanding of it, account for variation in symptoms far better than the particular characteristics or severity of the experiences encountered. Accordingly, we should also be wary, as indicated earlier, of the figures regularly cited for incidence of trauma amongst the US population post-9/11. These point to the extent to which, even apparently objective data, such as that measuring people’s anxieties in the aftermath of terrorist incidents, is itself a cultural construct based upon assumptions of human vulnerability and their ability to cope. As Furedi has noted, in the past, the dominant social script or narrative would have been one more focused on social and individual resilience and initiative.

Technical Fixations Despite all the evidence pointing to the urgent need for greater clarity of purpose and direction, most activity since 11 September 2001 has focused narrowly upon the technical means to combat terror. The standard fare of conferences and papers revolves around the assumed need for better intelligence, more surveillance, new detection equipment, protective clothing, and computer models to predict behaviour. When the public is engaged it is at the more basic level of identifying means for effectively communicating predetermined messages and information, or to exhort the need for further vigilance under the banal and general slogan of ‘alert, not alarmed’. It is also the case that whatever the government does in these regards there is an insatiable appetite for more. This comes from the posturing of opposition politicians, and the practical demands of emergency responders, as well as the commercial interests of security providers and consultants, who all appeal to the public’s understandable concerns. Some propose the creation of a US-style department of homeland security. Others too, inured by years of cynicism and mistrust in authority are now inclined to assume the worst and presume a cover-up. The urgent need to engage in a broader debate as to social aims and direction, based upon clearly principled beliefs and the desire to engender amongst the population a sense of purpose that would truly make it resilient to acts of terror is continuously put off for some other time, or not even considered. Yet, it is this sense of mission in the world that, having broken down at home, leaves us incredibly unarmed in the face of the limited threat posed by the likes of al Qa’ida and, failing that, what increasingly become labeled as their ‘sympathisers’. If the war on terror was ever hoped to help society rediscover a sense of unity and purpose, then what we are actually witnessing could not be any further from such goals. Far from bringing people together, it has proven deeply divisive and revealed the deep cracks that currently run through society and its institutions. What’s more, technical barriers or solutions to the problem of terror only make things worse as they encourage people to become ever more suspicious and mistrustful as to the activity of their neighbours – rather than bringing people together as the times require. Resilience is not a technology that can be bought. Rather it is an attitude reflecting wider patterns of social development and outlook. Accordingly, attempts to develop

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technical solutions to the problem of terrorism simply end up reflecting and reinforcing existing values. Focusing on the means and losing sight of the ends only builds lack of direction into the system. Presumably, those who are willing to risk their lives fighting fires or combating other emergencies, do so not so that their children can go on to do the same, but for some broader purpose. It is this that we seem to have lost sight of.

Real Resilience The concept of ‘resilience’ – the ability to withstand or recover from adverse conditions – has come of age subsequent to the terrorist attacks of the 11th of September 2001. Politicians, emergency planners and other officials, now talk of the need to ‘build’, ‘engender’, ‘improve’ or ‘enhance’ resilience in society. Unfortunately, by framing the discussion in the fashionable language of ‘risk’, an element of passivity and inevitability has been built into the solutions proffered. The UK Cabinet Office describes the aim of ‘building resilience’ in terms of reducing susceptibility to challenges ‘by reducing the probability of their occurrence and their likely effects’ [36]. The notion that it may be possible to shape conditions, outlooks and perceptions in advance, by setting a clearer political agenda, is not particularly considered. Hence, despite inherent elements of resilience, society continuously seems to down-play such factors, becoming fixated on more immediate problems and undermined by self-doubt. In reality of course, people and systems continue to display a remarkable degree of resilience given the chance [37]. Those directly affected by the events of 9/11 have had little choice but to get on with their lives and, with few exceptions that is what they have done. It is also the case that the total financial cost of these events, both structural and in terms of compensation amounted to less than 1% of US gross domestic product in any one year. To put this into perspective it is worth noting that the Enron saga that followed cost a great deal more. Building on such spontaneous responses, rather than undermining them, requires promoting a clearer sense of who we are and what we are for. This would necessitate truly engaging the public in a political debate as to aims and values. It would also force a need to be more judgmental of others than contemporary society allows. And in turn, this would emphasise the need for collective purpose over individual security in order to achieve predetermined social goals. Sadly, a focus on knowing, engaging, judging and acting is not so straightforward today. Despite this being the real role and responsibility of those in positions of authority, there is good reason to anticipate their reluctance to do so. For if we were to characterise resilient people as their having a greater sense of who they are and of what they can achieve together, along with a willingness to judge others and take action accordingly – it is quite possible to question whether the authorities in the UK, the US, or anywhere else nowadays, would view such a project with any degree of optimism. Resilient people are not necessarily easy to manage. They demand more from those in authority than maybe these latter are willing, or able, to provide. Accordingly, it is likely, for the foreseeable future at least, that there will be much talk about the need to engender social resilience, but very little by way of effective action. It is far easier to make glib references to the need to defend ‘our way of life’, ‘our values’,


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or even ‘freedom and democracy’, than it is to provide real content to such concepts through a concerted campaign to re-engage the public in political discourse. Indeed, few of the authorities concerned with civil defence or homeland security consider it their responsibility to lead on such an agenda. There is, of course, a reason as to why these matters are not being addressed. That is, that there is a failure to recognise that the problem has anything to do with the domestic situation at all. Terrorism is usually perceived as being a problem relating to others, out there. The notion that an absence of direction at home may somehow drive our perception of terrorist acts, as well as undermining resilience and encouraging the perpetrators themselves is a novel one for those in authority. Indeed, there is an even more direct relation between us and the terrorists. That is that terrorism often reflects the dominant forms of social understanding and values it emerges within. When society asserted the need to recognise the independent sovereignty of nation state, terrorists fought politically-motivated national liberation struggles. Now, on the other hand, we live in an age when political debate – beyond the confines of the personal – is weak, or non-existent. One consequence of this is the advent of terrorists without stated aims or goals. What’s more, this nihilistic lashing out against modernity is unrestrained by any sense of moral purpose and draws encouragement from the broader self-loathing evident in western culture. Giving it a name, such as al Qa’ida, rather misses the point. Its perpetrators are as likely to be found at home as anywhere else. They include Timothy McVeigh, the Oklahoma bomber, the Aum Shinrikyo cult, who planted the chemical agent sarin, on the Tokyo subway in 1995, and even the 9/11 hijackers themselves who, far from being poor kids from the Gaza strip were relatively wealthy and well-educated. They had all spent some considerable time attending Western universities and, ultimately reflected our own dominant norms and values. This points to a final problem relating to the war on terror – that is that even if Osama bin Laden and all his acolytes were captured or killed tomorrow, still the problem of terror would not have gone away. This is because a key driver to our perception and response to these events has been our own insecurities. And these are not about to go away. What’s more, by advertising how vulnerable we feel and how frail we have become in relation to any activity, at any time, in any location, we have effectively educated a new generation of the future disaffected, whether terrorists, animal-rights activists, hoaxers, loners or cranks, as to how easy it is to undermine our society using little more than plastic knives and bags of sugar. The sorry truth that lies at the heart of the war on terror is that the West is at war with itself. The acts of 11 September 2001, having been perpetrated by outsiders, served as a useful distraction from addressing where the problems really lie. In fact, those individuals proved so effective because in many ways they reflect our own nihilist culture. It is just that, consciously or not, they have captured this better than we do ourselves. Conclusions From the preceding discussion a number of tentative conclusions can be drawn; 1. A focus on our own societies, psychology and culture is a missing element necessary for understanding both our response to recent acts of terrorism and, the particular salience we attribute to them.

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2. More research is required to explore the largely Western origins of anti-human, anti-modern and anti-Western ideas, as well as how these then become adopted by others. 3. The erosion of social bonds in our society has left a weak, self-centred form of individualism that may be less capable of withstanding difficulties or of perceiving of a greater common good or purpose. 4. A proper understanding of risk perception has to take into account the determining influence of social factors, such as political disengagement and stasis, as well as being grounded in scientific evidence. 5. The key asymmetry used by terrorists is that of our respective attitudes toward risk-taking. We must reassert the inevitability of risk in all activity and highlight the fact that without taking risks nothing can be gained. 6. Government should neither make fatalistic statements about terrorism, nor offer the promise to protect us from all risks. Above-all there should remain a clear distinction between private intelligence and public information. 7. The public are the primary targets of terrorism and accordingly, the real first responders. Their attitudes and values in advance of such incidents are key to shaping outcomes. 8. People and systems are already resilient. Contrary to popular perception, in an emergency, the public rarely panics – displaying both rational and pro-social behaviour – and vital processes continue to function. 9. Real resilience is an attitude, or mindset. It derives from the quiet confidence of having a broader common purpose, combined with a willingness to judge others and to act when necessary. 10. Building real resilience requires re-engaging the public in an active sense, building from their spontaneous co-operative responses, rather than by-passing these using technical means. 11. Technical solutions, when used as an end in themselves – as opposed to a means to a broader end – can push people apart, promoting mistrust and suspicion and thereby further corroding social bonds. 12. Counter-terrorism strategies and national resilience need to be guided by, and embedded within, a broader framework of aims and values for the whole of society. 13. There is an urgent need to restore the centrality of a principled and positive political agenda for society that opposes the use of fear as a vehicle for winning arguments or building coalitions. 14. Social leaders need to focus society on a broader vision, beyond the immediacy of terrorism. It is only through this that they may hope to secure real loyalty and active engagement in achieving their purposes.

References [1] See for example; Reich W. Origins of Terrorism: Psychologies, Ideologies, Theologies, States of Mind, Woodrow Wilson Centre Press, 1998, or Hoffman B. Inside Terrorism, Columbia University Press, 1999. [2] See for example; von Hippel K. The Roots of Terrorism: Probing the Myths, The Political Quarterly, Special Issue, September 2002, or The Roots of Religious Extremist Terrorism, available at; http://www. kcl.ac.uk/ip/andrewsteele/sept11/papers/root.html


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[3] Furedi F. Culture of Fear: Risk-taking and the Morality of Low Expectation, Cassell, 1997, and Continuum, 2002. [4] Huntington SP. The Clash of Civilisations and Remaking of World Order, Simon & Schuster, 1998. [5] See for example; The Pew Global Attitudes Project, available at; http://people-press.org/pgap/ [6] Moore M. Stupid White Men, Penguin, 2002. [7] Durodié B. Sociological Aspects of Risk and Resilience in Response to Acts of Terrorism, World Defence Systems, Vol. 7, No. 1, pp. 214–216, 2004. [8] Putnam RD. Bowling Alone: The Collapse and Revival of American Community, Simon & Schuster, 2000. [9] Furedi F. Paranoid Parenting: Why Ignoring the Experts May be Best for Your Child, Penguin, 2002. [10] Furedi F. Therapy Culture: Cultivating Vulnerability in an Anxious Age, Routledge, 2004. [11] Furedi F. Courting Mistrust: The Hidden Growth of a Culture of Litigation in Britain, Centre for Policy Studies, 1999. [12] Beck U. Risk Society: Towards a New Modernity, Sage Publications, 1992. [13] Durodié B. Poisonous Dummies: Risk Regulation After BSE, European Science and Environment Forum, 1999, available at; http://www.scienceforum.net/pdfs/Durodie1.pdf [14] See for example; Burgess A. Cellular Phones, Public Fears and a Culture of Precaution. Cambridge University Press, 2003. [15] See for example; Fitzpatrick M. MMR and Autism: What Parents Need to Know. Routledge, 2004. [16] Power M. The Risk Management of Everything: Rethinking the Politics of Uncertainty, Demos, 2004, available at; http://www.demos.co.uk/catalogue/riskmanagementofeverythingcatalogue/ [17] Hunt B. The Timid Corporation: Why Business is Terrified of Taking Risk, John Wiley & Sons, 2003. [18] Heartfield J. The ‘Death of the Subject’ Explained, Sheffield-Hallam University Press, 2002. [19] See Durodié B. The Demoralization of Science, paper presented to the Demoralization: Morality, Authority and Power conference, University of Cardiff, 4–6 April 2002, available at; http://www.cf.ac.uk/ dmap/papers/durodie.pdf [20] Durodié B. Limitations of Public Dialogue in Science and the Rise of New ‘Experts’, Critical Review of International Social and Political Philosophy, Vol. 6, No. 4, 2003. [21] Op. cit. Furedi F. 1997. [22] Op. cit. Furedi F. 2004. [23] Quarantelli EL (ed.). What Is a Disaster?: Perspectives on the Question, Routledge, 1998. [24] Furedi F. Heroes of the Hour, New Scientist, Vol. 182, 8 May 2004. [25] Schuster MA, Stein B, Jaycox L, Collins R, Marshall G, Elliott M, Jie Zhou A, Kanouse DE, Morrison JL, Berry SH. After 9/11: Stress and Coping Across America, RAND, 2001. [26] Bleich A, Gelkopf M, Solomon Z. Exposure to terrorism, stress-related mental health symptoms, and coping behaviors among a nationally representative sample in Israel, Journal of the American Medical Association, Vol. 290, pp. 612–620, 2003. [27] Hyams KC, Murphy FM, Wessely S. Responding to chemical, biological or nuclear terrorism: the indirect and long-term health effects may present the greatest challenge, Journal of Health Politics, Policy and Law, Vol. 27, pp. 273–290, 2002. [28] Op. cit. Hyams KC, Murphy FM, Wessely S. 2002. [29] Blair T. Speech at the Lord Mayor’s Banquet, 11 November 2002, available at; http://www.number-10. gov.uk/output/Page1731.asp [30] Durodié B. Facing the Possibility of Bioterrorism, Current Opinion in Biotechnology, Vol. 15, pp. 264– 268, 2004. [31] Royal Society, Making the UK Safer: Detecting and Decontaminating Chemical and Biological Agents, April 2004, available at; http://www.royalsoc.ac.uk/files/statfiles/document-257.pdf [32] Huband M, Burns J, Krishna G. Chemical Weapons Factory Discovered in a London Flat, Financial Times, 8 January 2003. [33] Leppard D. New Government Setback as Ricin Plot Claims Collapse, Sunday Times, 5 October 2003. [34] Durodié B, Wessely S. Resilience or Panic? The Public and Terrorist Attack, Lancet, Vol. 360, pp. 1901– 1902, 2002. [35] Pupavac V. Pathologizing Populations and Colonizing Minds: International Psychosocial Programs in Kosovo, Alternatives, Vol. 27, pp. 489–511, 2002. [36] Cabinet Office, Draft Civil Contingencies Bill, June 2003. [37] Op. cit. Furedi F. 2004.



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Towards a Public Mental Health Approach to Terror Johan M. Havenaar and Evelyn J. Bromet

Introduction Since the United States Civil War in the 19th century and the World War I in the early 20th century, it has been recognized that some of the casualties of war are caused by the psychological impact of these experiences rather than just by their physical impact. Similarly, since the seminal descriptions of survivors of the Coconut Grove fire disaster in 1942 [1], many studies of natural and human-made disasters, including toxic exposures, have described their physical and psychological consequences [2]. By their very nature, the recent terrorist attacks are specifically intended to induce fear (terror) in the population in addition to physical casualties and damage. Hence it is useful to consider the lessons learned from research on the diverse catastrophic experiences over the past 50 years. The advent of structured interviews and clinical criteria in psychiatric research during the 1970’s spurred a large number of epidemiological studies that have quantified the impact of disasters on mental health and well-being [3]. The first study to use structured diagnostic interviews focused on the impact of the 1979 accident at the Three Mile Island nuclear power plant on rates of major depression and generalized anxiety disorder [4]. Since then, the DSM classification system officially operationalised Posttraumatic Stress Disorder (PTSD), and the ICD-10 introduced a similar category. Subsequently, much of the research on the psychological impact of disasters has tended to focus more or less exclusively on this PTSD diagnosis, even though it is increasingly recognized that the range of potential negative outcomes is far broader and includes affective, anxiety, substance abuse disorders and non-specific medical symptoms. Thus, while the research over the past decades has produced a wealth of information documenting the prevalence of mental health problems in the aftermath of disasters, and identifying the major risk factors and protective factors determining outcome, the recent work has focused a great deal on PTSD. The terrorist attacks on New York and Washington on September 11th , 2001 have once again given rise to a wave of post-disaster studies. There are both empirical and public health reasons for conducting further descriptive epidemiological studies in the wake of these disasters [5,6]. From a research perspective, the reasons include (a) ascertaining high risk groups among both children, adults, and the elderly; (b) identifying risk and protective factors as well as potential unique etiologic or pathogenic mechanisms; (c) completing the clinical picture beyond people who present for treatment; and (d) identifying new syndromes. Public health reasons include (e) estimating the preva-

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J.M. Havenaar and E.J. Bromet / Towards a Public Mental Health Approach to Terror

lence of psychopathological reactions in the community for needs assessment purposes; (f) gathering information that can be used for preparing and tailoring response programs; (g) evaluating the effectiveness of interventions; (h) monitoring the long-term health problems, particularly in cases involving exposures with uncertain future effects; (i) addressing public concerns about the health effects of the event; and (j) responding to possible legal challenges. In a recently published review of the disasters literature, we expressed the concern that contemporary disaster research has reached a point where further descriptive studies may be expected to yield little added value to what is already known [7]. We pointed out that recent studies tend to reconfirm findings that are well established. In part, this occurs because the majority of contemporary studies administer a core battery of interview schedules and questionnaires that contain pre-formatted questions and pre-determined answer categories. Thus, we suggested that except for the need for further studies about psychophysiological mechanisms associated with adverse outcomes, especially in cases where the disaster involves exposure to toxic substances with potential negative effects on the central nervous system, the main reasons for doing further disaster studies are likely to be in the public health domain. Conceivably, a merger of quantitative and qualitative methods might yield some significant novel findings about disaster’s impact. Along these lines, funding agencies, such as the National Institute of Mental Health, are in fact more interested in studies designed to develop and evaluate post-disaster mental health interventions than in further descriptive epidemiologic post-disaster research.

Challenges in Designing Disaster Studies Disasters by their very nature are unanticipated. As such a number of challenges arise in designing studies of their mental health sequelae. Assembling a research team The first such challenge is to identify collaborators and organize a research team. Relationships within any research team must be built on mutual trust and respect. In disaster studies, the team is likely to be assembled quickly and at the same time to find itself having to operate under extremely difficult circumstances and with major time constraints. Also, it is not unusual for some members of the research team or their relatives to be directly affected by the event. It is equally important to establish trust between the team and the affected population, as well as between the research team and people involved in relief work in the field. While this may seem obvious, these challenges are not easily achieved when both the research team and the affected population share the shock and devastation of the event. Thus, the research team needs to take stock of their own emotional responses and privacy needs as they consider how to deal with the same issues among potential study participants. Timing The design of an investigation will depend largely on the aims of the study and the conditions under which the study will take place. Most mental health studies will take place after the disaster occurs, and after the physical toll is known. Many recent studies have


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involved cross-sectional surveys, including telephone surveys. These studies try to show differences in rates of symptoms across time, but only longitudinal (follow-up) studies are capable of describing the course and outcome of post-disaster psychological effects, risk and protective factors, and benefits of intervention programs. The timing of the research, as well as of the follow-ups, will be determined by the specific research questions being addressed, as well as by the feasibility and availability of resources available for conducting the study. So far, we have focused on post-disaster research. It is also important to consider the challenges involved in studying “potential” disasters, such as future bioterrorist attacks in which the need for an entirely different type of study may arise. In this scenario, researchers may be confronted with an essentially unique situation, i.e., to design an investigation of whether certain observed health problems are the result of an as yet unknown attack [6]. This was the case in the initial days after the first cases of anthrax were diagnosed in Florida in the fall of 2001 and the source of the infection was unknown. This type of cluster analysis will not be further discussed here, but readers interested in this issue are referred to Fielder and colleagues [6]. Exposure identification The next step is to identify the relevant physical and psychosocial exposures. This issue is critically important because it will determine which end-points are to be assessed, i.e. only psychological or psychiatric sequelae or also global and/or specific physical health outcomes. In the realm of mental health outcomes, it is important to consider a range of potential clinical and subclinical domains, including depression, anxiety, substance use and abuse, somatic symptoms, and PTSD. Recent research has demonstrated that medically unexplained symptoms (MUPS) are an under-researched outcome of disasters [7]. They may occur especially after disasters which involve toxic exposure or in cultural settings where somatic complaints are the normative means for expressing distress. For each of the outcomes to be studied, the relevant competing risk factors, and the potential confounding variables, must be carefully measured as well. Often this means that the interviews or questionnaires will be lengthy, and this too poses a special challenge for disaster studies. One of the important challenges in disaster research, which gives rise to continuous debates at all stages of the research, from design and instrument selection to data analysis and interpretation, is to bridge the gap between the psychological and psychiatric approaches. Psychologists tend to approach research from a dimensional and dynamic point of view whereas psychiatric epidemiologists tend to focus on categorical disease end-points. To some extent, this will influence the sample size needed to achieve a specific result. More than that, these different approaches may give rise to incorrect use of terms, such as “PTSD” which is meant to be a clinical category but is often used to describe individuals with high scores on scales evaluating the intrusion, avoidance and hyperarousal symptoms encompassed by the DSM-IV definition of PTSD. Sample selection Once the aim of the study has been set, and the study design decided upon, the next step would be to define the affected population. This represents one of the most difficult tasks

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in disasters studies. The chaotic situation that occurs immediately after a disaster often makes it impossible to determine who exactly was affected and who was not. Immediately after the crash of the El Al Boeing 747 into a housing block in Amsterdam in 1992, killing 29 residents and 4 crewmembers, the authorities estimated that between 1000 and 1500 persons had directly experienced the crash. This included rescue workers who arrived during the early hours after the event. Six years later, after the endless rumours regarding possible presence of toxic agents in the cargo had finally been proven false, more than six thousand people came for a medical check-up because they feared that their health might have been compromised because of the event [8]. Because of the chaos and the need to maximize the number of people available at the disaster site, even tightly run organizations such as police and fire departments may be unable to produce accurate lists of officers who participated in relief work. Because of the difficulties in defining the sampling frame for a disaster study, many studies turn to convenience samples, such as litigants, web survey responders, telephone responders, insurance claimants, or clinic attenders. Prevalence estimates based on such samples are likely to be unreliable. For example, studies of help-seeking refugees from Cambodia residing in the US produced prevalence rates (of which disorder) varying from 22% to 92% [9]. Once the target sample is defined, it is often extremely difficult to identify an unaffected control group (or groups) who are similar in all respects except for exposure to the disaster. Usually control groups are selected from nearby towns. One obvious problem is that people in nearby towns may in fact be exposed via extensive media coverage, by working in or near the disaster area, or by having friends or family members living or working in the exposure site. For example, in a study of the effects of major floods in southern France, Verger and colleagues found that many control subjects from the unaffected villages nearby had family members or business interests in the flooded villages [10]. In disasters involving toxic exposures, the comparison sites should be screened for other contaminants that could lead to the same end-points. For example, one of the first western epidemiologic studies of the health effects of the 1986 Chernobyl accident, the International Chernobyl Project [11], evaluated the health status of five age-groups living in rural contaminated communities with that of controls from “non-exposed” villages and found no significant differences in physical health (hematological, thyroid, and general health measures). After the report was disseminated in Ukraine, the authorities claimed that the control villages were polluted by dangerous levels of pesticides.

