Long-term stress exposure
Long-term stress exposure has detrimental effects on health. While not the result of a terrorist act, the release of small quantities of radioactive material from the Three Mile Island reactor in 1979 resulted in measurable stress and metabolic changes among those living in the community.17,18 Even though the release did not pose an appreciable health risk, the uncertainties associated with exposure to an invisible and undetectable agent created lasting anxiety. This was amplified by the decrease in the resale value of homes in the area. The result left many residents feeling financially trapped in areas they might otherwise have left. Similar social and economic problems developed following the release of radioactive materials in Goinia, Brazil, in 1987.19-21 Previously a center for tourism, it took several years following the event before travel to the area returned to the level experienced before the accident. It is not difficult to see how a terrorist attack using a dirty bomb might cause similar changes.
Estimating the effects of terrorism
In addition to the difficulties of defining the presence of illness in community samples, community-wide rates do not tell the full story of the effects of terrorism. Community sampling may serve to estimate some aspects of the health impact of terrorist activities, but as was seen in New York City, evidence of elevated levels of possible illness may not reflect increased rates of mental health service use in the months that follow.22 It is impossible to know whether this is because the sampling techniques identify high levels of symptoms rather than clinically significant illness or because treatment is sought only after symptoms have persisted for an extended period.
Community sampling of residents in Washington, DC, after September 11th demonstrated lower rates of probable PTSD than rates in metropolitan areas not targeted by the terrorist attacks.1 The attack on the Pentagon was much less dramatic, received significantly less media coverage, and resulted in fewer deaths than the World Trade Center attacks. Compared with the New York attack, relatively few residents in the Washington metropolitan area knew anyone killed in the Pentagon attack and few actually saw the site of the attack during the rescue and recovery phases. The attack on the Pentagon also had little impact on the local economy. No businesses were destroyed, survivors remained employed, and there was no major impact on local transportation and service industries in the area.
While community rates of probable PTSD were low in Washington, DC, the community experience did not reflect the experience of those working at the Pentagon. When sampled 2 years after the attack, one fifth of those actually at the Pentagon during the attack, half of those injured during the attack, and one third of those who saw someone killed or worked with families of the victims met symptom criteria for PTSD related to the attack.23 Depression was also elevated in those who were present during the attack, injured, or exposed to the dead. Among those who did not meet symptom criteria for a disorder, 8% reported chronic moderate to extreme distress. While this study did not include a clinical interview to confirm diagnosis of PTSD, 70% of those who met study criteria for the disorder had accessed mental health treatment in the 2 years following the attack. The findings from the Pentagon sample are comparable to those found in survivors of the bombing in Oklahoma City. Among those directly exposed, 45% had a psychiatric condition and 34% had PTSD during the 6 months following the attack.
Similar rates of PTSD were diagnosed at 12-month follow-up.25 These studies indicate that among those most directly exposed to terrorist attacks, elevated rates of psychological distress or illness are present in both the short term and the long term.
The Pentagon sample demonstrated that even under the best circumstances, when individuals have high levels of social and economic support, the effects of terrorism can be substantial and longlasting among those most directly affected. Three fourths of the Pentagon sample was married and three fourths had at least a college degree. All respondents remained employed and had access to health care benefits. None were displaced from their homes as a result of the attacks.
Another somewhat unique aspect of the Pentagon sample was their ongoing exposure to reminders of the attack. They returned to the site of the attack on a daily basis, funerals of those killed in the attack continued for many weeks, and the gaping and smoke-stained hole at the site of the impact was visible for months. The presence of military assault vehicles with missiles and high-caliber machine guns, emergency escape hoods installed in office spaces, and passage through a metal detector on arrival at work each day provided clear reminders of the threat of future attacks. These reminders may have interfered with the extinction of arousal and intrusion symptoms that might have occurred in other settings.
Terrorism impacts individuals, communities, and society on multiple levels. Through acute and chronic symptoms of anxiety and depression, changes in health-related behaviors, or long-term strain and tension, its impact reaches many aspects of health and health care. The long-term consequences continue to be felt long after the media coverage subsides.
Dr Grieger is associate professor of psychiatry at the Center for the Study of Traumatic Stress of the Uniformed Services University of the Health Sciences in Bethesda, Md. He reports no conflicts of interest concerning the subject matter of this article.