Challenges in Instrument Selection Diagnosis vs. symptom checklists Once the research questions, study design and relevant outcome domains have been determined, the next step will be to translate these into specific measures. A large number of standardized diagnostic and symptom inventories are available, and certain measures, such as Diagnostic Interview Schedule (DIS), the General Health Questionnaire (GHQ), and the Impact of Events Scale (IES), have been administered in many disaster studies. Even though most of these instruments have been shown to have acceptable reliability and validity, it important to realize that when different instruments are used to mea-


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sure the same condition, or even when single instruments are used with different cut-off scores or diagnostic criteria, wide variation in prevalence rates will ensue. More specifically, in the recent National Comorbidity Survey-Replication (N = 9090), a subsample (N = 335) of those initially interviewed with the Composite International Diagnostic Interview (CIDI) were subsequently reinterviewed by clinicians over the telephone with an abbreviated 12-month version of the Structured Clinical Interview for DSM-IV (SCID) [12]. While 7.6% of the sample met DSM-IV criteria for Major Depressive Disorder on the CIDI, 5.2% met the same criteria on the SCID, with a chance corrected agreement which was at best moderate (Cohen’s Kappa = 0.6, 95% CI 0.2–0.6). It is therefore important to keep in mind that the variability in the prevalence rates achieved across different studies is in part attributable to the specific instruments included in the research. Having made the choice between dimensional or categorical (diagnostic) measures, or the choice to use both, the next issue to decide upon is the choice between self-report or interview methods. Self-report questionnaires are convenient and relatively cheap to use. They tend to have good sensitivity, but less favourable specificity. Interviews are more costly, and especially in the case of structured interviews, have reasonable specificity. The cut-points themselves may be culturally specific. For example, in the U.S., when asked to rate your health, the majority of people in the general population answer excellent or very good; few people say moderate, fair or poor. In Ukraine, the normative response is moderate, and the next most popular response is fair. Few people would evaluate their health as very good. In our Chernobyl research [13], it was necessary to extend the low end of the scale by adding a ‘very poor’ category in order to capture the full range of responses in a meaningful way. To date, most disasters studies have been conducted in the West. Whether our measures are equally reliable and valid across race and ethnic groups is a topic that has rarely been studied. Thus, for an event like September 11th that affected a diverse set of cultural and ethnic groups, our lack of knowledge about the cross-cultural validity of western measures and the absence of culturally sensitive measures for most of the affected populations limit what can be learned from current research. Similarly because the majority of the disasters occur in underdeveloped areas of the world, selecting appropriate instruments is a major challenge. Unfortunately, few disaster studies include an examination of cultural variations in idioms of distress or the cross-cultural validity of the instruments and assessment methods that are used [14]. The best way to handle the issue is to include investigators on the research team who are part of the community that was affected by the disaster although even then, the arduous task of establishing cross-cultural reliability and validity may be beyond the grasp of the typical disaster study that is done under both time and budgetary constraints. A further measurement issue is the assessment of the level of personal involvement and incurred stress as a consequence of the disaster. Usually in disaster studies, proximity to the disaster site is used as a proxy for exposure to stress emanating from the event. In addition, usually other information is collected to assess the level of personal involvement, such as whether the subject was injured, lost relatives or property, had to be evacuated, or witnessed dead or injured persons. When the exposure information is subjective (did you feel threatened by the event?), recall bias may be a special problem because the response will be influenced by current affectivity. However, even when the exposure information is presumed to be objective, recall bias is an issue, especially over time. Southwick et al. (1997) interviewed veterans from the first Gulf War about

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their traumatic experiences one month and again two years after their return home [15]. Eighty-eight percent changed their response to at least one item of the questionnaire that asked about their experiences in the field.

Challenges in Executing Disaster Studies Access to remote areas Not only is it difficult to define the affected population, in many cases it may also be difficult to reach the area. Many disasters in developing countries occur in remote areas, but even in areas that might be easily accessible under normal conditions, it might be difficult to get there because of disrupted transportation systems or restrictions imposed by the authorities regarding entry to the area. Conducting telephone surveys may be a way to circumvent these problems, providing telephones are working and telephones are widely available. When the Chornobyl accident occurred in 1986, many people in Kiev had party lines, and thus there was no guarantee that privacy could be achieved. Conditions at the disaster site will also make it difficult to adequately monitor the field work. Another problem is that affected populations or parts of them may have been evacuated or scattered. Response rates Even if eligible subjects can be reached, response rates may be low because people have other priorities and have no time to participate in a mental health study. The post-disaster period is often characterized by great turmoil, food and housing shortages, economic hardships and battles for benefits. These can all lead to relatively low response rates and potentially biased samples. However, this certainly is not always the case, and response rates of over 80% or even over 90% have been achieved (e.g., refs). Response rates from disaster follow-up studies have been disappointing to date. For example, in a 33-year follow-up after a mud slide in Aberfan, South-Wales, which killed 116 children, it was possible to trace 115 of the 145 survivors in the original cohort, but only 41 agreed to participate (28% of the total). Achieving a good response rate in the control group is sometimes more difficult because the motivation for participation is not as obvious. In the Aberfan study, only 19% of controls participated in the follow-up [16]. Informed consent In settings where the population is not literate, or distrust in authorities is the norm, including a western-style informed consent procedure may be challenging. However in our experience studying the effects of Chornobyl, while our colleagues in Ukraine, Belarus and Russia expressed outrage at the concept, virtually everyone whom we studied was happy to hear about confidentiality and related issues and did not hesitate to sign the consent form. A related concern that has been raised is whether trauma victims are able to give valid informed consent, especially during the early phase immediately after the event. DuMont and Stermac (1996) found that 14 out of 15 survivors of sexual assault who had signed consent forms to participate in a trauma study could not remember having


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given consent 10–39 months later [17]. However, in all cases the women reported that they had no problem with being approached by the research team and were willing to participate. Therefore, at this point in time, there is no evidence to suggest that participation has negative effects on participants, even in the immediate aftermath of traumatic experiences. In a similar vein, several authors have suggested that trauma survivors may be too fragile to endure the painful memories and the stress stirred-up by participation in PTSD research [17–19]. These concerns have largely been based on anecdotal evidence. The few empirical studies to investigate this issue found no negative effects of interviews among victims of interpersonal violence [20–22]. In fact in most studies, participants tended to view participation as a positive experience, while only a minority reported that the emotions aroused during the interview were stronger than they expected. In the Bromet follow-up 3 years after the Three Mile Island accident [23], one control mother said that the questions previously asked about her marriage were extremely upsetting and she thus refused to participate again; however, no other respondent refusing the followup interview suggested that her decision was based on the content of the previous assessment.

Challenges in the Analytic Phase Power Many disasters studies are by their very nature designed and implemented at short notice. Usually no power analysis has been done beforehand. Power problems are particularly likely to be problematic in studies focused on clinical diagnoses with relatively low prevalence, such as somatization disorder. Thus, the two published prospective studies in which subjects had by chance participated in a mental health survey and subsequently experienced a disaster had relatively small numbers of subjects [24–27]. While these studies are from a methodological point of view very valuable, their relatively low N’s have made it practically impossible to establish whether disasters have an effect on clinically diagnosable disorders after adjusting for baseline levels, even though symptom counts for these disorders significantly increased. Multiple comparisons An issue that comes up in any study involving extensive testing, and therefore also in disaster studies, is the multiple comparisons problem. This is further compounded by the fact that the measures themselves are highly intercorrelated (e.g., depression, anxiety, PTSD, somatic complaints). To date, very few disaster studies have controlled for multiple comparisons, and it is important that future studies consider this issue when establishing cut-points for establishing statistical significance. False positive responses The widely used Impact of Events Scale [28] or other PTSD scales contain measures of intrusion and avoidance symptoms. It is good to realize that with recurrent images of disasters shown on TV, high scores for intrusion may represent false positive answers, and

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instead may be tapping repeated exposure to images on the news networks. In a recently completed study of the mental health effects of an accident which occurred at an airbase in Lviv, in western Ukraine, where a jet fighter plane crashed into the public gathered to watch an air show, we found a modest but statistically significant correlation between the presence of intrusive symptoms on the IES and watching the event over and over again on TV (unpublished data). If the symptom inventories were not comprehensive in scope, false negatives can occur. Thus, for example, if acting out behaviours or substance abuse problems are not assessed, and anxiety and affective symptoms are evaluated, women will appear to have suffered more in relation to an event than males when in fact, the overall impact on psychological and substance morbidity may be similar. Reporting mental health effects In the situation of disasters, where the stress is collective, a public health perspective should be maintained when reporting on the psychological impact on a stricken community. For example, if the results show an increased rate of panic attacks in exposed vs controls, it is important to clearly communicate that this does not imply that “the population was in a panic.” Indeed, as Glass has indicated in this volume and elsewhere, the findings generally suggest that panic is the exception, not the norm [29]. As responsible citizens, it is our obligation as researchers to present a balanced picture of the impact of the event under study. Rarely do we include “positive” outcomes, rarely do we examine the functional consequences of psychological symptoms, and rarely are we mindful of the limitations of our measures. Thus in our opinion, it is important for investigators not to over-emphasize or over-dramatize the negative findings. Durodie and Wessely, also in this volume and elsewhere, take this point one step further when by suggesting that the strong emphasis placed on the negative impact of terrorist events by media and authorities – who mostly obtain their information from researchers and clinicians – may even be exploited by terrorist groups to their advantage [30,31]. Following these authors line of reasoning, negative findings from disaster studies may send an unintended message to the public that massive psychopathology is likely to ensue. For example, although generalizing from telephone survey research is problematic, the Galea et al. (2002) telephone survey in lower Manhattan in the immediate aftermath of the World Trade Centre attack was used to suggest how many people in the area below 110th street suffered from PTSD and depression at different points in time after the attack [32]. Although the investigators are aware of the study’s limitations (low response rate, generalizability of the findings, use of symptom measures with unknown reliability on the telephone, cross-cultural constraints), the results were reported as if the data provide precise estimates of the numbers of people with symptoms and presumably who might benefit from treatment. As noted above, disaster studies usually do little justice to describing the overall resilience of the population, or the positive effects a disaster can have in strengthening community ties or sense of patriotism. In the worst case scenario studies emphasizing negative outcome may instead strengthen victim identity among the survivors and/or suggest symptoms to future study subjects. In short, disaster research is a form of intervention, and like any intervention, it may have positive as well as negative effects which should be taken into consideration.


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Discussion In recent years many studies have been published about the health effects of disasters. The point has been reached where one might get the impression that every disaster either is or should be followed-up by a mental health study. As we indicated in the introductory paragraph, it is unlikely that studies which continue in the tradition of using the same standardized interviews with prefabricated answer categories over and over again will come up with new, clinically relevant information. Perhaps one of the main reasons that these studies are still being done is that they are a way for society at large, and mental health specialists in particular, to show their concern for the affected community. The study confirms for the victims that the outside world cares about them and may be a way to communicate the outcry of the affected population to the outside world. This raises the issue, however, of whether research is the best way to achieve this goal. From a scientific point of view, it is important that future studies be designed to investigate the effects of large scale mental health interventions. After the September 11th terrorist attacks, numerous support services were set up in the New York area, although reportedly socially underprivileged neighbourhoods received far less mental health support than more affluent parts of the city. As researchers, we are in a position to recognize and address disparities in the provision of mental health care after disasters and other catastrophic events. Indeed, since most disaster studies are epidemiologic in nature, and epidemiology is the scientific arm of preventive medicine, it behoves us as disaster researchers to recognize and address this issue. We also believe that it is timely to reconsider the need for rapid interventions in the intermediate aftermath of a disaster [33]. A number of studies have reported that “crisis support,” i.e., providing people who will listen and give practical and emotional support has positive effects on well-being (e.g. [34]). Undoubtedly people from the affected population will appreciate the attention and support offered to the community from the outside, whether this is provided by mental health professionals, clergy or lay people. It remains to be seen, however, whether providing such support by mental health professionals makes sense from a public health point of view. There have been relatively few studies which have systematically investigated the effectiveness of mental health interventions, such as psychological debriefing, in a randomized controlled fashion. The studies which have been done were unable to consistently show a positive effect of this type of intervention [35,36]. In two trauma studies, in fact, a negative effect of individual and group emotional debriefing were reported [37]. It remains to be further investigated whether these results also hold true in disaster situations. Even less is known about the effects of information provided by authorities in the immediate aftermath of an event. In the Amsterdam airplane crash disaster described above, it was believe that failure of the authorities to credibly falsify rumours about the presence of toxic substances aboard the freighter was one of the crucial factors which fuelled uncertainty and fear in the public. Similar allegations have been made about the way the British government handled the bovine spongiform encephalitis crisis [38]. More research is needed about the most effective strategies for risk communication in the wake of disaster. Despite our lengthy discussion of caveats and potential drawbacks of conducting disaster research, it is our experience that meeting the special challenges that disaster research poses is well worth the effort. Victims of disasters often wish to talk, and re-

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searchers who listen (not just prejudge all the questions and possible answers) may contribute valuable insights about coping with horrific stress. From a scientific point of view, because disasters are independent events, occurring indiscriminately to subjects regardless of their personal histories or personalities, they offer epidemiology the rare opportunity to study the effects of a “natural” experiment. Most importantly, the results of carefully designed and interpreted studies can be used for planning public heath interventions in the future.

References [1] Adler A. Neuropsychiatric complications in victims of Boston’s Cocoanut Grove disaster. JAMA 1943; 123: 113–119. [2] Havenaar J, Cwikel JG, Bromet EJ, ed. Toxic Turmoil: Psychological and Societal Consequences of Ecological Disasters. New York: Plenum, 2002. [3] Bromet E, Dew MA. Review of psychiatric epidemiologic research on disasters. Epidemiol Rev 1995; 17 (1): 113–9. [4] Bromet E, Schulberg HC. The TMI disaster: a search for high risk groups. In: Shore J, ed. Disaster Stress Studies: New Methods and Findings. Washington, DC: American Psychological Association, 1986: 2–19. [5] Morris J. The Uses of Epidemiology. 2nd ed. London: Livingstone, 1964. [6] Fielder H, Palmer SR, Coleman G. Methodological issues in the investigation of chemical accidents. In: Havenaar JM CJ, Bromet EJ, ed. Toxic Turmoil: Psychological and Societal Consequences of Ecological Disasters. New York: Plenum, 2002: 185–197. [7] Bromet E, Havenaar JM. Mental Health Consequences of Disasters. In: Sartorius N GW, Lopez-Ibor JJ, Maj M., ed. Psychiatry in Society. Chicester: John Wiley, 2002: 241–261. [8] Yzermans J, Gersons BPR. The chaotic aftermath of an airplane crash in Amsterdam: a second disaster. In: Havenaar JM CJ, Bromet EJ, ed. Toxic Turmoil: Psychological and Societal Consequences of Ecological Disasters. New York: Plenum, 2002: 85–99. [9] Abueg F, Chun KM. Traumatization stress among Asians and Asian Americans. In: Marsella MJ, Gerrity FE, ed. Ethnocultural aspects of Posttraumatic Stress Disorder: Issues, research and clinical applications. Washington, DC: American Psychological Association, 1996. [10] Verger P, Hunault C, Rotily M, Baruffol E. Risk factors for post traumatic stress symptoms five years after the 1992 flood in the Vaucluse (France). Rev Epidemiol Sante Publique 2000; 48 (2): 2S44–53. [11] Association IIAE. The International Chernobyl Project: An Assessment of Radiological Consequences and Evaluation of Protective Measures. Vienna: IAEA, 1991. [12] Kessler R, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, Rush J, Walters EE, Wang PS. The epidemiology of Major Depressive disorder. Results from the National Comorbidity Survey-Replication (NCS-R). JAMA 2003; 289: 3095–3105. [13] Bromet E, Gluzman S, Scwartz J, Goldgaber D. Somatic symptoms in women 11 years after the Chornobyl accident. Environmental Health Perspectives 2002; 110 (Suppl 4): 625–629. [14] Van Ommeren M. Validity issues in transcultural epidemiology. British Journal of Psychiatry 2003; 182: 376–378. [15] Southwick S, Morgan CI, Nicolaou A, Charney D. Consistency of memory for combat-related traumatic events in veterans of Operation Desert Storm. Am J Psychiatry 1997; 154: 173–177. [16] Morgan L, Scourfield J, Williams D, Jasper A, Lewis G. The Aberfan disaster: 33-year follow-up of survivors. British Journal of Psychiatry 2003; 182: 532–536. [17] DuMont J, Stermac L. Research with women who have been sexually assaulted: Examining informed consent. Canadian Journal of Human Sexuality 1996; 5: 185–191. [18] Templeton D. Sexual assault: Effects of the research process on all the participants. Canadian Family Physician 1993; 39: 248–258. [19] Drauker C. The emotional impact of sexual violence research in participants. Archives of Psychiatric Nursing 1999; 13: 161–169. [20] Walker ENE, Koss M, Bernsteing D. Does the study of victimization revictimize the victims? Psychiatry and Primary Care 1997; 19: 403–410.


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[21] Newman E, Walker EA, Gefland A. Assessing the ethical costs and benefits of trauma focussed research. General Hospital Psychiatry 1992; 21: 187–196. [22] Griffin M, Resick PA, Waldrop AE, Mechanic MB. Participation in trauma research: is there evidence of harm? Journal of Traumatic Stress 2003; 16: 221–227. [23] Dew M, Bromet EJ, Schulberg HC. A comparative analysis of two community stressors’ long-term mental health effects. Am J Comm Psychol 1987; 15: 167–184. [24] Robins L, Fischbach RL, Smith EM, Cottler LB, Solomon SD, Goldring E. Impact of diaster on previously assessed mental health. In: Shore J, ed. Disaster Stress Studies: New methods and findings. Washington: American Psychiatric Press, 1986: 21–48. [25] Smith E, Robins L, Przybeck T, Goldring E, Solomon S. Psychosocial consequences of a disaster. In: Janes H, Shore M, eds. Disaster Stress Studies: New Methods and Findings. Washington, DC: American Psychiatric Press, 1986: 50–76. [26] Canino G, Bravo M, Rubio-Stipec M, Woodbury M. The impact of disaster on mental health: Prospective and retrospective analyses. International Journal of Mental Health 1990; 19: 51–69. [27] Escobar J, Canino G, Rubio-Stipec M, Bravo M. Somatic symptoms after a natural disaster: a prospective study. American Journal of Psychiatry 1992; 149: 965–967. [28] Horowitz M, Wilner N, Alvarez W. Impact of event scale: a measure of subjective stress. Psychosomatic Medicine 1979; 41: 768–781. [29] Glass T, Schoch-Spana M. Bioterrorism and the People: how to Vaccinate a City against Panic. Clinical Infectious Diseases 2002; 34: 217–223. [30] Durodie W, Wessely S. Resilience or panic: the public’s response to a terrorist attack. Lancet 2002; 360: 1901–1902. [31] Gearson J. The nature of modern terrorism. In: Freedman L, ed. Political Quarterly. Oxford: Blackwell, 2002: 7–24. [32] Galea S, Ahern J, Resnick H, Kilpatrick D, Bucuvalas M, Gold J, Vlahov D. Psychological sequelae of the September 11 terrorist attacks in New York City. New England Journal of Medicine 2002; 346: 982–987. [33] Sensky T. The utility of systematic reviews: the case of psychological debriefing after trauma. Psychother Psychosom 2003; 72: 171–175. [34] Dalgleish T, Joseph S, Thrasher S, Tranah T, Yule W. Crisis support following the Herald of FreeEnterprise disaster: A longitudinal perspective. Journal of Traumatic Stress 1996; 9: 833–845. [35] Emmerik A, Kamphuls J, Hulsbosch A, Emmelkamp P. Single session debriefing after psychological trauma: a meta analysis. Lancet 2002; 360: 736–741. [36] Wessely S, Bisson J, Rose S. A systematic review of brief psychological interventions (“debriefing”) for the treatment of immediate trauma related symptoms and the prevention of post traumatic stress disorder. In: Oakley-Browne M, Churchill R, Gill D, Trivedi M, Wessely S, eds. Depression, Anxiety and Neurosis Module of the Cochrane Database of Systematic Reviews, Issue 3 ed. Oxford: Update Software, 2000. [37] Carlier I, Lamberts R, Van Uchelen A, Gersons B. The influence of occupational debriefing on post traumatic stress symptomatology in traumatized police officers. British Journal of Medical Psychology 2000; 73: 87–98. [38] Furedi F, Taylor-Goodby P. The assessment of asymmetric threat. Canterbury: University of Kent, 2002.



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Effects of Fear and Anger on Perceived Risks of Terrorism: A National Field Experiment Jennifer S. Lerner a , Roxana M. Gonzalez a , Deborah A. Small b and Baruch Fischhoff a a Carnegie

Mellon University of Pennsylvania

b University

Abstract. The aftermath of September 11th highlights the need to understand how emotion affects citizens’ responses to risk. It also provides an opportunity to test current theories of such effects. On the basis of appraisal-tendency theory, we predicted opposite effects for anger and fear on risk judgments and policy preferences. In a nationally representative sample of Americans (N = 973, ages 13–88), fear increased risk estimates and plans for precautionary measures; anger did the opposite. These patterns emerged with both experimentally induced emotions and naturally occurring ones. Males had less pessimistic risk estimates than did females, emotion differences explaining 60 to 80% of the gender difference. Emotions also predicted diverging public policy preferences. Discussion focuses on theoretical, methodological, and policy implications.

Effects of Fear and Anger on Perceived Risks of Terrorism: A National Field Experiment Terrorist attacks on the United States intensely affected many individuals and institutions, well beyond those directly harmed. Financial markets dropped, consumer spending declined, air travel plummeted, and public opinion toward government shifted. These responses reflected intense thought – and emotion. The attacks – and prospect of sustained conflict with a diffuse, unfamiliar enemy – created anger, fear, and sadness. A growing literature considers the interplay of emotions and risk perception (see [Holtgrave and Weber, 1993 #2073] [Loewenstein, 2003 #2084; Loewenstein, 2001 #2085] [Mellers, 1999 #2086] [Schwarz, 1996 #2089] [Slovic, 2002 #2078]. Its theories can both illuminate current events and be tested by them. Early research found that positive emotions trigger more optimistic risk assessments and negative emotions trigger more pessimistic ones, even if the source of the emotion has no relation to the target risks [1]. Recent research replicates carryover effects of emotion, but demonstrates the importance of examining specific emotions rather than global (positive-negative) feelings [2–6]. Experiments guided by appraisaltendency theory [4,5] have demonstrated that some negative emotions trigger optimism.

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J.S. Lerner et al. / Effects of Fear and Anger on Perceived Risks of Terrorism

Appraisal-tendency theory assumes that emotions not only arise from [7], but also elicit [3–6] specific cognitive appraisals. Such appraisals, although tailored to help the individual respond to the event that evoked the emotion, persist beyond the eliciting situation – becoming an implicit perceptual lens for interpreting subsequent situations. For example, fear arises from [7] and evokes appraisals of uncertainty and situational control [4], two central determinants of risk judgments [8], whereas anger is associated with appraisals of certainty and individual control [4,7]. Consistent with appraisal-tendency theory, laboratory studies have found that anger triggered in one situation evokes more optimistic risk estimates and risk-seeking choices in unrelated situations. Fear does the opposite, evoking pessimistic estimates and risk-averse choices [5]. Appraisals of certainty and control moderate and (in the case of control) mediate these effects [4,5]. If these findings generalize to the risks of terrorism, then an angry country could endorse different policies than a fearful one. The existing evidence, however, comes almost exclusively from experiments with controlled conditions and college-student samples. The present study tested whether these patterns would hold with a nationally representative sample that received emotion inductions and answered questions at home. No previous emotion experiment has used a national sample; few have used a topic so inherently salient that respondents already have strongly held beliefs. To further test generality, the study measured risk perceptions with different response modes (verbal, numeric), while considering both naturally occurring and experimentally induced emotions. Members of a nationally representative sample vary in many ways. Our analyses focus on age and gender. Compared with women, men generally report lower risk estimates [9]. Given the many factors that covary with gender in a national sample (e.g., income, longevity, social status), a gender difference in risk estimates may be multiply determined. One intriguing (but previously untested) explanation implied by appraisal-tendency theory is that gender differences in emotional experience will account for differences in risk estimates. Drawing on the demonstrated effects of fear and anger on risk perception [5] and men’s tendency to report experiencing less fear and more anger than women [10,11], we predicted that women would perceive greater risks than men and that differences in experienced fear and anger would mediate this result. Conventional wisdom holds that adolescents have a sense of invulnerability that encourages risky behaviors. However, studies have found similar risk perceptions for adolescents and adults [12]. A recent study of a nationally representative adolescent sample measured predications of life events (e.g., pregnancy, school completion, violent crime) and found accurate to optimistic predictions, except for exaggerated estimates of premature mortality [13]. We oversampled adolescents, in order to have the statistical power to detect age differences. The tragic terrorist attacks provide a unique opportunity for testing psychological theories and laboratory findings, using experimental methods with a nationally representative sample and considering issues of intense interest. In addition, the results may also help citizens and policy makers understand the complex emotions and cognitions evoked by the attacks.


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Method1 Overview Our two-part field experiment drew a random sample from Knowledge Networks’ nationally representative panel, originally recruited through random-digit dialing. Individuals agreeing to participate in this panel receive a WebTV and free interactive Internet access, in return for completing occasional surveys. Characteristics of the 75,000 households in the panel closely match the U.S. Census (for details on the Knowledge Networks panel, see http://www.knowledgenetworks.com/ganp/). For the present study, respondents received an e-mail message announcing the survey’s availability. Respondents agreeing to participate received the survey and provided informed consent. Survey alerts were sent on two dates: September 20th and November 10th, 2001. Each time, respondents had approximately 14 days to respond. September 20th procedure (Time 1) A random sample of 1,786 Knowledge Networks panel members (ages 13–88) answered questions about the attacks and completed several psychosocial scales, two of which are relevant here: (a) the five-item Anxiety Subscale from the Stanford Acute Stress Reaction Questionnaire [14] (α = .78) and (b) a four-item face-valid Desire for Vengeance Scale [15] (α = .69). We performed a principal-components factor analysis on each question set (no rotation), then used regression scores from the factor in subsequent data analyses. November 10th procedure (Time 2) The same 1,786 panel members received a message describing the second study and inviting those who could spend 20 uninterrupted minutes alone to participate. The survey was opened by 1,030 people. The study sample included the 973 who completed almost all the survey questions. Sample Preliminary analyses separated adolescents (N = 143) and adults (N = 830). Demographics for each subsample roughly matched Census figures.2 Both were 49% male. The mean ages were 45.9 (SD = 16.8, range: 18–88) and 15.3 (SD = 1.15, range: 13–17). Across the sample, self-reported ethnic-group membership was as follows: 12% African American, non-Hispanic; 12% Hispanic; 8% other, non-Hispanic; and 68% White, nonHispanic.3 Among the adults, 14% reported not completing high school, 31% said they had graduated high school or received a general equivalence diploma, 23% reported having some college education but no degree, 23% said they graduated from a 2- or 4-year college, and 9% had advanced degrees. 1 Given space constraints, methodological details could not be included in this report. This information is available on-line (http://computing.hss.cmu.edu/lernerlab/papers.php) or by request from the authors. 2 Weights adjusted for variable number of telephone lines per household and oversampling of some geographical areas. They included a nonresponse adjustment and poststratification weighting to demographic benchmarks from the Current Population Survey. For sampling details, see http://www.knowledgenetworks. com/ganp/. 3 When an adolescent did not identify his or her race, we inferred it from parental race. When parental race was missing, race was randomly assigned according to the proportions in the cases for which race was known.

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Experimental manipulation As respondents opened the second survey, a computer algorithm randomly assigned them to one of three emotion conditions. Respondents answered questions about their mood, then received a two-part emotion induction. The first part presented text like the following, followed by a box for typing a response: The terrorist attacks evoked a lot of emotion in Americans. We are particularly interested in what makes you most ANGRY about the attacks. Please describe in detail the one thing that makes you most ANGRY about the attacks. Write as detailed a description of that thing as possible. If you can, write your description so that someone reading it might even get ANGRY from learning about the situation. • What aspect of the terrorist attacks makes you the most ANGRY? • Why does it make you so ANGRY?

The other two conditions replaced “ANGRY” with “SAD” or “AFRAID.” Respondents in each condition then saw a picture and heard an audio clip about terrorism that had, in pretests, evoked the target emotion more than the other two emotions. (We focus in this report on fear and anger; the sadness manipulation will be reported elsewhere.) In order to evaluate the effects of actual media portrayals, all stimuli came from major media outlets, primarily CNN and the New York Times. The anger text and picture involved celebrations of the attacks by people in Arab countries. The fear text warned of anthrax and bioterrorism; the picture showed postal workers wearing flimsy masks. Measures of risk perception Each respondent judged risks in three ways, differing in response mode, focal event, and risk target. For the first set of questions, respondents judged the likelihood of future events for the United States, on a verbal response scale anchored at 0 (extremely unlikely) and 8 (extremely likely). Typical items were, “Safety in airline travel will improve dramatically as a result of the terrorist attack,” “Another major terrorist attack will occur within the next 12 months” (reverse-scored), and “The United States will be able to capture Osama bin Laden.” Analyses of this Risk of Future Events for the United States scale used mean responses to the nine items (α = .73). It is possible that placing greater analytic demands on respondents might diminish emotion effects. In order to test this possibility, we included two other risk scales that asked respondents to generate precise probabilities. First, the Risky Events and Precautionary Actions for Self scale asked respondents to indicate the probabilities that they themselves might experience eight risky events and precautionary actions within the next 12 months. Then, the Risky Events and Precautionary Actions for Average American scale asked respondents to indicate the probabilities that the average American might experience the same eight events and actions within the next 12 months.4 The anchors for these scales were 0% (the event is impossible) and 100% (the event is certain to happen). Five items concerned terrorism; three concerned routine risks (α = .74 for Self, 4 Judgments may be subject to a self-enhancement bias wherein respondents believe that they face less risk

then the “average American” [19,20]. We examined whether this bias persists despite the sense of vulnerability potentially instilled by the terrorist attacks.


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α = .85 for Average American). Item-level responses were negatively skewed (toward low probabilities). Averaging items on each scale produced more normal distributions. Policy preferences Finally, respondents evaluated four “possible government policies” on a 4-point Likert scale anchored at 1 (strongly opposed) to 4 (strongly support). Manipulation checks At the end of the survey, respondents reported how they felt while writing about their feelings, viewing the picture, and hearing the audio clip. They rated five-item scales for each focal emotion (fear: α = .94, anger: α = .94). Response scales ranged from 0 (do not feel the emotion the slightest bit) to 8 (feel the emotion even more strongly than ever before). We averaged responses on each scale for subsequent analyses.

Results5 Are teens different from adults? The data for teens and adults were consistent with recent findings (B. Fischhoff et al., 2000) in that the teen and adult samples revealed the same patterns on all analyses. Therefore, we collapsed the samples, weighting teens proportional to their representation in the U.S. Census data. Self-reported emotions Across the fear and anger conditions, the mean self-report for anger was 5.06. The mean for fear was 3.46. Analyses of variance (ANOVAs) indicated that the emotion primes significantly increased the target emotion. Respondents reported more anger in the anger condition (M = 5.39) than in the fear condition (M = 4.73), F (1, 649) = 13.55, p < .001. They reported more fear in the fear condition (M = 3.72) than in the anger condition (M = 3.22), F (1, 649) = 9.18, p < .01. As anticipated, females reported less anger than men, F (1, 645) = 6.16, p < .05 (Ms = 4.84 vs. 5.29) and greater fear, F (1, 645) = 21.43, p < .001 (Ms = 3.84 vs. 3.08). There was no interaction between emotion condition and gender. Thus, the emotion primes increased the target emotions, for males and females. Nonetheless, anger was the dominant emotion across conditions.6 5 Although doing so weakened the experimental effects, we included every respondent for whom we had data, regardless of whether the respondent followed instructions to (a) be completely alone during the survey (75.6% complied), (b) write feelings corresponding to the emotion prime (81.4% complied), and (c) complete the survey in one sitting (87% completed within the same day). Comprehensive statistics on response and completion rates are available from the authors. 6 It may have been socially undesirable to admit feeling fear while the United States president called for courageous and retaliatory responses. In pilot tests with the same stimuli conducted 4 weeks before Time 2, reported fear was higher.

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Risk perceptions Do experimentally primed emotions affect risk perceptions? We predicted opposite effects on risk perceptions for fear and anger. In order to test for generality, we elicited judgments of 25 risks, over three scales, with two response modes. The Risk of Future Events for the United States scale was a nine-item Likert scale, with verbal response options. The two eight-item Risky Events and Precautionary Actions scales (Self and Average American) used a numerical probability scale. As expected, each risk scale showed more optimistic (i.e., lower) estimates in the anger condition than in the fear condition (see Fig. 1). For the Risk of Future Events for the United States scale, the mean response was 3.38 in the anger condition and 3.62 in the fear condition, F (1, 644) = 7.93, p < .01. Similarly, on the Risky Events and Precautionary Actions for Self scale, the mean estimated probability was 30.5% in the anger condition and 35.2% in the fear condition, F (1, 644) = 8.25, p < .01. The highest mean was for fear-condition females (37.7%), and the lowest was for anger-condition males (27.3%). The same pattern emerged with the Risky Events and Precautionary Actions for Average American scale (Manger = 48.1%, Mfear = 52.0%), F (1, 644) = 4.55, p < .05. Thus, experimentally priming emotions triggered global effects on risk perceptions, well beyond the specific foci of the stimuli and even with the more analytic probability response scale. Gender differences As predicted, males were more optimistic than females, an effect that did not interact with emotion-condition effects (see Fig. 1). Females’ risk estimates were higher than males’ for risks to the United States (Mfemale = 3.65, Mmale = 3.34), F (1, 640) = 18.28. Similar patterns appeared for risks to the self (Mfemale = 35.92%, Mmale = 29.61%), F (1, 640) = 18.04, and for risks to the average American (Mfemale = 53.29%, Mmale = 46.51%), F (1, 640) = 15.97, all ps < .001. On the latter two scales, the difference in mean probability judgments ranged from 1.0% to 14.9% across the 16 items, with an overall mean difference of 6.4%. Mediators The foregoing results are consistent with emotion manipulations having causal effects on risk judgments. However, the condition differences might also reflect aspects of the manipulations other than the emotions they evoked. We evaluated the possibility with two analyses. Why do the fear prime and anger prime have opposite effects on risk estimates? A multivariate analysis of covariance (MANCOVA) tested whether controlling for respondents’ self-reported emotions would diminish the relationship between emotion condition and risk perception.7 The MANCOVA included the three risk scales as dependent measures, the self-report scales for fear and anger (respectively) as covariates, and emo7 A multivariate analysis was warranted (rather than nine ANOVAs), given the similar patterns for the three scales. In addition, this analysis reduced the chance of Type 1 error.


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Figure 1. Mean perception of risk as a function of emotion condition, separately for males and females. Results are shown for the three scales, which measured (a) perceived risk to the United States (nine items), (b) probability of risky events and precautionary actions for oneself (eight items), and (c) probability of risky events and precautionary actions for the average American (eight items).

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tion condition (anger, fear) as the independent variable. Results supported the hypothesis. Significant associations appeared between the fear covariate and higher risk perceptions, F (3, 640) = 48.08, Wilks’s λ = .82 (η2 = .19), as well as between the anger covariate and lower risk perceptions, F (3, 640) = 11.35, Wilks’s λ = .95 (η2 = .05), both ps < .001. When these covariates were considered, the once-significant effect of emotion condition, F (3, 640) = 5.30, p = .001, Wilks’s λ = .98 (η2 = .02), no longer predicted risk perceptions, F (3, 640) = 1.86, p = .14, Wilks’s λ = .99 (η2 = .01). Do emotions experienced shortly after September 11th predict risk estimates 6 to 10 weeks later? The second analysis examined whether naturally occurring fear and anger showed the same patterns as experimentally primed fear and anger. At Time 1, 9 to 23 days after September 11th, respondents completed the Desire for Vengeance Scale and the Anxiety Subscale of the Stanford Acute Stress Reaction Questionnaire. If emotion has lasting effects on risk perceptions, respondents who were more anxious shortly after the attacks should have made more pessimistic risk estimates at Time 2, 6 to 10 weeks later, compared with respondents who were less anxious; similarly, respondents who were initially more angry (as measured by their desire for vengeance) should have made lower risk estimates at Time 2 than respondents who were less angry. We tested these predictions by calculating partial correlations between Time 1 self-reported emotions and Time 2 scores on the three risk measures, controlling for the nonfocal emotion.8 Table 1 displays the results. As predicted, naturally occurring emotions shortly after the attacks reliably predicted risk estimates for diverse events 6 to 10 weeks later; this was true for both of the response scales (verbal, probability). Moreover, although both anxiety and vengeance are negative feelings, they had opposite correlations with risk perceptions. Greater anxiety predicted higher risk estimates; greater desire for vengeance predicted lower risk estimates.9 The results in Table 1 and the experimental effects provide convergent evidence for fear and anger having significant and distinct effects on risk perceptions. Why do men and women view risks differently? A MANCOVA tested the hypothesis that self-reported emotional experience mediates the gender difference in risk estimates. Consistent with the hypothesis, the data Table 1. Partial correlations between naturally occurring anxiety and desire for vengeance (measured soon after September 11th ) and risk perceptions (measured 6–10 weeks later) Risk perception Risk of future events for the United States

Anxiety

Desire for vengeance

.10∗

−.16∗∗

.24∗∗

Risky events and precautionary actions for self −.07+ Risky actions and precautionary actions for average American .13∗∗ −.07+ Notes. These correlations control for the nonfocal emotion (anxiety or vengeance, respectively), pre-existing anxiety disorders, and political ideology. All p values are two-tailed. + = p .08. ∗ = p .05. ∗∗ = p .001. (N = 973). 8 In previous research, desire for vengeance correlated positively with conservative attitudes [21]. Therefore, we controlled for political ideology in all our analyses involving vengeance. 9 Two of the correlations for vengeance fell just short of significance with a two-tailed test, but achieved significance with a one-tailed test. The lower reliability of these results may reflect imperfect measurement of the underlying concept of anger. The scale alpha was only .69, and item content did not address anger exclusively.


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Table 2. Relationships between gender and risk estimates

Risk of future events for the United States Relation to gender Risky events and precautionary actions for self Relation to gender

Pearson correlation

Semi-partial correlation

% Variance explained

squared

squared

by emotion

.018

.007

.611

.037

.007

.811

Risky actions and precautionary actions for average American Relation to gender .018 .007 .611 Notes. The semi-partial correlations control for participants’ self-reported experience of fear and anger.

showed significant associations between the fear covariate and higher risk perceptions, F (3, 635) = 45.45, Wilks’s λ = .82 (η2 = .18), as well as between the anger covariate and lower risk perceptions, F (3, 635) = 11.06, Wilks’s λ = .95 (η2 = .05), both ps < .001. The original gender difference, F (3, 637) = 10.10, p < .001, Wilks’s λ = .96 (η2 = .05), was weaker, but still significant, when these covariates were taken into account, F (3, 635) = 4.14, p < .01, Wilks’s λ = .98 (η2 = .02). In order to determine how much emotions mediated the gender difference in each outcome, we calculated the semi-partial correlations between gender and risk outcomes, controlling for self-reported emotion during the study. We then calculated the squared semi-partial correlations, which represent percentage of variance explained (see Table 2). The results were consistent with the MANCOVA. Controlling for self-reported emotions did not fully explain the gender difference in risk perception, but self-reported fear and anger explained 81% of the variance in risk estimates on the Risky Events and Precautionary Actions for Self scale and 61% of the variance on the other two scales. How realistic are lay risk perceptions? As in previous research, respondents assigned each negative event a lower probability of occurring to them than to the average American (see Table 3). For example, they saw a mean 20.5% personal chance of being hurt in a terrorist attack within the next year, but a 47.8% chance for the average American to be hurt. Because respondents estimated the chance that each event would occur within the next year, it is now possible to evaluate the accuracy of their predictions, and we are undertaking a study to do this. In the meantime, a few aspects of the data merit note. If probability judgments are interpreted literally, then the mean probability judgments should equal the relative frequency of the associated events occurring. In this light, the flu-risk judgments would be accurate if, in the ensuing year, about 50% of the respondents had a disease that they considered the flu. Compared with the historical flu rates, this mean judgment is moderately elevated, for both the Risky Events and Precautionary Actions for Self and Risky Events and Precautionary Actions for Average American scales [16]. The average estimated personal probability of being a victim of violent crime (other than a crime of terror) also agrees with historical statistics [17], if one uses the median to represent the skewed distribution. However, the 43% estimated probability for the average American to be the victim of violent crime (other than a crime of terror) is much higher than official estimates, as is the mean for dying from any cause. These high estimates could reflect an availability bias, with media reports exaggerating other people’s apparent

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Table 3. Respondents’ probability estimates that within the next 12 months they and the average American would experience risky events and take precautionary actions Event or action

Scale

Mean

S.D.

Median

probability estimate Being hurt in a terror attack Having trouble sleeping because of the situation with terror Traveling less than usual Screening mail carefully for suspicious items Taking antibiotics against anthrax Getting the flu Being the victim of violent crime (other than terror) Dying from any cause (crime,

Self Average American Self

20.5 47.8 23.5

22.5 35.7 29.5

10.0 50.0 10.0

Average American Self Average American Self Average American Self

44.0 34.0 53.9 53.6 60.0 22.1

27.6 36.2 25.3 38.8 29.6 30.3

45.0 20.0 50.0 50.0 60.0 5.0

Average American Self Average American Self Average American Self

39.3 46.8 59.5 22.0 43.0 35.0

30.2 31.3 29.2 22.9 30.1 34.3

35.0 50.0 50.0 10.0 40.0 25.0

illness, accident) Average of all items (N = 973)

Average American 52.6 35.2 50.0 Self 32.3 18.7 30.4 Average American 50.1 21.3 50.0 Notes. All t values for paired comparisons were significant at p < .001. The distribution of the individual items (excluding the average of all the items) were negatively skewed. A Wilcoxon sign-rank test was therefore performed, and the results were equivalent to the parametric results.

vulnerability [18]. They could also reflect sporadic problems with translating beliefs into probability judgments, especially regarding risks for average Americans.10 Nonetheless, the judgments in Table 3 suggest that respondents perceived unrealistically high rates of risks for themselves and even more elevated risks for the average American. Does emotion affect policy preferences beyond risk perceptions? Finally, we expected that responses to two of our “possible government policies” would show effects of fear and anger. Table 4 displays the items and results. Compared with fear-condition respondents, anger-condition respondents supported the (vengeful) deporting policy more strongly and the (conciliatory) contact policy less strongly. Selfreported emotions from Time 1 (vengeance) and Time 2 (fear, anger) showed a similar pattern. Regardless of emotion, respondents supported providing Americans with honest, accurate information. Unexpectedly, an emotion difference emerged for investing in general capabilities over specific solutions; fearful respondents showed modestly more 10 One difficulty with open-ended probability response modes is that respondents may use “50” to express

uncertainty (i.e., “fifty-fifty”), rather than a numerical probability [22,23]. Saying “50” when one cannot resolve one’s beliefs inflates summary statistics for risks typically assigned much lower probabilities. Such a “50 blip” occurred for the estimates of personal risk for two events: being injured in a terror attack and taking antibiotics against anthrax. Removing all “50%” responses for the former event reduces the mean probability estimate from 21% to 12% and the median from 10% to 5%. Removing all “50%” responses for the latter event reduces the mean probability estimate from 22% to 17% and the median from 5% to 3%.

Table 4. Emotion and policy preferences Partial correlations

Means for

Test for

with selfreported affect at Time 1a

with selfreported emotion at Time 2b

experimental condition at Time 2

mean difference between fear and anger at Time 2

Anxiety

Vengeance

Fear

Anger

Fear

Anger

t (df)

.02

.02

−.01

.09∗

3.47

3.43

−0.68 (634)

.05

−.02

.09∗

.02

3.58

3.47

−2.19∗ (635)

−.06

.28∗∗

−.12∗∗

.26∗∗

3.48

3.63

2.52∗ (634)

General policy preferences Provide Americans with honest, accurate information about the situation, even if the information worries people Invest in general capabilities, like stronger public health, more than a specific solution like smallpox vaccinations Emotionally-responsive policy preferences Deport foreigners in the U.S. who lack valid visas Strengthen ties with countries

−.02 −.09∗ 3.23 3.08 −2.17∗ (631) in the Moslem world −.02 −.13∗ Notes. Policy response scales ranged from 1 (strongly opposed) to 4 (strongly support). a Time 1 emotions represent individual differences shortly after September 11th . Partial correlations between Time 1 emotions and policy questions control for the non-focal Time 1 emotion (anxiety or vengeance, respectively), pre-existing anxiety disorders, and political ideology. b Time 2 emotions represent self-reported feelings in response to the emotion manipulations. Partial correlations between Time 2 emotions and policy questions control for the non-focal emotion (fear or anger, respectively). All p values are two-tailed. ∗ = p .05. ∗∗ = p .001. (N = 973).


Partial correlations

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support for this policy than angry respondents did. In sum, emotion primes significantly shifted views on terrorism policies; naturally occurring emotions showed corresponding patterns.

Conclusions A field experiment, using a nationally representative sample and a multimethod approach, found that fear and anger altered beliefs and attitudes regarding matters of national interest. Experiencing more anger triggered more optimistic beliefs; experiencing more fear triggered greater pessimism. These effects held across a range of risks (terror and non-terror related) and with both a verbal response scale and a more analytical probability response scale. Thus, two negative emotions had consistently divergent effects on risk estimates, providing additional evidence for the importance of examining specific emotions, rather than just global moods. Across all risks, males expressed less pessimism than did females. Differences in reported emotion explained 60% to 80% of the variance in these effects. As has been found previously, respondents saw themselves as less vulnerable to risks than the average American, and less likely to take precautionary measures. However, these judgments of relative risk did not reflect unrealistic optimism, in an absolute sense. Some risk estimates (e.g., for the average American being a victim of violent crime) reflected pronounced pessimism, considering historical risk rates. Other risk judgments (e.g., being injured in a terror attack) can be evaluated only now, when the actual risk is known because a year has passed since completing the survey. Given the events (or lack thereof) in the year since the survey, respondents appear to have been deeply pessimistic when estimating a 20% chance of being hurt in a terror attack for themselves and a 48% chance for the average American. Although our comparisons between fear and anger focused on risk estimates, emotions also influenced public policy preferences. As expected, experimentally primed anger activated more punitive preferences, and fear enhanced preferences for conciliatory policies and investment in broadly applicable precautionary measures. Extrapolating results from an experiment to a real-world setting requires matching conditions between the two. Our study used television (WebTV) to focus respondents on an all-too-familiar topic for 15 to 20 min. The manipulation involved activities that one might encounter in everyday life. Specifically, respondents were asked to dwell briefly on a common emotion, then experience a related picture and text from the news media. Thus, the effects we observed might resemble those evoked by comparable news reports and periods of reflection. A more sustained focus (e.g., a crisis, intense political debate, memorial period) could be expected to increase the effects. Similar emotional manipulations (by experimenters, politicians, etc.) should have similar effects, proportional to their emotional power. Citizens need to understand these processes in order to apply their hearts and minds to what might be a protracted struggle with the risks of terror.

Authors’ Note Originally published in Psychological Science, 14, 144–150. Copyright © 2003, Blackwell Publishing. Reprinted with permission.


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National Science Foundation (SES-0201525), National Institute of Mental Health (MH62376), and American Psychological Association (Division 9) grants supported this research. We thank David Fetherstonhaugh, Mike Dennis, Bill McCready, Justin Malakhow, Bill von Hippel, Shelley Taylor, Dan Martin, George Loewenstein, and Steve Klepper. Correspondence address: Jennifer Lerner, Department of Social and Decision Sciences, Carnegie Mellon University, Pittsburgh, PA, 15213. Phone: 412-268-4573; E-mail: [email protected]. References [1] Johnson EJ, Tversky A. Affect, generalization, and the perception of risk. Journal of Personality and Social Psychology 1983; 45: 20–31. [2] DeSteno D, Petty RE, Wegener DT, Rucker DD. Beyond valence in the perception of likelihood: The role of emotion specificity. Journal of Personality & Social Psychology 2000; 78: 397–416. [3] Keltner D, Ellsworth PC, Edwards K. Beyond simple pessimism: Effects of sadness and anger on social perception. Journal of Personality and Social Psychology 1993; 64: 740–752. [4] Lerner JS, Keltner D. Beyond valence: Toward a model of emotion-specific influences on judgment and choice. Cognition and Emotion 2000; 14: 473–493. [5] Lerner JS, Keltner D. Fear, anger, and risk. Journal of Personality and Social Psychology 2001; 81: 146–159. [6] Tiedens LZ, Linton S. Judgment under emotional certainty and uncertainty: The effects of specific emotions on information processing. Journal of Personality & Social Psychology 2001; 81: 973–988. [7] Smith CA, Ellsworth PC. Patterns of cognitive appraisal in emotion. Journal of Personality and Social Psychology 1985; 48: 813–838. [8] Slovic P. Perception of Risk. Science 1987; 236: 280–285. [9] Slovic P. Trust, emotion, sex, politics, and science: surveying the risk assessment battlefield. Risk Analysis 1999; 19: 689–702. [10] Biaggio MK. Assessment of anger arousal. Journal of Personality Assessment 1980; 44: 289–298. [11] Grossman M, Wood W. Sex differences in intensity of emotional experience: A social role interpretation. Journal of Personality & Social Psychology 1993; 65: 1010–1022. [12] Quadrel MJ, Fischhoff B, Davis W. Adolescent (in)vulnerability. American Psychologist 1993; 48: 102– 116. [13] Fischhoff B, Parker A, Bruine de Bruin W, Downs J, Palmgren C, Dawes RM, et al. Teen expectations for significant life events. Public Opinion Quarterly 2000; 64: 189–205. [14] Cardeña E, Koopman C, Classen C, Waelde LC, Spiegel D. Psychometric properties of the Stanford Acute Stress Reaction Questionnaire (SASRQ): A valid and reliable measure of acute stress. Journal of Traumatic Stress 2000; 13: 719–734. [15] Skitka LJ. The desire for vengeance scale: University of Illinois at Chicago, 2001. [16] Adams P, Marano, M. Current estimates from the national health interview survey. Hyattsville, MD: National Center for Health Statistics, Vital and Health Statistics, 1995. [17] RAND. National Crime Victimization Study. Santa Monica, CA: RAND, 1998. [18] Kahneman D, Slovic P, Tversky A, eds. Judgment under uncertainty: Heuristics and biases. New York: Cambridge University Press, 1982. [19] Taylor SE, Brown JD. Illusion and well-being: A social psychological perspective on mental health. Psychological Bulletin 1988; 103: 193–210. [20] Weinstein ND. Unrealistic optimism about future life events. Journal of Personality and Social Psychology 1980; 39: 806–820. [21] Skitka LJ, Tetlock PE. Providing public assistance: Cognitive and motivational processes underlying liberal and conservative policy preferences. Journal of Personality and Social Psychology 1993; 65: 1–19. [22] Bruine de Bruin W, Fischbeck PS, Stiber NA, Fischhoff B. What number is “fifty-fifty”?: Distributing excessive 50% responses in elicited probabilities. Risk Analysis 2002; 22: 713–723. [23] Fischhoff B, Bruine de Bruin W. Fifty-fifty = 50%? Journal of Behavioral Decision Making 1999; 12: 149–16.



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Threats, Chemicals and Bodily Symptoms: A Psychological Perspective Omer Van den Bergh Research Group for Stress, Health and Well-being, Department of Psychology, Tiensestraat 102, B-3000 Leuven, Belgium Abstract. Terrorism caused by chemical, biological or nuclear agents differs from terrorism using explosive forces. It is argued that ideal situations are created to attribute a wide variety of vague, systemic symptoms to environmental stimuli. A series of laboratory studies is discussed showing symptom learning in response to odorous chemical substances: the experience of a few symptom episodes in association with such substances is sufficient to subsequently feel symptoms upon perceiving the substances alone. This is more likely when the substances are foul smelling or endowed with negative meanings. Persons tending to negative moods and emotions appear more vulnerable to these processes. Implications for medically unexplained symptoms are discussed.

1. Explosives and Chemical, Biological and Nuclear (CBN) Agents Terrorism using guns, bombs or missiles (or civilian airplanes turned into missiles, for that matter) is psychologically devastating for many reasons, the major ones being: 1. unpredictability of the threat in time and space; 2. lack of controllability of both its occurrence and its effects; and 3. the seriousness of its potential effects, namely the loss of lives and the destruction to property, housing and personal environment. Life threatening events that are highly unpredictable and uncontrollable almost prototypically represent the most powerful stressors for living organisms. Numerous studies have tried to create laboratory conditions with similar characteristics in order to investigate their psychobiological effects under controlled conditions. Obviously, animal studies have been going farther along that road than human studies [1,2]. Human studies have mostly relied on “naturally” occurring circumstances. Overall, it is hard to find a relevant psychobiological parameter in living organisms that is not affected by a deep sense of continuous threat of life and insecurity [3]. Terrorism using chemical, biological or nuclear/radioactive agents (CBN) shares many characteristics with terrorism using explosive forces, but diverges from it as well. The occurrence of an explosive event may be unpredictable, but once it occurs it has a clear spatio-temporal structure, that is, both its location and its time course are defined. In addition, its immediate destructive effects on humans and material goods can readily be circumscribed, and mostly, there is a clear and understandable way how to deal with them. This is different for terrorism involving CBN agents. Many agents may be hard to perceive and/or understand and their impact may be spread out in space and time. Therefore, it is not only unpredictable where and when CBN agents might be encountered,

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but it might even be unpredictable whether they are there at all (“Isn’t this some kind of powder? Is this powder anthrax or not? Is there nuclear fall out around here or not? Is the drinking water deliberately polluted or not?”). This makes them extremely capable of creating stress and anxiety [4–9]. In addition, unlike an explosive attack, their effects, time course and ways to handle them are much more difficult to define. Rather than a sudden and often ferocious disruption of one’s bodily integrity, bodily harm may be more subtle and spread out throughout the body and over time. For example, vague, systemic symptoms may be the result of exposure to some kind of toxic agent and prelude a fatal course only in the long run. As a result, such symptoms may become a source of uncertainty, severe concerns and stress, persisting long after a CBN event. In other words, the spatio-temporal and causal structure of a CBN event and its effects are more difficult to grasp compared to those of an explosive event, and, as a consequence, are even more difficult to handle and to clearly communicate as well.

2. Learning Associations One way to reduce unpredictability is trying to detect stable relationships between events, such that one event can be used to predict another. This may also increase controllability, because if an event can be predicted, it may possibly allow for actions influencing its course. Learning associations between events can therefore be seen as an adaptive process in situations of unpredictable threat and can help to transform a general and undefined sense of anxiety into a focused fear [10]. In fact, one of the basic elements of the psychobiological make up of most organisms is the orienting response towards new and unpredictable events, which can be considered some kind of “what’s that?” question [11], facilitating learning of predictive and causal relationships between events. The (potential) occurrence of aversive events of major importance that lack a clear, phenomenal cause-effect structure such as CBN terrorism may have some important psychological implications. First, the chronic state of apprehensive anticipation of future negative events may by itself induce vague, arousal related bodily symptoms that are amenable to interpreting them as effects of CBN agents. Second, as there may be no clearly defined and perceivable threat, the range of potential threathening stimuli in the environment to alert to may become extremely wide. For example, salient odors or chemical products with unnatural colors, or even normal air conditioning systems may become suspicious environmental stimuli. Third, without a clearly defined cause-effect structure of the event, spurious correlations between events may easily be perceived as cause-effect relationships, especially when pre-existing beliefs about such relationships exist [12]. In sum, threats of CBN terrorism may facilitate attributing a wider range of health effects to a wider range of environmental stimuli. It may be obvious that this analysis does not only apply to threats caused by potential CBN attacks, but also to other subjectively experienced health threats caused by environmental stimuli that are difficult to predict and control. For example, similar characteristics may emerge from the conviction that one is gradually being poisoned by the ubiquitously present chemical pollution in our modern way of life, a conviction that is prominent among patients that suffer from Multiple Chemical Sensitivity (chemical intolerance, or environmental illness) [13]. Or the conviction may arise that radiation from secretly transported radioactive goods in a crashed airplane is causing health problems in


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people living in the crash area [14]. Or the belief may emerge that exposure to the fumes and dust from collapsed buildings or in war zones is detrimental for one’s health because they contain toxic elements [15]. These examples do not intend to suggest that health problems with clear and measurable biomedical abnormalities may not have been caused by the events mentioned. We only argue that either or not on top of those, medically unexplained symptoms may emerge and attributed to environmental stimuli.

3. Learning Associations Between Chemicals and Bodily Symptoms Subjective health symptoms are by definition psychological events: bodily signals have to be sensed, perceived, appreciated and interpreted, put into language and expressed. Thus, signals from bodily dysfunction are but one, yet an extremely important source of information, but psychological processes related to each of the information processing steps can seriously influence and bias subjective health symptoms [16]. No wonder that correlations between subjective symptoms and objective signs of pathology can vary anywhere from zero to almost one [17]. The previous analysis of a potential CBN threat suggests that such a situation creates ideal conditions to perceive subjective health symptoms and attribute them to toxic agents in the environment. In order to investigate processes of symptom perception in response to chemicals in greater detail, we developed a respiratory symptom learning paradigm and ran a series of laboratory experiments with the following general features: Subjects were invited to take part in a study, investigating the effect of different air mixtures on subjective health and well-being. It was told that some air mixtures might cause health complaints that would quickly disappear after a trial. The basic model implied the administration of a number of breathing trials of two minutes each (Fig. 1). Air enriched with CO2 (ranging between 5.5% to 10%, depending on the study) served as a respiratory

Figure 1. Schema of a respiratory conditioning paradigm and a typical result (means ± SD) [12].

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challenge to induce symptoms and two odorous chemicals were used as harmless cues, for example dilute ammonia and niaouli, a mixture containing mainly eucalyptus oil. In the learning phase, subjects breathed one odor mixed with CO2 (called a CS+ trial), and the other odor mixed with room air (called a CS− trial).1 In the test phase, the CO2 was not administered anymore and the breathing trials contained only the odorous chemicals. Respiratory frequency, tidal volume, end-tidal fractional concentration of CO2 and heart rate were measured throughout the experiment and subjective symptoms were registered after each trial. This experimental laboratory model has important features that are relevant for medically unexplained symptoms in response to chemicals: (1) it involves human subjects; (2) the major dependent variable consists of a wide variety of subjective symptoms; (3) CO2 inhalation may represent a conceptual laboratory analogue for a toxic exposure; and (4) harmless odoring chemicals are introduced to serve as cues for or elicitors of the symptoms. In addition, both bodily responses and subjective symptoms are measured, allowing to investigate the concordance/divergence among the two sets of responses. An important methodological advantage is also that the associative learning effect can be tested both within subject and within odor, meaning that both the subjects and the odors serve as their own controls. As a result, any difference in symptom reports among the two chemicals in the test phase can unequivocally be attributed to the formed association between an odor and symptoms, in other words, to learning. Admittedly, the emotional distress created in such laboratory conditions is minimal and remote from real threats caused by terrorism or disasters involving potential releases of CBN agents. Nevertheless, a quite consistent and compelling set of results were obtained in a series of experiments: 1) After a few symptom experiences induced by the odor mixed with CO2 , the odor alone altered respiratory behavior and induced elevated levels of somatic symptoms “as if the subjects were still breathing CO2 ”. In other words, symptoms had been learned [18–22]. 2) The symptom learning effect was selective: when one odor was foul smelling and the other was neutral to pleasant, symptom learning occurred only in response to the foul smelling odor (see Fig. 1). When both odors were foul smelling (e.g. irritant ammonia and nonirritant butyric acid) learned symptoms emerged to both, suggesting that the unpleasantness of the odors was the critical variable for the selective association effect [18–21]. 3) The symptom learning effect was specific: no effects appeared for symptoms usually not provoked by CO2 (“dummy symptoms”) and the effects could not be explained by learned arousal/anxiety in response to the odors: We never observed a conditioned heart rate increase and the effects were largest for the subset of symptoms that is typically elicited by CO2 , namely the respiratory subset [19–21]. 1 Technically, this is a differential Pavlovian conditioning paradigm in which the CO enriched air is an 2 unconditional stimulus (US) and the odors are conditioned stimuli (CS). The odor mixed with CO2 enriched air is called a CS+, whereas the odor mixed with regular room air is called a CS−. Both odors are administered to the same subject (within subject design), but the specific odor used in each trial type (CS+ or CS−) is counterbalanced between subjects. The test phase consists of presenting both the CS+ and CS− without the US. Typically, a difference is found between measures of the response to the CS+ and the response to the CS−.


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4) Learned symptoms were quite persistent: it did not matter for the size of the learning effect whether the test phase was run immediately after the learning phase or one week later [22]. 5) A straightforward extinction procedure, involving a series of unreinforced exposures of the odor only after learning had occurred, readily reduced the learned symptoms [21]. 6) Once symptoms were learned to one odor, they generalized to newly presented odors but only when these odors were also foul smelling. For example, subjects conditioned to have symptoms to ammonia showed elevated symptoms also to (first time presented) foul smelling butyric acid and acetic acid, but not to fresh smelling citric aroma [22]. 7) Mental thoughts and images can also serve as cues for symptoms: Merely evoking an image of a situation that had previously been paired with the experience of CO2 -induced symptoms elicited those symptoms and altered respiratory behavior. Again, unpleasantness of the the imagined situations appeared to be an important variable because learning effects only showed up when the imagined situations were stressful [23]. 8) Important individual differences occurred. The level of neuroticism or negative affectivity (NA) in normal subjects facilitated the learning effects: Learned symptoms and their generalization to new odors were overall more elevated in a group of subjects scoring high for negative affectivity [20,22]. Similarly, the learning effects on symptoms were overall stronger in a group of “psychosomatic” patients. This suggests that neurotic and psychopathological groups are more vulnerable to learning medically unexplained symptoms [19]. 9) Although both (respiratory) symptoms and altered respiratory behavior were learned, the symptoms in the test phase were not a reflection of the actual (learned) physiologic responses. Rather, the symptoms were relying on an activated memory representation of the symptoms experienced in the acquisition phase. This activation process was automatic, in that it required little or no conscious mental resources [20]. Other recent evidence was in accordance with this finding: Within-subject correlations between self-reported respiratory symptoms and a objective measures of respiratory behavior were significantly lower in persons with high negative affect, in particular when they were in an unpleasant situation [24]. In other words, under the same circumstances that led to optimal learning, they were interoceptively less accurate. 10) Manipulations of a priori beliefs about the health effects of chemical pollution had quite important effects on symptom learning. In one study [25], half the subjects were given information to read in the waiting room before participating, describing the so-called wider context of the experiment, whereas the other half was given irrelevant reading materials. The relevant text was mainly copied from websites warning against the ever increasing chemical pollution of our environment that may make some people oversensitive so as to cause chemical intolerance, environmental illness and multiple chemical sensitivity. In addition, a case story of a MCS patient was given to read (see appendix). This manipulation of a priori beliefs facilitated symptom learning in two ways: only one learning trial (instead of three) was sufficient to cause symptom learning and it now occurred also in response to fresh smelling odors. This suggests that not the

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unpleasant perceptual quality as such, but the negative meanings evoked by the unpleasantness of the chemical is an important variable in symptom learning. 11) In several studies, we also collected contingency awareness data. In other words, we measured whether subjects were aware of the relationship between a particular chemical and the occurrence of CO2 induced symptoms during the learning phase. Although we have previously reported in several individual studies that contingency awareness did not matter for symptom learning, a recent investigation pooling data from several studies showed that contigency awareness was critical indeed [26]. That is, only subjects who could verbalize which particular odor (CS+) had been “causing” most symptoms during the learning phase showed elevated symptoms towards the same odor during the test phase. However, contingency awareness was necessary but not sufficient, because not all aware subjects showed learning. Also other variables (see the previous points above, such as unpleasantness of the chemicals, situations, etc.) were additionally important. 12) The importance of contingency awareness was further demonstrated in a study using butyric acid and ammonia as odors. Although the data of the learning phase showed most symptoms to emerge in response to the CS+ odor, the contingency awareness measure showed an erroneous contingency awareness in several subjects: there was a bias towards indicating butyric acid as the odor that had been causing most symptoms in the learning phase, when, in fact, it had been ammonia. In subjects with a reversed contingency awareness, also a reversed symptom learning effect occurred, that is, they reported more symptoms to butyric acid than to ammonia consistent with their erroneous retrospective belief [27]. The above are all laboratory findings and little is currently known about their ecological validity. However, apparent similarities with real life phenomena suggest they may have an important heuristic value to understand medically unexplained symptoms. For example, persons with medically unexplained symptoms score generally higher for neuroticism or negative affectivity, which parallels the finding that persons with high NA and psychosomatic patients are better symptom learners. Also, medically unexplained symptoms seem to occur more likely in adverse or stressful circumstances, which resembles better symptom learning in response to unpleasant stimuli or situations. In addition, in our laboratory studies no correspondence was found between physiologic responses and subjective symptoms, which is also typically observed in studies with high symptom reporters [28].

4. Symptom Learning and Medically Unexplained Symptoms The existence of medically unexplained symptoms and syndromes promotes two extreme positions. One is that some specific explanatory mechanism of dysfunction in the body must exist that has yet to be discovered. The other assumes that such symptoms are mainly the result of perceptual-cognitive processes, amplifying (relatively minor) bodily sensations resulting from stress and anxiety. Several investigators hold positions inbetween these extremes, but common to both views is a static model, that is, symptoms of a particular illness are considered as invariantly determined by the same set of processes.


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An important implication from the above findings is, however, that symptom perception is a dynamic process, implying that the relative importance of several mechanisms and sources of information may change over time within an individual. This means that we do not subscribe to the view that symptoms have either a biomedical or a “psychological” basis, but can have both in varying degrees, depending on the circumstances. Indeed, the basic message of the above set of findings is that the simple experience of a few symptom episodes caused by a “true” source in association with a harmless odorous chemical is sufficient to induce symptoms when subsequently perceiving the chemical only. In other words, symptoms that could be called “medically unexplained” were learned, implying a shift from relatively accurate interoception of true changes in the body in a first phase to a biased and inaccurate perception in a later phase. The latter situation reminds of the concept of “somatovisceral illusion” [29]. The above paradigm allows to investigate biased interoception and attribution of symptoms to internal and external stimuli after experimental induction of symptoms. However, it remains silent as to the source of the symptoms in real life in the first place. We believe that any symptom episode without a clear explanation (e.g. stress-induced hyperventilation, chronic fatigue syndrome, fybromyalgia, see Sharpe & Bass [30]) may easily be perceived in contingency with or attributed to the presence of harmless environmental cues. The psychosocial context, including the government and the media, may contribute to making specific biochemical cues more salient and induce beliefs facilitating false attributions of normal stress reactions and normal disease symptoms (such as the flu) to such contamination, as might happen in cases of ‘mass psychogenic illness’ [4, 6,25,31–33]. In that respect, threats of CBN attacks may create ideal conditions for mass psychogenic illness to emerge. The present perspective is also consistent with the view advocated by Wessely, Nimnuan and Sharpe [34]. They consider the so-called functional syndromes, (e.g. chronic fatigue syndrome, fibromyalgia, MCS, but also irritable bowel syndrome, Gulf War syndrome, etc.) as basically having a common ground. Indeed, patients show considerable symptom overlap, share the same non-symptom characteristics (e.g. predominance of women, elevated psychiatric co-morbidity) and respond to the same therapies. The authors assume that the different diagnostic categories mainly reflect differences in attributions of symptoms to sources. Symptom perception processes and patient’s causal attributions of symptoms to cues may determine which particular physician will be consulted, and depending on the specialty of the consulted physician, different illness labels may be applied. Obviously, both patients and physicians may reinforce each other in selective perceptions and specific causal attributions. Once a causal structure has been established in the patient’s mind, subsequent confrontations with the environmental cue alone may trigger anticipatory processes at several levels of functioning, both physiological and perceptual-cognitive, subserving the experience of subjective symptoms. One potential physiological source of symptoms, the importance of which may be underestimated, is hyperventilation-induced hypocapnia. This may be a particularly relevant source because of its strong link with stressful arousal [35], its wide range of systems in the body that may be affected [36], its episodic nature and – therefore – the difficulty to diagnose it in typical laboratory conditions. It may be either the main and primary source of symptoms or a secondary one on top of other less transient sources, contaminating the clinical picture. When occurring in a “chemical context”, it may act in the same way as the CO2 -induced hyperventilation in

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our studies. This was recently shown in an experiment using the same symptom learning paradigm with odors, but now with voluntary hyperventilation rather than CO2 inhalation to induce symptoms in the learning phase. It was found that typical sensations of hyperventilation, such as lightheadedness, were being reported in response to sensing the odor that had been associated with voluntary hyperventilation [37]. This view may explain a number of observations in functional syndromes, such as MCS. First, (1) the origin of MCS appears in some cases to be linked to episodes of stress and not to toxic exposures; [39] (2) there is a substantial overlap among the symptoms of MCS and those of hyperventilation, such as intermittent flares of fatigue and weakness, dizziness or light-headedness, cognitive difficulties (concentration and memory), shortness of breath, sore throat, dry mouth, palpitations and “racing heart”, gastro-intestinal problems and feelings of anxiety or depression [18,40–42]; (3) Leznoff [43] observed that exposure of MCS patients to their chemical trigger induced hyperventilation in 73% of them. Also in a recent study with Gulf War syndrome patients [44], particularly strong tendencies to hyperventilate were observed in response to sensing diesel vapors in the laboratory, that reminded to diesel exposures during active duty in the Gulf. One can easily imagine cases in which both hyperventilation and toxic exposures are involved. For example, a toxic exposure may be a primary source of symptoms, causing learned symptoms and anxiety to odoring substances or specific “contaminated” environments. Subsequent exposures to those environments may induce hyperventilation as part of anticipatory anxiety and in this way become a secondary source. Occasional episodes of hyperventilation may intermittently reinforce learned symptoms, making the source of symptoms quite variable and elusive. In that respect, hyperventilation may not just be some epiphenomenon in several stress-related conditions, but act as an important source of symptom learning. Because this may loosen the link between symptoms and their physiological correlates (see above), a one-to-one relationship between hypocapnia and the presence of symptoms should not be considered critical for the hypothesis [38].

Conclusion Subjective symptoms are inherently plastic. The occurrence of symptom episodes in association with environmental cues, such as odors, may easily give way to symptom learning, implying attributing and experiencing symptoms to such cues. Threats of CBN terrorism may create ideal conditions for symptom learning. Both real toxic exposures and several stress related sources of symptoms, among which hyperventilation may be a prominent one, may act as initial causes of symptom episodes. Learning mechanisms may further shape perceptual-cognitive mechanisms and trigger additional physiological stress responses to form a dynamic state, characterized by negative affectivity, interoceptive vigilance, catastrophic expectancies and medically unexplained symptoms.

Acknowledgement I am indebted to Johan Bresseleers for his help and comments on earlier versions of the chapter.


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[24] Van den Bergh O, Winters W, Devriese S, Van Diest I, Vos G, De Peuter S. Accuracy of Respiratory Symptom Perception in Persons with High and Low Negative Affectivity. Psychology & Health 2004; 19: 213–222. [25] Winters W, Devriese S, Van Diest I, Nemery B, Veulemans H, Eelen P, Van de Woestijne KP, Van den Bergh O. Media warnings about environmental pollution facilitate the acquisition of symptoms in response to chemical substances. Psychosom Med 2003; 65: 332–338. [26] Devriese S, Winters W, Van Diest I, De Peuter S, Vos G, Van den Bergh O. Perceived rather than actual contingencies between odors and symptoms determine learning of symptoms in response to chemicals. Int Arch Occ Envir Health 2004; 77: 200–204. [27] Devriese S, Winters W, Van Diest I, Van den Bergh O. Contingency awareness in a symptom learning paradigm: Necessary but not sufficient? Consciousness and Cognition 2004; 13 (3): 439–452. [28] Houtveen JH, Rietveld S, de Geus EJ. Exaggerated perception of normal physiological responses to stress and hypercapnia in young women with numerous functional somatic symptoms. J Psychosom Res 2003; 55 (6): 481–490. [29] Cacioppo JT, Tassinary LG. Inferring psychological significance from physiological signals. Am Psychol 1990; 45 (1): 16–28. [30] Sharpe M, Bass C. Pathophysiological mechanisms in somatization. Int Rev Psychiatry 1992; 4: 81–97. [31] Bartholomew R, Wessely S. Protean Nature of Mass Sociogenic Illness: From Possessed Nuns to Chemical and Biological Terrorism Fears. Br J Psychiatry 2002; 180: 300–306. [32] Romano JA, King JM. Chemical warfare and chemical terrorism: Psychological and performance outcomes. Military psychology 2002; 14 (2): 85–92. [33] Donovan S. (2002). Bioterrorism Summaries from Annual Session 2002: Recognizing and treating the psychological effects of terrorism. American College of Physicans. [34] Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: one or many? Lancet 1999; 354 (9182): 936–939. [35] Van Diest I, Winters W, Devriese S, Vercamst E, Han JN, Van de Woestijne KP, Van den Bergh O. Hyperventilation beyond fight/flight: Respiratory responses during emotional imagery. Psychophysiology 2001; 38: 961–968. [36] Gardner WN. The pathophysiology of hyperventilation disorders. Chest 1996; 109: 516–534. [37] Van Diest I, De Peuter S, Vos G, Devriese S, Van de Woestijne KP, Van den Bergh O. Conditioned lightheadedness in response to odors using hyperventilation as unconditional stimulus. Paper presented at the Fifth Conference on Psychology & Health organized by the Research Institute for Psychology & Health 2004 May 10–12, Kerkrade, The Netherlands. [38] Hornsveld HK, Garssen B, Dop MJ, et al. Double-blind placebo-controlled study of the hyperventilation provocation test and the validity of the hyperventilation syndrome. Lancet 1996; 348: 154–158. [39] Schottenfeld RS. Workers with multiple chemical sensitivities: a psychiatric approach to diagnosis and treatment. Occup Med State Art Rev 1987; 2: 739–753. [40] Shusterman DJ. Critical review: The health significance of environmental odor pollution. Arch Environ Health 1992; 47: 76–87. [41] Lehrer PM. Psychophysiological hypotheses regarding multiple chemical sensitivity syndrome. Environ Health Perspect 1997; 105: 479–483. [42] Pearson DJ. Psychologic and somatic interrelationships in allergy and pseudoallergy. J Allergy Clin Immunol 1988; 81: 351–361. [43] Leznoff A. Provocative challenges in patients with multiple chemical sensitivity. J Allergy Clin Immunol 1997; 99: 434–437. [44] Fiedler N, Giardino N, Natelson B, Ottenweller JE, Weisel C, Lioy P, Lehrer P, Ohman-Strickland P, Kelly-McNeil K, Kipen H. Responses to controlled diesel vapor exposure among chemically sensitive Gulf War veterans. Psychosom Med 2004; 66: 588–598.

THE RUSSIAN PERSPECTIVE



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Immediate Interventions – The Experience of the Emergency Mental Health Service of EMERCOM of Russia Sergei Aleksanin All-Russian Center of Emergency and Radiation Medicine, EMERCOM of Russia, Lebedeva str. 4/2, St. Petersburg, 194044, Russia More than 100 years ago the famous Russian surgeon Dr. Pirogov first suggested that among other things war is an epidemic of traumatism. Similarly, it is no exaggeration to state that modern emergencies, be they terrorist acts, technological accidents or natural disasters, can cause mental trauma on an epic scale. Our experience at EMERCOM in Russia, confirms this fact. It is not by accident that only ten years ago the Ministry decided to create in 1998 a Psychological Support Service to assist the work of EMERCOM. We did so because of the increasing need for systems of psychological support and assistance both to those injured in emergencies, and also to the emergency workers themselves. Such an organizational structure allows: • A wide network of regional services for day to day management; • Mobile groups of psychologists from the personnel of the Emergency Psychological Help Center (Moscow branch of ARCERM) and the Department of Medical Psychological Problems of ARCERM; • Psychological support for the activities of emergency workers (professional selection, preparation, monitoring and correction of condition) linked to an agreed set of standards. In the past three years Service experts have accompanied emergency workers to attend the earthquake on Sakhalin island, the flood on Lena river in Lensk, have rendered psychological help to the relatives of the victims of air catastrophes, the “Kursk” submarine, and also during recent terrorist acts in Moscow. In this paper I will report on some of our experiences giving emergency psychological help to the victims of terrorist acts. Emergency psychological help is an independent area of psychological practice. It has two unique elements: • The index events and its effects on emotions, cognitions and the personality of those affected almost by definition is unexpected; • Emergency psychological help needs to be given rapidly. Despite the above, emergency psychological help is governed by conventional principles. However, the emergency situation does give certain special challenges.

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1. There is a different relationship between the psychologist and the emergency victim to that between the psychological and the normal client seen in clinical practice. The latter has specifically requested psychological help for a defined problem, the former has not. Looking after the needs and privacy of any client is always important for all psychologists wherever their work, but these issues are different for the psychological outreach that is the sine qua non of emergency psychology. 2. The principle of “first do not harm”: must be born in mind in these situations, particularly because time is short, and interventions rarely prolonged. It may not be possible or desirable to address long standing pre emergency problems within the client. 3. Voluntary consent remains important, even if in the emergency situation is the psychologist who makes contact with the client, rather than vice versa. 4. Confidentiality: must also be respected in emergency circumstances, with the rare exception of when the psychologist considers the behaviour of the client to be dangerous to the client or other people. In this ethical emergency psychological help does not differ from psychological assistance in non emergency situations. 5. Professional motivation: becomes especially important in the emergency situation, since there can be other strong motives (self-statement, social acceptance, etc.). 6. Professional competence remains critical, even in the demands of an emergency. The expert rendering the emergency psychological help must have appropriate and relevant professional qualifications, and must also be acting for professional, as opposed to personal, motives. The professional must also be prepared to work in demanding, and even occasionally dangerous, situations. Emergency psychological help can be divided into three stages. I. Preparatory stage The purpose of a preparatory stage is the detailed plan of the emergency psychological help. Information should be gathered concerning psychological aspects of the emergency as follows: • To find and secure a secure setting for psychological help – which needs to be located in proximity to wherever the injured are being managed, and their relatives are assembling. It should also be near facilities that have to deal with victim identification and the inevitable interactions between the bereaved and the authorities; • To have an approximate assessment of the numbers of people needing help; • To have a realistic appraisal of the resources needed in terms of expert numbers, time, equipment and other resources. This information is necessary for the optimal organization of the emergency psychological help. II. A basic stage At the basic stage of the emergency psychological help there are two basic directions of activities of the specialist-psychologists: to help emergency workers participating in the


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mitigation of consequences of the emergency and to help injured. The content of activity of the psychologists depends on the specific situation encountered. III. A closing stage In the final stages of emergency psychological help the tasks are as follows: • • • •

Psychological help for those in need; Psychological support of the emergency workers; Analysis of information obtained during the emergency psychological help; Some forecast on future developments and needs based on available data.

Approaches to the Emergency Psychological Help All the methods of emergency psychological help should be short-term, namely: neurolinguistic programming, body-oriented therapy, arttherapy, short-term positive therapy, suggestive technology, relaxation methods and methods directed on self-regulation, rational psychotherapy and others. Emergency psychological help is a system of short-term individual or group measures to restore the psychological/psychophysiological state of the victims of a crisis or extreme event and mitigation of negative emotional experiences. The choice of measures is determined by the resources available and the individual situation.

Examples of Work on Rendering Emergency Psychological Assistance Psychologists from the ARCERM of EMERCOM of Russia participated in the aftermath of the terrorist acts in Moscow (Guryanova street, 17 and Kashirsky highway, 6) during the period from 9.09 to 17.09.99. The basic themes of the work undertaken by the psychologists were: • Prevention of potential mass negative emotional responses from interfering with emergency activities (see Krasnov Chapter 9 as well); • Determining which victims needed emergency medical psychological help (i.e. those in high risk categories); • Definition of specific tasks requiring participation of experts-psychologists in the mitigation of consequences of the emergency situation, including search and rescue activities, medical and social help to the population and keeping order in the affected area. Psychologists used such methods as psychological observation and interview. To restore mental health the techniques of rational psychotherapy and decreasing the level of psychological strain were selected. As it turned out, panic attacks and other negative responses were observed during the first hours of emergencies due to acute emotional shock state and also lack of information. Some injured needed urgent psychotherapy alongside pharmacological therapy. Individuals who become caught up in disaster situations can be grouped as follows:

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• The injured, their relatives and intimate friends (this group is at the highest risk of stress responses and consequently requires urgent medical psychological help); • Bystanders – the inhabitants of the nearest houses, etc. (whose actions might interfere with emergency service activities); • Individuals arriving at the emergency area (maladaptive psychological responses are less probable). Our experience of emergency scenes suggests the following priorities: 1. Giving emergency individual psychological help to the injured. 2. Identification of those requiring emergency psychiatric help. 3. Identification of those liable to spread panic and engaging them with the psychological intervention. 4. Selection of those capable of prevention of mass negative psychological responses (panic) among the population. 5. Psychological correction and medical psychological rehabilitation of personnel of search and rescue detachments.


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Social, Community and Individual Responses to Terrorist Attacks V.N. Krasnov Moscow Research Institute of Psychiatry

1. Introduction Terrorism has been accompanying mankind for centuries. It shows itself in purposeful, usually planned aggression against group of persons, or organization or specific country, and implemented actually with military means at the time of peace. The principal aim of terrorists is to bring fear and demoralization to as many people as possible. This aim reflects the psychological basis of terrorism – namely acquiring irrational power, as a rule, bye frustrated persons with an inner conflict between high selfesteem and insignificant actual achievements. Extremism (including political extremism and separatism) is not always associated with terrorism, but in the absence of humanitarian values, extremists sometimes commit acts of terror in order to draw public attention or use them as their “last argument”. A terrorist finds his identity in an act of terror, and he is unable to find it in everyday life. This aspect of terrorism is associated with another danger. I mean creating the halo of heroism and romanticism around terrorists among young people and in certain groups with low ability for self-actualization and lack of humanitarian values. Threat to life is the major destructive psychological factor that influences the population, even if it is not the only one. Threat to life is characteristic that puts acts of terror in line with other emergency situations, including natural and technological disasters. Therefore the experience of “Disaster psychiatry” can be used as model of care in terrorist attacks and their aftermath. Disaster psychiatry is developing last years very intensively in Russia [1,2,5,9,12] alongside with other countries [3,4,10,11,13]. Disaster psychiatry or as it is sometimes known, the psychiatry of catastrophies or extreme situations, is a relatively new area of psychiatric knowledge which development does require close connections with clinical and social psychology. The subject matter of this branch of psychiatry is the mental health consequences of technological catastrophies, floods, earthquakes, terrorist attacks, ethnic clashes, military actions, etc. The practical issues of disaster psychiatry concern, first of all, developing the optimal forms of rendering psychological and psychiatric aid to communities that find themselves in these extreme situations. Russia has the National Service for Disaster Medicine under the Ministry of Public Health, which is also in contact with the Ministry of Emergency (Table 1) (see also Chapter 8, Aleksanin). This service deals with the management of medical consequences and provision of medical care in natural disasters, major accidents, catastrophes, epi-

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V.N. Krasnov / Responses to Terrorist Attacks Table 1. Organizational structure of the national service for disaster medicine

All-Russian Center of Disaster Medicine “Zaschita” (“Protection”) • Clinic with a multiprofile field hospital, including a psychiatric (psychotherapeutic) unit • Institute for Disaster Medicine and Special Professional Training • Center for medical evaluation and rehabilitation (intended mainly for rescue workers) • Department of medico-technical problems of emergency care • 7 regional branches In the Center for Disaster Medicine, there is always psychiatric team on duty. Besides, the Ministry of Emergency has the All-Russia Center for Extreme Medicine in St. Petersburg, and the Department in Moscow with the psychological rescue team.

Table 2. The structure of the network on rendering psychiatric and psychological aid to people in extreme situations Organizational lever

Team

On the alert

Federal

2 teams at Moscow Institute of Psychiatry and at the State Research Center for Social and Forensic Psychiatry being ready

1 person constantly available at the Field General Hospital

Regional

Local

to be deployed to a disaster site 2–3 teams at leading psychiatric institutions of a regional being ready to be deployed to a disaster site Teams on request at leading psychiatric institutions

1 person constantly available at the Regional Centre for Disasters Medicine None

demics, local military conflicts, terrorist attacks and other emergencies. The Center organizes and provides emergency and consultative medical care in emergency situations. It has 7 branches in the different regions of Russia. Local centers are organized alongside the emergency medical care stations. Special psychiatric teams are integrated into general medical institutions of the service for Disaster Medicine (Table 2). In all the recent terrorist incidents in Moscow the specialized Moscow Psychotherapeutic Polyclinic has taken the leading role in service provision, together with the Center of Disaster Medicine and other institutions. Regrettably in recent years we have gained considerable knowledge from studying a wide variety of extreme situations, terrorist attack and catastrophes as well as their consequences. Our observations suggest that the following issues should be specifically considered: 1. The associations of psychological and psychopathological features of responses to extreme situations; 2. The distinction between individual and group responses to extreme situations;

V.N. Krasnov / Responses to Terrorist Attacks

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Table 3. Mental reactions in exreme situations • 0.5–5% – reactive psychotic disorders (the number depends not only on the casual threat, but also on specific environmental circumstances, interpersonal and informational influences, additional exhaustion factors and physical condition); • 70–80% – acute situational reactions, mostly psychologically understandable and physiologically adaptive: anxiety, fear, tension, vegetative arousal; • in 30–35% these reactions meet the criteria of “acute stress reaction” and require psychological care (psychological counseling, short-term psychological intervention), otherwise they develop into affective (depressive, anxiety) disorders or post-traumatic stress disorder; and at delayed stage and under the influence of unfavorable factors there appear cognitive and personality problems. Table 4. Development stages of mental disorders (changes) in people under extreme situations • Changeable combinations of adaptive and maladaptive forms of situational responses. • Synergetic influences between somatic (vegetative), and psychological components of situational responses. • Combination of individual and group forms of responses. • The disorders either diminishing or getting complicated (from asthenic and psychovegetative forms to the affective forms). • If the unfavorable situation is maintained there are tendencies to personality changes such as hostility, social escape, substance abuse and so on; • If there are additional noxious factors (intoxications, brain traumata, severe somatic illnesses) then cognitive changes may lead to the development of psychoorganic syndromes. • Low threshold for coping with subsequent extreme situations as well as in facing with the events or objects symbolizing an extreme situation.

3. The way in which the delivery of care is altered as the psychological reactions change with the passage of time. In addition to the traditional knowledge of psychology and psychopathology of disasters, certain tendencies have been evident during the last decades. These include a decrease in the frequency of psychotic reactions, with a corresponding increase in the number of somatoform, affective spectrum, adjustment disorders and PTSD (Tables 3, 4). We also need to take note of the multifactorial nature of the psychosocial consequences of disasters (Table 5). Another new development is recognition of the informational component of terrorist activities. It is very clear that the speed, growth, sophistication and variety of modern information technologies acts to substantially increase the negative potential of terrorism, not least by gaining access to an almost limitless audience. The mass media, especially television, afford organizers and perpetrators almost unlimited opportunities for strengthening the impact of terrorist acts and for spreading the propaganda measure of the terrorists themselves. The dramatic and perverted aesthetics of modern terrorism are used in a very sophisticated way when planning terrorist actions, anticipating the inevitable global audience for the events. Emphatic examples of this were the events on September 11, 2001 in the USA and the capture of hostages in a Moscow theater, October 23–26, 2002. Yet at the same time, the mass media have huge, though still little used, possibilities to neutralize the immediate fear inducing and propaganda influence of terrorist activities: introducing agreed ethical standards during news coverage; giving well balanced information on the events; deheroization of terrorists while bringing to light instances of constructive and rational behavior of individuals who became victims of terrorist actions.

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V.N. Krasnov / Responses to Terrorist Attacks Table 5. Factors of extreme situation

External • Response due to a direct threat to life • Short-term situational threats • Long-term unfavourable situations • Additional noxious influences (intoxications, traumata, etc.) Internal • Particular personality traits (anxiety, histrionic components, emotional instability) • Passive or active personal position in response to the extreme situation • Poor somatic (physical) conditions • Residual cerebral (organic) dysfunctions Informational environment • Availability or absence of information that explains the emergency situation and predicts its development • Availability or absence of communication and chance for interaction with the relatives, acquaintances, as well as officials involved in the situation • The media showing the images of the catastrophe and naturalistic pictures (negative information environment), or providing balanced information including, besides threat and damage, also pictures of rational and constructive behavior, positive activities and mutual support

Such objectives are all attainable by the mass media and do not contradict the general standards and ethics of journalism in open societies. The undoubted impact of the media and information technology also mandates the careful preparation and training of official “spokepersons”, who will be called upon to represent the authorities and rescue agencies and sanctioned to inform the population about the course of events (see Appendix to this volume). The competence with which this is done can lead to either public reassurance or public anxiety. The main factor of fighting terrorism is to uncover and to support natural psychological resilience, either at the individual or group level. Actual instances of resilience in the face of terrorist threat, examples of self-control and mutual help, of resisting panic are not only worthy of being covered by mass media, but they should also become a subject of scientific analysis with a view to developing evidence based recommendations to prevent social and psychological consequences of terrorism. Almost all persons exposed to the extreme life-threatening situations are potentially participants in group disorganized behavior, yet so called mass panic is in practice a rare reaction of people in extreme situations (see Glass, this volume). More predictable negative reactions are either hostility or apathy-like states, sometimes associated with varying degrees of antipathy towards the rescuers. For some victims, the threat to their ethnic identity (threat directed against specific ethnic group) m a be more important that threat to their life and losing their family members. Some regressive forms of reactions with transient cognitive disturbances and difficulties in the performance of simple tasks are very frequent, especially in a prolonged life-threatening situation. However most persons involved in extreme situations are still able to show rational and constructive behavioural responses regarding their own safety, provided they receive equally rational and constructive information about the real threat and the ways to avoid or minimize it. Long-term consequences of terrorist attacks include not only mental health problems in the victims but also limitations in their social functioning, which, in turn, impact on the social environment of the victim and influence social processes at large.


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Table 6. Structure of psychiatric care in emergency • First aid + psychological care • Immediate medical care • Secondary medical care with elements of specialized care • Specialized care (psychiatric, psychotherapeutic) • Rehabilitation of victims (medico-psychological and social, organization of social support) • Psychoeducation (including training for managers, persons in charge and officials)

On the basis of our long history of organizing care in emergency situations we can summarise some of the main organizational issues as we perceive them (Table 6).

2. Preventing and Overcoming the Consequences of Emergency Situations 2.1. Terroristic act in Moscow theatre centre, October 23–26, 2002: Main events and the organization of psychological and psychiatric aid to the victims At 9 P.M. October 23, a terrorist group captured a theater in Moscow during the performance. The performing actors were taken hostage, with many children and adolescents among them. The terrorist demanded an end to the war in Chechnya and threatened to begin killing hostaged unless Russian troops were immediately withdrawn from Chechnya. If an assault on the building was made they threatened to blow themselves up with the hostages. The captives were mainly held in the music hall under the threat of death with a few demonstrative gunshots fired. Several people attempting to escape were shot. For two and a half days the unsteady communication between the hostages and the outer world was maintained first via mobile phones and later with the aid of some members of parliament, popular artists and doctors who were admitted to the negotiations. Through their mediation, several groups of young children (under the age of 12) and some seriously sick hostages were released. Early in the morning, October 26, the hostages were released, as result of the assault made by Russian Special Forces. Before the assault a neurotropic “soporific” gas was pumped into the building through ventiducts. During the assault, 36 terrorists were killed and several hostages died of gunshot wounds. Along with this, about 70 hostages died of cardiopulmonary decompensation. Some more captives died in hospitals in the following days. The overall dead toll among the hostages was 129. After relatively short-term treatment, 499 people were discharged from hospitals. The Medical headquarters of Moscow government gave medical and medicalpsychological help. The headquarters started working as early as 10 P.M., November 23, very soon after the main Government headquarters dealing with the security situation was established. A medical rehabilitation center for aid to the victims was organized in the War veterans’ hospital located in the vicinity of the theater. During the first day, aid was primarily given to the relatives of the hostages and resident of the neighborhood. It is important to note that the relatives and friends of the hostages started to gather near the theater from the first hours of the capture. Some of them needed medical and psychological assistance. A number of individuals created a psychologically tense atmosphere with their behavior. In order to minimize their activities either psychological aid or other means were required.

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Dr. Yu. Boiko, head psychotherapist of Moscow, was on the staff of the Medical headquarters for the aid to victims from the first hours after the terrorist attack. More than 40 specialists (mostly psychiatrists with a psychotherapeutic training and clinic psychologist) worked under his supervision. They counseled those who sought help at the above-mentioned rehabilitation center, as well as those among the crowd of the relatives who gathered near the captured building. Their objective was to discover individuals who needed medical-psychological help, and to reveal “negative leaders” who disorganized the crowd with their overly expansive and provocative actions. After the organization of the Medical headquarters, the staff from other institutions joined that team. One of them was a group supervised by Z. Kekelidze that consisted mainly of psychiatrists from the Center of Social and Forensic Psychiatry Psychotherapists and psychologists from several state institutions joined as well. Two groups of psychologists (from the Ministry of Emergency Situations and the Ministry of Internal Affairs) worked relatively independently but in coordination with the main headquarters. Their work mostly involved psychological support for the members of trained rescue units and special forces. The activities of psychiatrists, psychotherapist, and psychologists were not limited to the period of the capture of hostages and their release as a result of the assault on October 26. Their work continued and is still in progress in a number of hospitals where the hostages were sent. Psychotherapeutic counseling rooms were set up. Where experts aided everyone who sought help, as well as advised medical doctors on the state of health of individual patients. Besides, counseling rooms were organized at several institutes and outpatient hospitals, where psychological, psychotherapeutic and comprehensive psychiatric aid was offered. Several counseling centers still continue to assist the victims who seek help. All such treatment is carried out free of charge at these state institutions. Some of the victims needed hospital examination and treatment. They were sent mainly to the Moscow specialized “Clinic of neurosis” or to special unit for the victims of emergency situations at the Center of Social and Forensic Psychiatry, as well as to other clinics of Moscow. Some individuals are treated at the Speech Pathology and Neurorehabilitation Clinic of the Moscow Research Institute of Psychiatry. They manifest more complex organic disturbance of the central nervous affect than was expected, due to fact that captives were weakened by hypodynamia, food and water shortage, and were in state of long-term psychological stress. The mental state of many victims was manifested in complex of anxiety-depressive, asthenic, and cognitive disorders, which testifies to the multifactorial nature of these victims – the former hostages and their relatives. 2.2. Current experience with terrorist attacks Many emergencies of recent years require attention in order to specify the notion of their psychological psychiatric consequences, as well as the possibilities of assistance to the victims. Accumulated experience shows the necessity for further careful study of the challenges and problems of psychological psychiatric assistance during emergencies, though these problems are not new: there already exist some definite organizational approaches and working principles for their solution. Nevertheless, each new emergency raises further questions that require clarification. We can single out the following organizational problems, related to assistance in emergencies:


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1. The need for active cooperation between various specialists, organizations, services and departments (sectors) during the emergency; this kind of cooperation must be provided by central administration responsible for elimination of emergency and its consequences. 2. The readiness of multidisciplinary professional teams and specialists (psychiatrists, interns and psychologists) to work in the conditions of emergency. This readiness should be provided in each region, city and district on the basis of particular institutions’ specialists’ functional duties, which usually work with regular “routine” schedule of clinical and counseling psychological practice. 3. The clarification of the professional status of people, who work during emergency (presence of certificate confirming their proficiency to work during emergencies), including their affiliation to state institution with corresponding authority. 4. Distribution of functions between various specialists (clinical diagnostics and therapeutic help, psychotherapeutic help, psychological counseling, psychological help, psychologist’s participation in psychotherapy, social support, etc.). 5. Development, substantiation and approval of ethical deontological and legal norms of medical psychological and psychosocial “interferences” as assistance to the victims. Principles of partnership should extend to all work during emergencies, however due to the situation and the possible poor condition of some victims as seen in the Moscow Theatre siege, paternalism and assertive measures and variants of help are unavoidable and should be foreseen. 6. Provision of adequate informational support for all rescue measures. Those aspects of work can be illustrated in Table 7. Each emergency has its own particularities and circumstances, so, correspondingly, the reactions of victims are different. These differences help to see not only the role of the stressor itself (threat of death, realization of loss) but also the role of preceding factors, various biological and psychological premises in the mechanisms of response. Of course, there are common patterns of psychic (and psychosomatic) response and development of psychological and psychiatric consequences of emergencies. As far as the mechanisms are concerned – there is no reason to question the traditional and much confirmed division of response into acute and prolonged. The psychopathological manifestations of the former appear in various guises ranging from stupor to “storms” of movement, though in modern conditions those reactions are rare. In both cases there are elements of confusion, intellectual failure, helplessness, though their short term nature and tendency to recover do not always provide grounds for psychiatric interference. At more distant stages together with disorders of the affective spectrum (including anxious and somatoform disorders) there are regressive forms of psychic response. They mostly appear in exaggerated intellectual failure and excessive exhaustion after psychic effort. Table 7. Operational tasks to provide medical psychological help in emergencies 1. Cooperation of services and specialists. 2. Functional readiness. 3. Status of specialists. 4. Distribution of functions and tasks. 5. Ethical and legal regulation. 6. Informational support.

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What is important to note as a general pattern requiring attention while evaluating the condition and assistance is the somatic autonomic expressions of acute response to stress. Somatic autonomic shifts are non specific as well, but they are mostly related to cardio-vascular system and reflect sympaticotonic shifts of autonomic regulation up to hypertension crisis, episodes of stenocardia, etc. The kind of contrreaction or delayed reactions like hypotonia or vascular regulation disbalance with hypotonic crisis and the threat of cordial or cerebral ischemia are no less dangerous. Somatic vulnerability which appears at the acute stage requires systematic control, because at further stages it often leads to long term disorders in cardio-vascular and other physiological systems. However such outcome is not inevitable, and timely adequate help at early stages prevents the development of the pathological changes previously mentioned. Rescuers, including all participants in rescue operations and the provision of help, are also affected by many different special factors. Psychological and physical involvement in rescue operations can itself mobilize psychological resources, and assist in coping with the inevitable impact of the work and the sheer weight of the work load. But, no doubt, rest is required after that, and sometimes even medical and psychological help, without which somatic and psychic health of the rescuers is in danger. It was confirmed by the experience of assistance to the victims during the explosion in the metro on February 6, 2004 and during roof collapse in the aqua park on February 14, 2004. Once again, acute responses to stress, despite their diversity, are well described and in theory at least should not present any difficult in diagnosis. However, one problem is that this diagnostic function is the responsibility of the medical teams, because it is important to keep in mind combined lesions in the complex mixture of understandable psychological responses and psychopathological symptoms (barotrauma during the explosion in the metro, commotions, contusion in both cases, cold trauma in the case of roof collapse, etc.). At the same time it is important to take into account that offering psychological help must always on a voluntary basis. People are not always ready to accept help, so it should be offered in different forms. Until now some of the types of help that have been given to victims are ill defined, and may not even have names. For example, a group of colleagues from Moscow Research Institute of Psychiatry offered psychological support to the relatives of the deceased during the identification of body remains – this work is vital, but does not fit easily into our existing classifications and structures. Such work required not only psychological sympathy and emotional support, but also primary medical help related to cardiovascular and other responses and the worsening of somatic illnesses. At the same time it was necessary to keep some distance yet be ready to offer help without imposing it in this tragic procedure. But most of all what is needed is more study relating to the cooperation or otherwise between the different services. This may be the most crucial area of further work related to emergencies. Joint efforts of medical and psychological community with the involvement of lawyers are necessary to deal with the dilemma of legal norm of medical aid appealability and the ethical impulse to provide help when it really is necessary. On another level the relationship between professional prerogatives of a psychiatrist (as a diagnostician, pharmacotherapist and psychotherapist), an internist (as an “urgent” diagnostician and general therapist) and a clinical psychologist should also be clarified.


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In foreseeing emergencies of different kinds (including the regrettably low probability that terrorism will disappear on the global stage) it seems important not only to organize help to the victims but also to raise people’s vitality, their resistance to terrorism and to stressors and survival in tragic circumstances. Recent emergencies give impressive examples of people’s vitality and constructive behavior in circumstances which might otherwise have provoked panic and helplessness. This experience is worth studying and evaluating from both psychological and social point of view in order to mobilize such evidence for psychoeducational activities. Reserves of vitality – at the individual, group and population level, with all associated their gender, age and culture aspects – require studying no less then pathological phenomena.

References [1] Aleksandrovsky Yu, et al. Psychogenias in emergency situations. Moscow: Meditsina, 1991, 97 p. (in Russian). [2] Boiko Yu. Antistress medical care in emergency situations and after them. Social and Clinical Psychiatry 2003; 13 (2): 60–67 (in Russian). [3] Cohen R. Mental Health services for victims of disasters. World Psychiatry 2002; 1 (3): 149–152. [4] Individal and community responses to trauma and disaster: the structure of human chaos, Ursano RI, Caughey BG, Fullerton CS (eds). Cambridge, New York. Melbourne: Cambridge University Press, 1994, 422 p. [5] Kekelidze Z, Morozova I. Psychiatry of emergency situations. In: Dmitrieva B. (ed.), Handbook of Social Psychiatry. Moscow: Meditsina, 2001, pp. 415–446 (in Russian). [6] Kokhanov V, Krjukov V, Kibrik N. Specific features of mental disorders in the victims of the terroristic act in Budennovsk. Disaster Medicine 1995; 11–12 (3–4): 64–67 (in Russian). [7] Kokhanov V, Goncharov S. Vital problems of organization of psychiatric aid in emergencies (the system of the All-Russian Service of Disaster Medicine). Disaster Medicine 1997; 17 (1): 7–15 (in Russian). [8] Kokhanov V, Krasnov V. Psychiatric aid for victims of emergency situations. Concise guide for medical practitioners. Moscow: Zashchita, 1997, 46 p. (in Russian). [9] Krasnov V. Methodological and organizational aspects of disaster psychiatry. Disaster Medicine 1997; 17 (1): 21–24 (in Russian). [10] Lopez-Ibor JJ. The Psycho(patho)logy of Disasters. In: XII World Congress of Psychiatry. Plenary Lectures, Yokohama, 2002, pp. 3–11. [11] Responding to disaster. A guide for mental health professionals. Austin LS (ed.). Washington: American Psychiatric Press, 1992, 256 p. [12] Smirnov V, et al. Psychiatry of disasters. Military Medicine Journ 1990; (4): 49–56 (in Russian). [13] Terrorism and disaster. Individual and community mental health intervention. Ursano RI, Fullerton CS, Norwod AE (eds). New York: Cambridge University Press, 2003, 348 p.



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Approaches to the Study of Suicide Terrorism: A Perspective from Russia V.N. Krasnov Moscow Research Institute of Psychiatry The attempts to explain suicide terrorism from the perspective of view of individual psychology or psychopathology show little promise to date. In contrast, there are good reasons to believe that cultural psychological research into the long standing and stable systems of clan up-bringing by North Caucasian people may be more informative. However, during the Soviet period the psychological study of these problems was ideologically forbidden, whilst also not forbidden by contemporary Russian psychology it was not possible because of the particular security circumstances in North Caucasus. Of course, it is possible to make some inferences regarding the personality of the terrorist from individual biographies, but the contribution of individual biography is likely to be very small in comparison to socio-psychological, political, ethnocultural factors. As we have no opportunity to study terrorists, let alone any possibility of studying a representative group using sound methodology, instead we must rely on what are admittedly generalizations from available data sources, no matter how imperfect. The data we have comes from our work of many years, made in collaboration with psychiatric and psychological specialists from the Chechen Republic and international organizations, such as World Health Organization (WHO) and Medecins du Monde, who took care of Chechen people, especially in refugees’ camps on the territory of Ingush Republic. The current press sources, and some recent books [2,6,7] have been also used for the analysis of behavioral appearance and possible motives of terrorists actions. Our point of view can be only tentative. But we should take into account the obvious difficulties on the way of the systematic study of terrorism. For example, in 2002 one thousand citizens from two cities (Grozny and Gudermes) and two country regions of Chechen Republic were studied with the methodological assistance of the Moscow Research Institute of Psychiatry and the technical assistance of a group of Chechen specialists under the supervision of Dr. K.A. Idrissov [4]. The goal of the study was to reveal the extent to which psychiatric disorders were spread among different groups of people and to define the needs for psychiatric assistance and counseling. The main instruments used were General Health Questionnaire (GHQ-28) (D. Goldberg) and the München Scale of Posttraumatic Stress Disorder. The Diagnostic Research Criteria for ICD-10 and the Hopkins Symptom Check List (SCL-90) were used as additional instruments. The studies reported a high prevalence of mental disturbances (86.3%) according to the GHQ-28 criteria, mostly stress related disorders. For example, probable posttraumatic stress disorder (PTSD) was found in 31.2% of all examined people. PTSD was less common in the youngest age group (10.6% at the age of 18–25 years), but increased with age (51% at the age of 46 and more).

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V.N. Krasnov / Approaches to the Study of Suicide Terrorism

Kh. Akhmedova [1] has carried out psychological research with the methodological assistance of the Moscow Research Institute of Psychiatry in the refugee camps in the Northern Caucasus. She has reported that the setting of long term trauma is fertile ground for the growth of responses such as fanaticism with ideas of revenge, particularly amongst young people. Fanaticism is characterized by an unshakable and unchangeable certainty about the necessity of revenge and the associated narrowing of a person’s value systems.. The events of the past are viewed in a narrow, one-sided way. Motives of revenge become stronger and stronger, and more reasons for revenge are found [1,3]. Not only personal experience, but also the experience of the family or even the whole people (ethnic group) plays a major role. It is important to notice that in conditions of both long-term social instability and continuing military operations with all their consequences any conflicts with representatives of administration and/or government are always associated with national identity. It is necessary to keep in mind that these tragic events can occur during the period of a teenager’s self-identification, and this can also influence the development of terrorist’s personality. Due to immaturity, youthful suggestibility and lack of personal life experience these young people easily fall under the influence of older “mentors”. Religious fanatics, such as vakkhabites, are especially dangerous because they emphasize and use the theme of outward aggression, traumatization of people and the threat of destruction of the Chechen ethnos and identity. As an alternative to this they promote the idea of national and supranational (Islamic) resistance as a heroic life path. Fanaticism can be regarded as a shift of personality or a change of personality, which strongly disposes towards terrorism. The development of fanaticism is accompanied by the growth of aggressivity. According to Kh. Akhmedova [1], but perhaps not surprisingly, such people are inclined0 to refuse any psychological help. Suicide terrorism involving women (for example, Chechen women who took part in terrorist attacks in Russia) requires special attention. For the development of female suicide terrorist the concurrence of 3 main factors is required: 1. Frustration experience with depressive features – loss of meaning, aversion to life; suicidal thoughts; 2. Religious and the strict ethnocultural prohibition of suicide in traditional family way of life of North Caucasian people; 3. Consistent “mentor’s” training or direct coercion to sacrificial terrorism proceeding from an older relative, usually an older brother but occasionally an older women.

Commentary on Factor 1 Ideologists of Chechen separatism try hard to create and promote the image of a desperate widow, avenging her husband’s death. But in practice most of the young women suicide terrorists are not widows. However, it is true that often some of their both close and distant relatives, have died or disappeared. This is important in the development of a psychological readiness to terrorist actions, but alone is probably not sufficient. What is also needed is for these immediate or recent losses to be linked with the long term ethnocultural perception that these are insults that require a response, invariably a violent response – in other words revenge. Thus any discussion of aggression towards the


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Chechen people is perceived within the language of insult and revenge. The actual circumstances of any tragic event are usually viewed one-sidedly. The legend or mythology of widowhood is particularly wide-spread because it naturally invokes sympathy and compassion. In some cases personal crisis directly related to the death of relatives or threat to the individual’s life can be linked to the development of depression. But in the atmosphere described above this crisis gradually acquires “causal” connection with not only the family’s experience of such tragic events, but also with the wider military and political situation. Finally we must not forget the archaic but still persisting concepts of “blood revenge” as a natural response to the murder of one of family members.

Commentary on Factor 2 The conflict between the depressive negation of life or desire to die and the ethnocultural ban on suicide is solved in the form of sacrificial revenge. The traditional culture of North Caucasian people condemns suicide not only as an act of an individual but also because of the shame it brings to her family and the whole clan. It is stigmatized alongside the stigma of mental disorders. Suicide is usually covered up as an accident, and mental disorders are often kept in secret even from the wide circle of relatives, let alone neighbors and acquaintances.

Commentary on Factor 3 Suicide terrorists from Chechen Republic, especially women – are mostly natives from the countryside. As such they tend to have a lower level of education and narrower world outlook. Many of them have never left Chechnya. There is some preliminary evidence to infer the presence of dependence and suggestibility, which is also associated with depression. These traits are exploited by more experienced and educated “mentors” – who are usually not only supporters of Chechen separatism but also adherents to Islamic extremism, the so called vakkhabism. The latter usually do not take part in terrorist attacks that involve a threat to the terrorists’ life. Young women experiencing a psychological crisis or a protracted frustration with depressive features are isolated by older “mentors” from outward contacts – for example by moving to remote villages, to an environment of multiple religious rituals, endless reading of suras and so on. This occurs alongside the persistent repetition of the theme of revenge to the enemy for all the perceived disasters and insults to national dignity. The women become a kind of hostage and become more and more psychologically submissive to the mentor. After that comes practical training in the mechanics of suicide terrorism – learning to use weapons, explosives, how to navigate through the city that is the chosen target of the terrorist operation. The last stage of training can take place close to the intended place of operation. From our modern perspective it is hard for us to imagine that it is possible to recruit a significant number of young people, including women, ready to die in an act of sacrificial revenge. The process of training of a suicide terrorist is well beyond our own experiences and imagination, and cannot be understood outside the framework of the traditional, archaic system of family and clan upbringing. This is the system of values which maintains a strict hierarchy of submission and obedience: “the older – the younger”, “man –

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woman” (at least in the outward rituals of behavior), “clan – family – individual”. The value of individual’s life is very small in comparison to the significance of the clan as an integrated formation. In such conditions a young woman not only has to submit to older women in her family or to a brother of her own age, but all her upbringing in a traditional “village” family is a preparation for sacrificial revenge for the honor of her family and clan. These traditional upbringings also cultivate heroic ideals related to the history of family, clan and ethnic group. These ideals reflect the readiness to sacrifice oneself for the good of the family and clan. We can suppose that they oppose the hedonistic culture of modern civilization. It is also likely that these cultural values are weakened by urbanization – hence the predominance of rural communities and individuals in known cases of suicide terrorism. The use of the symbolic “black widows” dresses by the female terrorists who took part in the Moscow theatre siege in 2002 can be regarded as the reduction of ideal heroism to its theatrical forms. This subterfuge with its ostensible heroics could be seen as appealing for the suggestible young women not acquainted with outward effects of urban life. On the other hand this subterfuge was intended to influence the audience (in the theatre hall) and especially Russian and international TV audience. Religiousness, including Islam, does not have deep roots in the post-Soviet culture of the North Caucasian people, at least among the majority. Religiosity became the ideological form of opposing mind and opposing behavior. The clan ideology of serving one’s family is more traditional, and it can be a foundation for the purposeful development of readiness for sacrificial quasiheroic behavior – combatant, “partisan” terrorism among teenagers and young people, suicide terrorism among young women. “Jihad” permits suicide as a sacrifice for the sake of the Islamic idea and of one’s people. Mentors and ideologists of terrorism, who are often psychologically sophisticated, find young women who are experiencing life crisis, depression and/or, suicidal feelings. At the same time mentors, usually older brothers, use their clan position of superiority to its full extent, up to and including blackmail and intimidation. Male teenagers, on the other hand, are offered a more “masculine” kind of sacrificial heroic – namely participation in military operations as members of armed units.

The Importance of the Aesthetics of Terrorism Terrorism has aesthetics of its own which seem to form not spontaneously but systematically, taking into account modern forms of informational influence upon people. Visual means of influence, first and foremost the TV, are used above all. Written and oral statements in the conditions of relative freedom of speech decrease in value and do not lend people’s credibility. That is why the written and spoken word is more and more often replaced by bright spectacular images on TV. It combines the aesthetics of destruction with the sight of large-scale explosions, fires, building crashes and the aesthetics of theatric tragedy. One example of this is the attack on World Trade Center in New York on September 11, 2001, which was clearly intended to be broadcast all over the world, as indeed it was. It caused the unwilling, but revealing, amoral utterance by the famous composer, Karl Heinz Stockhausen, who said that “I am delighted with the beauty of this attack.” Another example is the subtly organized “show during the show” – the taking of


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hostages in the theater in Moscow, October 23–26, 2002. Firstly this was a re-enactment of familiar scenarios or symbols familiar to us from disaster films. Secondly, it contained allusions to theatrical sacrificial rituals, influenced by historical costume dramas. The main characters were elegantly dressed young women in the costumes of mourner, nun or secret cult follower. The “producers” of the action or drama not only have the possibility of showing themselves to the world but even have the possibility of constantly correcting or refining the images of themselves that they would like to project on the world screen. The power of such suggestive methods of terrorists has been described by many witnesses, even by persons with very analytical and critical attitude [7]. Comparing the terrorist acts, conducted by the same center, 7 years after the capture of big hospital in North Caucasus in 1995 we can see considerable changes in the “asthetical” arrangement of the brutal performance [5,7]. In connection with the hostages’ taken during the musical “Nord-Ost” in Moscow we would like to consider the informational component of the terrorist attack. • The event itself had clearly been planned as a broadcast televisual event, with transmission via the broadcast networks was a certainty. • As a broadcast event the terrorist attack showed a certain cynicism of the Russian TV channels, because alongside with reports, surveys and discussions of the event they did not drop their regular advertisement or commercial breaks. This combination of real time tragedy and commercial advertisement however may have reduced the impact of the terrorists actions or intentions, who may have expected to see continuing extreme dramatization of the event, with the consequent intimidation of the population and pressure on politicians. Almost certainly inadvertently, the decision to continue commercial breaks, whilst made for cynical reasons, may have added an air of normality to the televising of the siege.

Conclusion Suicide terrorists are not typologically uniform. We can single out two types of Chechen suicide terrorists: 1. Young women: a) Mostly dependent introverts, with occasional elements of psychological immaturity, who have a lack of social experience. They are mostly villagers with ordinary intelligence, relatively low levels of education, who may be experiencing depressive spectrum disorders. b) They have been exposed to traumatic experiences, although this may not have been very personal in all instances, instead involving their family or immediate social networks. They idea of revenge, often itself a replacement for direct suicidal action, rarely is self generated but comes from the influence of older people. c) They receive intensive training in special conditions, for example in the family of distant relatives, or (rarely) close relatives, in small camps with groups of other young women. Here they are taken care of for several months by older women or men and undergo an intensive religious and simplified military training. It is noticeable that well-educated, active, often extravert women

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with significant social experience, who also had traumatic experiences and also become fanatical in the pursuit of revenge, yet do not strive to sacrifice themselves, instead actively recruit others from the population of more vulnerable women as described above. These more extravert women can and do participate in the psychological and technical preparation of other more vulnerable women for suicide terrorism and martyrdom. 2. Men. In general males rarely become suicide terrorists, who are more typically young women and teenagers. Men become suicide terrorists in extraordinary cases, and each case requires its own explanation. There is some indirect data to suggest that a psychological trauma is an obligatory component. The trauma should be related not only to the death of relatives and/or personal threat to life but also to humiliation, personal but most particularly to a perception of national dignity. In such cases we need to address the traditional codes of upbringing of highlander peoples: in the codes of honour of the clans the male is attributed some chivalrous qualities. Under such codes the male cannot be wrong and cannot be humiliated. It follows that the feeling of guilt is not formed culturally, the place of selfcriticism is given to the ideas of man’s valor, protection of one’s honour, which can not be separated from the protection of family’s and clan’s honor. This is one of the key moments of ethnic self-identification. Humiliation from outsiders, especially wounding of ethnical affiliation feelings, is intolerable. And from this comes ideas of revenge. The psychological mechanisms of revenge, and its links with fanaticism and aggression were studied by K. Idrisov [3] and Kh. Akhmedova [1]. A kind of ethnic hyper-identification was revealed recently in the study of forced migrants [8]. If revenge is impossible to achieve in open combat (which would be the preferred option for a male brought up in traditional highlanders’ behavior codex) another option in such “desperate” circumstances can be suicide terrorism. Then children, women, hospital patients, chance passengers and people of one’s own ethnicity can all become victims: fanatism destroys all ethical barriers in fulfillment of the goal of revenge. Suicide terrorism acquires irrational forms – it offers a macabre escape from intolerable feelings of offended dignity, and affirms the person’s sense of right, and of course the “other’s” wrong. This fanatical blindness is the principle difference between modern suicide-terrorist and Japanese kamikadze of World War Two, who directed their planes only to military objects.

References [1] Akhmedova Kh. Fanaticism and idea of revenge in persons with post-traumatic stress disorder (PTSD). Social and Clinical Psychiatry 2003; 13 (2): 15–23 (in Russian). [2] Chlebnikov P. The talk with barber. Moscow: Detective-Press, 2004, 282 p. (in Russian). [3] Idrisov K. PTSD dynamics in civilians that experienced life-threating situations in a local military conflict. Social and Clinical Psychiatry 2002; 12 (3): 34–37 (in Russian). [4] Idrisov K, Krasnov V. Mental health of the Chechen Republic population in the long-term emergency situation. Social and Clinical Psychiatry 2004; 14 (2): 5–12 (in Russian). [5] Kokhanov V, Krjukov V, Kibrik N. Specific features of mental disorders in the victims of the terrorostic act in Budennovsk. Disaster Medicine 1995; 11–12 (3–4): 64–67 (in Russian). [6] Olshansky D. The psychology of terrorism. S-Petersburg: Piter, 2002, 286 p. (in Russian).


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[7] Popova T. Nord-Ost in the eyes of hostage. Moscow: Vagrius, 2002, 238 p. (in Russian). [8] Soldatova G, Shaygerova L. Psychological adaptation of forced migrants. Psychol. Journal 2002; 23 (4): 66–81 (in Russian).



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Cross-Confessional Investigation of Religious Visions of the World in the Context of the Fight against Terrorism V.F. Petrenko a,1 and A.I. Yartseva a Russian Academy of Sciences, Faculty of Psychology, Moscow State University, Moscow, Russia

Religion and Terror This article discusses the project of a cross-confessional investigation of religious mentalities and values in the context of extremism and terrorism. September 11, 2001, became a turning point in the history of human civilization and revealed a crisis in value systems as well as in humanitarian, cultural and religious identity. A well-known, but officially unrecognized during the Soviet period, Russian historian B.F. Porshnev once expressed a paradoxical idea that cannibalism had not existed in the history of mankind (though this contradicts anthropological investigations) because those who had eaten other human beings never considered their victims as humans – i.e. as self. This idea has resonances with the phenomena of genocide and terrorism because extreme nationalists and proponents of ‘class despotism’ and religious fanatics responsible for acts of extremism do not consider their victims as equal to themselves and their culture. The issue of genocide and terrorism can be analyzed from the point of view of terrorist’s identity and his national, clan or religious grounds and lack of internalized common human values. Terrorism and genocide, which is close to it, had existed long before the 21st century. However, the terrorism of the 21st century has a number of characteristics that establish a new phenomenon – namely, a mutated religious consciousness and religious values. The majority of world religions have developed in the course of overcoming tribal and clan identity. The idea of “One God” carries the implication, overtly or not, of uniting mankind on basis of religious belief. The Christian principle ‘there’s no Greek and no Jew but a Christian’ is known in other formulations in both Buddhism and Islam. The rise of world religions was associated with rise of huge empires and states where various ethnic groups coexisted, not only on the basis of force alone, but also on basis of common religious belief and value systems imposed by religious ideology. Governing polyethnic territories, developments in economy and trade and consistent humanization of human spirit resulted in the development of common human values. Mankind started perceiving itself as a single species sharing a common world history. The concept of ‘mankind’ came to unite people irrespective of their race, religion and nationality. And, finally, modern science and advances in evolution biology and genetics indicate population unity and 1 E-mail: [email protected]

116 V.F. Petrenko and A.I. Yartseva / Cross-Confessional Investigation of Religious Visions of the World

common genetic stock, when diseases that emerge at one part of the world can be easily transported by modern transport to other parts of the world. Before September 11, industrially developed countries emphasized the importance of security, but with the emphasis on national defence against external aggressors, principally other state actors. And for the superpowers the main symbol of overwhelming and unanswerable state power was possession of the nuclear bomb. Possessing nuclear weapons seemed to be a reliable guarantee of the military safety of the country within the framework of state alliances and the doctrine of MAD (“Mutally Assured Destruction”). However, advances in modern technology, and our dependence on the same technologies in hierarchical functional systems, mean that a minor mishap can disrupt a whole system (for instance, electricity supply or Internet communication). Likewise, the high density and mobility of modern populations create conditions for small groups or even single individuals to ‘privatize’ the possibility of a large-scale destruction, for example by biological terrorism. The ‘sick mind’ of the fanatic becomes a real source of danger. For these reasons we propose that the role of the humanities in understanding terrorism has never been more important. Philosophy, psychology, sociology, ethnology and ethnography, religious disciplines, cultural anthropology, pedagogics, ethics and aesthetics not only study consciousness and cultures but also formulate and promote new, also futurological, ideas concerning being in this complicated world. The tragic events of autumn 2001 showed that even the United States, the now dominant world power, is vulnerable to international terrorism. This attack caused an emotional shock all over the world, not just within the confines of the United States. Besides the large number of victims and material damage involved, it was also a challenge to democratic values and the open society, and also to values of religious consciousness. These events reflected the civilization break predicted by Samuel Huntington and changed the geopolitical map of the world. The shock was also partially associated with the fact that in the new self written history of the civilized world it was believed that the variability of value/morals systems could be, and indeed had been, restricted by the framework of so-called common human values presented explicitly in the Universal Declaration of Human Rights. Different civilizations had been interacting in a globalised world on basis of certain moral standards and common human values. This basis was destroyed by the acts of terrorism on September 11, which were also an example of a pathogenic mutation of the now non shared value systems. Terrorism as a social and cultural phenomenon has a long history. Some authors trace its episodes back to the Bible while the majority tends to date it to the 19th century. However, the acts of terrorism on September 11 have certain characteristics that point to a new phenomenon – a pathogenic mutation of religious ideology and culture. In our opinion, they can be described as follows: 1. Those acts were not directed at individuals (usually a political leader) but at innocent and peaceful populations. In Russian history, the assassination of czar Alexander II by Russian terrorists or the assassination of Indian Prime Minister Gandhi by a terrorist from the “Tigers of Liberation of Tamile Ilama” were acts against specific persons and their policies. 2. Those acts were anonymous. No political organization claimed responsibility for the attacks. Russian terrorists of the past did not disappear from the crime scene and did their best to turn the resulting trial into a political performance.

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3. Those acts strongly resembled religious sacrifice because they inevitably included the death of the terrorist. They were not associated with revenge motives or vendetta. Terrorists had enjoyed the hospitality of the country they attacked and even studied there. Terrorist acts rather resemble stories from the Old Testament, such as ‘Abraham sacrificing his son’. In this case the ‘son’ was not represented by numerous innocent victims but by terrorists themselves. Islam, like other religions, rejects suicide, but on the other hand ‘changing’ one’s own life into many others’ can be interpreted as ‘death in combat’ – in other words martyrdom. Thus the shahid is not carrying out an act of suicide, which would be seen as selfish, but acting altruistically for the community – an act of martyrdom. 4. For the first time, an aircraft was used as a direct means of terrorism – the aircraft, instead of delivering the “bomb”, became itself the bomb. It was the end, not the means. Such conscious use of usually peaceful technological achievements for killing other humans indicates the technological “know how” of modern terrorists, and confirms Freedman and Durodie’s view (Chapter 4) of the terrorist as a modern risk entrepreneur. Any glance at history shows that the use of air power for bringing destruction to civilians is nothing new – the change is using civil aircraft for that purpose, and also for using the aircraft as a “suicide” weapon. Analysis of the differences between modern suicide terrorism and the Japanese kamikaze movement might prove instructive here. 5. Those acts were not a form of protest against specific political or military developments. We can compare it with a certain form of institutional advertising or image promotion, which is not aimed at promotion of a specific product but at promotion of a certain lifestyle. In this sense, we can speak about ‘institutional terrorism’ which is directed against a particular value system, such as the so-called American way of life. The twin towers of the World Trade Center are one key symbol of the latter, and indeed a wider Euro-American civilization. In our analysis, we presume that terrorist attacks of September 11 ideologically constitute a pathogenic mutation of Islam. Islam is a world religion and is based on certain common human values. Mutation can occur in any (quasi)religious consciousness. Take, for instance, Aum Shinrikyo. Members of this sect committed a number of terrorist attacks in the Tokyo Metro though its ideology was based on the largely pacifist religion of Buddhism. In order to defend society against religious fanatics and ideological extremists from the standpoint of a free and open democratic society, we need to reconstruct their vision of the world and, specifically, their value systems. The importance of the programme Russian psychological science has been actively working in the field of experimental psychosemantics (Petrenko, 1982, 1988, 1997) which can be traced back to Kelly’s personal constructs theory and Osgood’s semantic space investigations. We use the semantic space technique for the analysis of political and religious mentalities. We describe the dynamics of changes in public consciousness by means of analysis of semantic space transformations. We develop the typologies of respondents, political parties and ethnic cultures on basis of similarities in their semantic space. And, finally, by applying determinant analysis (Chesnokov, 1982), we distinguish the respondents’ characteristics (or


determinants) that determine their belonging to a specific mentality or specific vision of the world. In our previous publications on the ethnic and political mentality of the inhabitants of Russia (Petrenko & Mitina, 1997; Petrenko & Mitina 1985, 1997, 2001), we described our methods and techniques used for analysis of public consciousness and generalization of dynamics. This research did not concern directly the religious consciousness of the inhabitants of Russia or their attitude to religion. However, it did provide interesting data concerning religious aspects of life. Thus, when we studied the attitude of the population towards reforms in the economy and politics, a relatively weak factor of religious consciousness showed up, specifically, the influence of the Russian Orthodox Church in Russian political space. Another investigation dealt with geopolitical views of the Russians (Petrenko, Mitina & Bertnikov 2003) and their perception of other countries, and it also detected the presence of religious factor. So far, the analysis of current mentality and political consciousness of the Russians inevitably brings us to the subject of religious consciousness and specific confessions. Objective of this study: cross-confessional investigation of value systems in religions spread in Russia and establishing to what extent they are spiritually acceptable to Russians. Methods: psychosemantic methods close to those of Kelly’s ‘repertory grid method’ and Osgood’s semantic differentiation and G-sorting. Material: 300 fragments of religious canonical texts containing moral judgements (Russian Orthodoxy, Catholicism, Protestantism, Judaism, Buddhism, Islam and Hinduism presented by Krishna Consciousness) and representative texts of communist and fascist ideologies, which claimed in the 20th century quasi-religious status. These texts will be evaluated by priests, pastors, rabbis, muftis etc. and form the basis for a multidimensional axiological semantic space, which will reflect respective (quasi)-religious values and show similarities and differences between them. Afterwards, the same descriptors will be used on the population in different regions of Russia – both believers and non-believers – and in ethnic territories in order to establish the ‘density’ of followers and analyze tolerance for other people’ religious views. We expect that on major factors the positions of religions in axiological semantic space will be close, and they will oppose the commonplace consciousness and totalitarian ideologies i.e. spiritually world religions will be close to each other. One can also expect spiritual closeness of Russian Orthodoxy, Catholicism and Protestantism, all being Christian confessions, and their connection with Judaism within the frames of the Judaic-Christian culture. Finally, we have to expect a rather flat axiological semantic space for religious fanatics and proponents of totalitarian ideologies (cognitive simplicity) and their ‘blackand-white’ (Manichean) consciousness.

Tasks for Future Investigations A. Cross-confessional investigation of values, including the development of axiological semantic space based on judgements of priests, pastors, rabbis, mullahs, lamas, etc. on respective scriptures, as well as specific ideologies – communism and fascism (the proponents of the latter are extreme nationalist groups). The data matrix will be subjected to factor and cluster analysis in order to determine the categorical structure of the worldview for every religion. The positions of re-


ligions in the value space will show similarities and differences in value orientations, common human values (as invariants) and specific traits. This is important for constructive inter-confessional communication and interaction of different cultures. B. Determining moral values in the Russian population, in different regions and national republics by finding out the attitudes of people towards the same fragments of canonical religious texts and placing them in the axiological semantic space. High concentration of respondents by a confession/ideology shows the density of followers. C. Establishing social and demographic determinants of the confession/ideology. Chesnokov’s ‘determinant analysis’ will allow to determine age, social and national characteristics of the followers of a confession/ideology. D. Investigation of religious and ideological roots of fanaticism and extremism. This is an extra task because its implementation, specifically, working with representatives of extremist groups and religious fanatics require special experience. In this investigation, we intend to outline the methods and approaches to studying totalitarian consciousness and religious extremism. Pilot study of the Russian population’s views concerning values of world religions The above mentioned psychosemantic approach towards values was previously applied in our pilot investigation performed on 200 respondents. All respondents were highly educated and volunteered to participate in this study because of their interest in religious subjects. They were asked to complete the so-called reflective matrices i.e. they put themselves in the shoes of a ‘Russian Orthodox’, a ‘Catholic’, a ‘Buddhist’, a ‘Krishna’ follower, a ‘Judaist’, a ‘Moslem’, and also from their own point of view, from the points of view of a ‘common person’ (‘person from the street’), a communist and a fascist. Naturally, this pilot investigation does not reflect the ‘objective’ position of different religions but respondents’ ideas about these religions. A more objective picture will be obtained in the course of the main study involving the immediate proponents of religious mentalities (priests, mullahs, rabbis, lamas, etc.). Therefore, here we deal with role positions or ‘social representations’ (Moskovici, 1998). Such an investigation is also important for psychologists because besides checking on value judgements they give information about the population’s views on specific confessions and ideologies. Method: Semantic space development on the basis of canonical religious texts containing value and normative statements from the Old and New Testaments, Bhagavat Gita, Moslem Hadith, Koran, The Book of Exodus) and some texts reflecting communist and fascist ideologies. Procedure: Respondents were asked to express their agreement/disagreement on the texts or statements using a 7-point scale (from +3 ‘agree completely’ to −3 ‘absolutely disagree’). They received in total 160 religious and ideological statements. They were not informed about the sources of these statements though some of them were easily recognized. Data processing: Individual matrices with 10 role positions on 160 statements (or descriptors) were brought together and formed one group matrix which was subsequently analyzed by means of factorial analysis with the help of SPSS. As a result, four factors were selected that explained 42%, 27%, 8% and 6% of total variance.


Factor 1 (F1) had on one axis statements like: • Do not murder (Exodus) • Love your enemies, and pray for those who persecute you (The Gospel according to Matthew) • Hate shall never stop hate in the world but it stops in the absence of hate (The Dhammapada) • Do not resist him who is evil; but whoever slaps you on your rights cheek, turn to him the other also (The Gospel according to Matthew) • Wars cannot be conducted for the sake of gaining territory (Hadith). The other axis contained the following statements: • He is unworthy who is unable to revenge (Nietzsche) • Those who want to live have to fight and those who keep away from fight do not deserve to live (Hitler) • The stronger shall rule the weaker (Hitler) • One shall be punished by death for the crime committed (The Book of Deuteronomy) • A soul for a soul, an eye for an eye, an ear for an ear, a tooth for a tooth and wounds shall be avenged (Koran) • If a man does evil but for the sake of loyal faithfulness, he shall be as righteous as he is in the right way (Bhagavat Gita). Thus, on one axis we have here the judgements that forbid violence even with best intentions. Many of these statements contain a negation. In its strongest expression, it demands love for enemies. On the opposite axis we have the statements that belong mainly to Nietzsche and Hitler that emphasize the right of the strong. There are also statements from the Old Testament and the Koran about the right to retribution. We can see the locations of representations of religions in semantic space (Table 1). From the point of view of our respondents, Christianity, Buddhism, Krishna Consciousness preach forgiving, tolerance and no evil deeds even for the sake of good purpose. On the opposite axis, we find representations concerning fascism. It is known that fascists strove to prove their racial superiority in every possible way including genocide. Representations on communism are close to those on fascism though communism practiced genocide not for racial reasons but for ‘class reasons’, with certain exceptions. So far, this opposition between religions and ideologies looks rather logical. There is but one exclusion. That is Islam. In axiological space, it opposes other religions. It could be explained by its rigid norms and by associations with fundamentalism and negative experiences with the war in Chechenia. Neutral happen to be representations on Judaism. Perhaps, the respondents are not well informed about this religion. Rather neutral are ‘common persons’ representations while representation of ‘myself ‘ are shifted in direction of tolerance. Thus, the first factor has been interpreted in the following way: “Violence forbidden ↔ Violence for the sake of a good purpose (or ‘The end justifies the means’)”. Factor 2 (F2) included statements like: • Do not take gifts (The Book of Exodus)


Table 1.

• Whoever exalts himself shall be humbled, and whoever humbles himself shall be exalted (The Gospel according to Matthew) • No piece for those who strive to satisfy their wishes (Bhadavad Gita) • The love of money is a root of all sort of evil (First Timothy) • Wealth gives rise to immoderate desires (Islam Nadjul Balagha) • Wine and gambling are great sins (Koran) • If you want to live quietly, learn to do without things which are unnecessary (Tolstoj) • Pride precedes death and arrogance precedes fall (The Book of Proverbs). On the opposite axis we have the following statements: • Follow your passions, good or evil (Nietzsche) • Evil instincts serve their purpose as they preserve the species (Nietzsche). The contents of factor 2 can be expressed as “Control of passions and desires ↔ Selfindulgence”. Almost all religions demand self-restriction and humility (see Illustration 1). On the opposite axis we find the representations of ‘myself’ and ‘common person’s’. Religion establishes a certain ideal towards which one should strive. However normal people are disposed to passions, pride, bodily desires and attractions. Communist ideology also imposes some limitations (‘communal is more important than individual’). As for fascism, according to our respondents, it is neutral on this issue. Factor 3 (F3) had to do with the pair “Rigid norms of behavior ↔ Possibility to choose”. On the one hand, we offered strictly normative statements like: • The thief’s hand shall be cut off as retribution for his gain (Koran) • Man is responsible for all sins of the woman (Nietzsche)


• People must not eat the meat of animals (Bhagavad Gita) etc. There were also statements that left the choice with man: • As your soul wants it, you can get and eat meat (The Book of Deuteronomy) • Church belief is slavery (Tolstoj), etc. On factor 3, Judaism and Islam, being strictly normative religions, oppose Christianity (Russian Orthodoxy and Catholicism) that allow more freedom of choice, as well as communism with its conscious choice (Table 2). Weak Factor 4 (F4) included the statements interpreting being as illusion and those on primacy of individualism (a kind of moral solipsism) like the following: • Ruler of death does not see those who see the world as mirage (The Dhammapada) • Living means permanently pushing away things that have to die (Nietzsche). The other axis presented the statements that emphasize involvement in the world of people: • Man finds happiness only in serving others (Tolstoj), etc. On factor 4, role representations of Buddhists and the followers of the Krishna Consciousness (both being individualistic religions), are away from Christianity, Islam and Judaism while representations referring to ‘myself’, a ‘common person’ and a ‘communist’ are neutral (Table 2). Factor 4 can be interpreted as “Illusive nature of being ↔ Inclusion in the world of people”.

Table 2.


We would like to stress that these results are not based on profound religious analysis but reflect our respondents’ representations concerning religions. However, we plan to work with those who are professionally involved in religious activities, i.e. priests, pastors, mullahs, rabbis, lamas etc. and with proponents of the two mentioned ideologies (fascism and communism). Semantic space based on their judgements, together with representations of the population will provide a picture of religious views and show common people’s attitudes to specific religious confessions or ideologies. Psycho-semantic analysis exposes the deepest religious and moral feelings of persons while sociological surveys reflect only conscious reactions of respondents and are not free from ‘social desirability’, ethnic influences and social conformity with religious rituals. Such an investigation will make it possible to determine an approximate percentage of true believers and those who claim to be believers, as well as the percentage of people oriented at specific religious values. As for the extra task formulated as the “Investigation of religious and ideological roots of fanaticism and extremism”, we have to work among extremists. Naturally, what we aim at is not a psychodiagnostic method that would allow to control any presumed ‘terrorist mentality”, whatever that may be, nor to be used as a means of control by security agencies, as by George Orwell’s ‘thought police’. Those who do not want to show their attitudes, can imitate some social wishes. However, in order to develop counterpropaganda and ideological weapons against extremism, we have to reconstruct its ideology. Psychosemantic investigation has to resolve this issue. Besides, data on positions of different religions in axiological semantic space will contribute to our understanding the status of these religions in the interconfessional communication.

References Kelly GA. A theory of personality. The psychology of personal constructs. N.Y. 1963. Osgood Ch. Dimensionality of the semantic space for communication. Scand J of Psychology (Stockholm) 1966; 7 (1). Moscovici S. The machine that makes Gods. Moscow, 1998 (in Russian). Petrenko VF. Introduction to experimental psychosemantics: investigation of representations of common consciousness. Moscow, 1982 (in Russian). Petrenko VF. Psychosemantics of consciousness. Moscow, 1988 (in Russian). Petrenko VF. Basics of psychosemantics. Moscow, 1997 (in Russian). Petrenko VF, Mitina OV. Psychosemantic analysis of the dynamics of public consciousness. Moscow, 1997 (in Russian). Porshnev BF. Social psychology and history. Moscow, 1979 (in Russian). Huntington SP. The clash of civilizations and the remaking of world order. London, etc.: Touchstone Books, 1998. Chesnokov SV. Determinant analysis of socioeconomic data. Moscow, 1982 (in Russian). Petrenko V, Mitina O, Brown R. The semantic space of Russian political parties on federal and regional levels. Europe-Asia Studies 1995; 47 (5). Petrenko V, Mitina O. The psychosemantic approach to political psychology: Mapping Russian political thought. States of Mind: American and post-Soviet perspectives on contemporary issues in psychology. New York: Oxford Univ. Press, 1997, p. 19–48. Petrenko V, Mitina O. A psychosemantic analysis of the dynamics of Russian life quality (1917–1998). Europ. Psychologist 2001; 6 (I): 1–14. Petrenko V, Mitina O, Bertnikov K. Russian citizens’ representations of the country’s positions in the geopolitical space of the Commonwealth of Independent States, Europe and the world. Europ. Psychologists 2003; 8 (4): 238–251.



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Special Features of Emergency Psychological Assistance during Acts of Terrorism Y.S. Shoigu Center of Emergency Psychological Aid of the EMERCOM, Russia The threat of terrorism is becoming ever more evident in recent years. This can be seen both from the context of Russia and in the wider world. Terrorism is becoming an inescapable phenomena of modern society, and it cannot but tell upon mental health and psychological condition of people. These pressures can also be amplified by the inevitable role of the mass media, which, while highlighting tragic events and providing information about them, also can place additional stressors on victims of terrorism. All this makes psychological help necessary for people who have suffered in emergency situations, including terrorist attacks. There are three main tasks which psychologists fulfill while providing emergency psychological help: • Exposure and timely correction of unfavorable psychological reactions, which appear in response to a particular situation and to maintain optimal psychological and physiological condition of the victim. • Prevention of unfavorable mass reactions among the victims. • Precautions against delayed consequences for the victims hurt in the incident. It is important to notice, that these tasks are characteristic of emergency help, that is, short-term help, which is provided immediately after the event, accident or terrorist attack. There are three main stages in the provision of emergency help: the preparatory stage, the main stage and the final stage. The first task of a specialist at the preparatory stage is to obtain essential information about the number of victims and their psychological state, about the peculiarities of medical aid organization and social conditions (is there hot food, tea, adequate provision for rest, etc.?) and to make this data the basis for building the system of assistance optimal for these conditions. During the main stage the fundamental task is the provision of emergency help to victims and staff. The longer the situation lasts, the more help will be needed by the staff, who can easily be overlooked. At the final stage the specialists’ tasks are to make a prognosis about the future consequences of the incident, and to give the victims information concerning where they can obtain help in the future. The term “victims” requires explanation and elaboration. In a broad sense, victims are all the people who receive psychological help after the event. We can single out five groups of victims: victims, relatives, witnesses, spectators, secondary victims. It is necessary to briefly describe each of these groups (Table 1).

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Name and short definition of the group

Peculiarities of behavior and psychological response

Peculiarities of emergency help provision

Victims – people physically hurt during the event

This group has the broadest range of psychological response to traumatic experience from the absence of unfavorable response up to the extreme forms of its expression

Relatives of the victims who were physically hurt or people who lost their property as a result of emergency

Victims of this category gather in locations where information is available or as near as possible to the places of tragedy. There can be different kinds of response to traumatic situations (weeping, hysterical reactions, aggression, etc.). Unlike the first group, nearly everyone in this category shows some psychological consequences. The appearance of mass reaction is possible They can be usually found in the same locations as the second group. As they were not involved in the event, but it happened very close to them, they often start repeating in their minds different variants of the situation’s development. This can lead to strong psychological trauma. The stage of shock lasts comparatively longer with this group. Phobic disorders can be found comparatively more often They can be found in locations with best views to the site of occurrence. The appearance of mass reactions is possible

If victims of this group are in hospital, it is appropriate if specialists from this medical institution provide psychological assistance. A smooth transition from emergency psychological help to rehabilitation recovery work is desirable It is possible to achieve maximum efficiency of help when work is based on the principle of individual short-term sessions. The choice of particular method depends on the peculiarities of the situation, the victim’s response and his or her personal circumstances

The provision of emergency help is often organized according to the principle of control aimed to prevent mass reactions

They rarely seek specialists’ help. They usually have phobic response to traumatic situation

The provision of emergency help is possible through various kinds of hot lines

Witnesses – people who became indirect participants of the situation: neighbors, witnesses

Spectators

Secondary victims – people, whose psychological problems are connected to receiving information about the event through mass media

Medical assistance to this group can be provided in groups of different sizes. While treating this group it is necessary to pay special attention to the prevention of delayed responses

It is possible to single out one more category of people who may need help from psychologists – the specialists of various emergency services, who perform their official duties at emergency sites: rescuers, firefighters, policemen, social services, etc. The assistance to this group can be built on the principle of creating the most optimal conditions of work and rest, as well as the organization of group sessions aimed at peer support and recovery – sleep deprivation can create severe psychological pressures that should be watched for. Specialists working at emergency sites often do not have special training for this kind of work, for instance, those working in the social services. In this case

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psychological response is similar to the one of “witnesses”. It is necessary to keep this in mind while providing emergency psychological help. The approach used to provide emergency psychological help can be called eclectic. To provide assistance of this kind methods from different areas of modern psychological science and practice are used: body oriented approach, gestalt-therapy, art-therapy, rational approach, cognitive approach, neurolinguistic programming, short-term positive therapy and others. However, some conditions restrict the application of this or that method in provision of emergency assistance. The most important of these conditions are: 1. Limit of time – the assistance must be provided quickly, so the method must be short-term; 2. Lack of conditions (separate room, silence, etc.) for individual work, so the method should not require the isolation of psychologist and his patient. In conclusion, it is important to notice some special circumstances which influence emergency help after terrorist attack. Unlike natural and technological catastrophes, the terrorist attack is the result of purposeful criminal activities. This fact has a particular meaning to people. A terrorist attack is even less predictable than many other situations. This leads to the uncertainty in the future, defenselessness, inability to protect oneself and one’s relatives, the feeling that tragedy can occur in any place at any time. These emotional experiences are more intense after a terrorist attack than in any other situation. The second peculiarity of people’s experience after a terrorist attack is the appearance of ethnical, political or any other intolerance. “They” come in – the outcast group which is to blame for the tragedy. “They” are associated not only to particular criminals who organized the terrorist attack, but with all representatives of their nationality (or even the group of nationalities), political party etc. The widest range of expression of this kind of intolerance ranges from fear of members of that community to aggressive actions against them. Those specific issues should be taken into account while providing psychological help during such emergencies as a terrorist attack. Thus, the provision of emergency psychological assistance after terrorist attacks is an important element of mental health protection and prevention of delayed response of victims.



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Perception and Experiencing of “Invisible Stress” (in Relation to Radiation Incidents) N.V. Tarabrina Traumatic Stress Disorder Laboratory, Institute of Psychology, Russian Academy of Sciences

Introduction Sixteen years have passed since the Chernobyl catastrophe. Although a great quantity of scientific research has been done and published during this time period, there have been only a few psychological studies. The quantity of publications in the popular press is enormous. However it’s important to mention, that journalists sometimes make negative contributions to elucidating the Chernobyl tragedy, such as promoting “radiation hysteria,” especially during the first several years after the catastrophe. There are still diverse and often contradictory points of view on the problem of delayed consequences of radiation on human health. Academician Ilyin, a member of the Central International Committee for radiation defense who personally took part in liquidation of the consequences of the Chernobyl disaster, has clearly shown that 7 years after the catastrophe there has been NO increase of general oncological morbidity and mortality among surrounding population exposed to radiation. These results were in accordance with the prognosis of the International Consulting Committee (ICC) that was formed the auspices of the International Chernobyl Project. The results of the ICC activities created an ambivalent reaction including direct accusations that the scientists were a part of the “atomic mafia”, the ICC proceedings were repeatedly criticized not only by journalists and writers, but by professionals as well. This criticism arose because the Chernobyl catastrophe had acquired unique social and political resonance. Certainly, it is too early to come up with final conclusion about such an important questions. For instance, the scientific report by World Healh Organization in 1996 demonstrated an increase in thyroid gland cancer among children living in the polluted Chernobyl areas. As early as in 1993 professor Gus’kova, medical director of the Institute of Biophysics Hospital, where the first victims of the Chernobyl catastrophe were treated, published a review paper that considered various methodological approaches to research involving the consequences of radiation. In this review studies were divided into two groups: those that meet and those that do not meet criteria for scientific research. For example, examining the studies from the second group, Gus’kova demonstrated how easily one could come to a wrong conclusion about the influence of radioactivity on the development of various diseases. These analyses led Gus’kova to the unambiguous con-

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clusion that “only the scientists who have no expertise in the field of radiation consequences explain various biological and medical deviations by exposure to radiation. One cannot ascribe these deviations to radiation especially if the normal rate of morbidity is not known, and those diseases are most likely the result of psychological factors and stresses. It is most difficult to estimate the role of radiation exposure per se in the development of mental and psychosomatic disorders in individuals, exposed to radiation. To date the findings have been very contradictory. Loganovsky in 1999 published the results of clinical and epidemiological research examining the mental health of survivors of the Chernobyl disaster. He found “dramatic deterioration of mental health”, especially in the personnel, who had worked at Chernobyl between 1986 and 1987. The origins of those mental disorders were attributed to a combination of unfavorable factors related to a radioactive, as well as non-radioactive nature. It is difficult to disagree with in such an explanation; however it provides little clarification in the complex picture of psychological consequences of radioactive impact. In the above-mentioned ICC report on the International Chernobyl project, the experts presented posttraumatic stress disorder as one of psychological consequences of the Chernobyl catastrophe. The emotional impact on human mind of such traumatic events as violence, armed conflicts, and various industrial and natural disasters have been extensively studied. These kinds of psychological trauma have common etiology: so called “acute” stress due to a specific traumatic event. On the other hand, survivors of the “invisible stressors,” such as threats of radioactive, chemical, bacteriological, and other similar contaminations have received very little attention. The “invisible stressors” do not visible affect one’s environment, therefore their perception and estimation of possible harmful effects are based on individual’s knowledge of their presence as well as on the unconscious or partly conscious fear of their detrimental impact on one’s life and health. Several years ago my laboratory at the Institute of Psychology of the Russian Academy of Sciences in collaboration with the Psychophysiology Laboratory of the Harvard Medical School carried out a study of psychological effects of the stressful experience of possible radioactive contamination in workers (military, fire-fighters, etc.) who participated in containing the disaster at the Chernobyl Atomic Power Station. I would like to express my gratitude to our American colleagues, Drs. Roger Pitman, Scott Orr and Natasha Lasko, for their continuous generous support of our scientific endeavors. As it was mentioned above, the traumatic effects of work in the disaster area on the psychological health of disaster workers (known under the general name of “liquidators”) in general, and development of PTSD in particular, have not been extensively studied. After the Chernobyl disaster from 200 to 600 thousand “liquidators” were employed at different times to do the clean up, making clear the necessity of studying the consequences of the radiation threat experienced by the liquidators. The goal of our research was to examine workers’ characteristics of perception of the radiation threat and to establish the nature of emotional and personality changes that occurred in those who survived a radiation threat crisis.

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Subjects and Methods Subjects (N = 65) were male ex-disaster workers who participated in the Chernobyl reactor clean-up. Excluded were subjects with a radioactive illness in any stage, medication free, or any kind of a cerebral pathology. Demographic and psychometric data appear in Table 1. All subjects experienced a similar, allegedly traumatic event, viz., one to two months’ exposure to radiation during clean-up of the nuclear power station in Chernobyl in 1986. Russian-language versions of following instruments were administered to each subject: 1. 2. 3. 4. 5. 6. 7. 8. 9.

Structured Clinical Interview for DSM-III-R (SCID) [7] Clinical-Administered PTSD Scale (CAPS) [8] Mississippi Scale for Civilian PTSD [9] Impact of Event Scale [10] Minnesota Multiphasic Personality Inventory – MMPI State Trait Anxiety Inventory – STAI [11] Beck Depression Inventory – BDI [12] Symptom Check List 90-revised – SCL90-R [13] Radiactive Threat Perception Questionnaire (RTPQ) [14]

Results and Discussion Results of t-test comparisons between the PTSD and non-PTSD groups for the various psychometric measures are presented in Table 1. Both diagnostic groups were similar in regard to their mean ages and education levels. The PTSD group scored significantly higher than the non-PTSD group on all the measures of PTSD and general psychiatric symptomatology, state and trait anxiety, depression. Our diagnostic assessment involving the use of the SCID (structured clinical interview) revealed prominence of symptoms of physiological arousal as specific to a clinical picture of PTSD in the liquidators. In follow-up interview, some “liquidators” who had not met criteria for PTSD at the time of initial observation, but manifested some PTSD symptoms, reported that with the passage of time and especially when they did not feel well or heard about other Chernobyl liquidators becoming ill or dying, they’d have increasingly frequent intrusive memories of their experience at Chernobyl. Meanwhile, they began to attribute most of their emotional problems, such as irritability, insomnia, and unpleasant life events in life (e.g., divorce) to Chernobyl. Thus Chernobyl became a new point of reference in the liquidator’s life, which divided it into what life was like before the disaster and how life changed after it. In our study, the “liquidators” suffering from PTSD reported a much higher degree of psychological discomfort than the “PTSD-free” group (the differences between the two groups are statistically significant and consistent along all the psychometric scales used). MMPI has been shown to produce discrimination between PTSD and non-PTSD populations [9,15–19]. Several studies have suggested that the clinical scale configurations associated with PTSD diagnosis include: F-2-8/8-2 [9,19,20], 8-2-7 [21], 2-8-7, and F-8-7 [22]. In the present study, the PTSD group scored significantly higher on the MMPI F-scale and most of the clinical scales. The three-point MMPI code configuration

132

N.V. Tarabrina / Perception and Experiencing of “Invisible Stress” Table 1. Demographic and psychometric data PTSD n = 21

non-PTSD n = 44

t

p

M

SD

M

SD

35.4 12.1

5.8 2.5

38.3 12.9

7.2 2.6

1.6 1.1

0.1 0.3

47.5 84.6

10.3 20.0

49.2 69.1

7.2 10.0

0.7 3.8

0.4

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