Omar Sultan Haque, MD, PhD, MTS

Any psychiatric diagnosis has the potential for empowering the clinician to treat the patient’s suffering as well as inspiring the patient to participate in an effective treatment. Alas, diagnosis also has the potential for stigmatization and dehumanization. Whereas diagnoses of personality disorder all too often have been used to stigmatize patients, the rush to eliminate Enduring Personality Change After Catastrophic Experience (EPCACE) from the International Statistical Classification of Diseases, Revision 11 (ICD-11) is foreseeably an instance in which patients vulnerable to aloneness will be less likely to receive effective treatment and thus will become even more voiceless, further disempowered, and more vulnerable to humiliation throughout the life cycle’s inevitable stressors and losses.

EPCACE was incorporated into ICD-11 as a form of Complex PTSD (cPTSD) as of June 2018. EPCACE is defined as an enduring personality change lasting for a minimum of 2 years that a patient experiences following a catastrophic stressor (ICD-10). The events of the stressor must also be so extreme that one should disregard any genetic vulnerabilities or predispositions that would further influence personality changes. These experiences can include imprisonment in concentration camps, disasters, and long-lasting capture with a persistent threat to life.

ICD-10 EPCACE represents the experiences of a particularly vulnerable population group, one marked by great loss, separation from a community, and aloneness. Such isolation from nourishing connections is a major dimension of deep and enduring personality change. Especially in cases of massive psychic trauma such as the Holocaust, involving the loss of an entire community and its way of life, fundamental bonds of social connection, trust, and support are broken, and the individual is left profoundly alone. Such affective changes point to the insufficiency of research on survivors left in such a devastated state.

We acknowledge that there is great variability in the experience and suffering of survivors of catastrophic events. As with any clinical diagnosis, a diagnosis of EPCACE is no substitute for a formulation tailored to the needs of the individual patient and that patient’s family. An EPCACE-based formulation can highlight such factors as extreme helplessness and aloneness, whether human agency was the cause of the catastrophic event, whether the event involved humiliation of the survivor, and whether the survivor remained in the zone of danger after the catastrophic event. These factors may be evident both individually and transgenerationally, as they are in the suffering of some of the survivors of the Holocaust who remained in areas where anti-Semitism and its dangers continued to be prevalent.

With careful attention to individualization of formulation, there is evidence for the benefits of EPCACE being included in the next revision of DSM as its own unique diagnosis. While care needs to be taken to avoid a reductionist and dehumanizing misuse of the diagnosis of EPCACE, the presence of this diagnosis in standard diagnostic taxonomies of psychiatric disorders can guide treatment formulations to good effect. Furthermore, EPCACE is an integrative diagnosis that offers clinicians the capacity to transcend diagnostic categorization by bridging personality disorder with trauma-related disorder, fulfilling an integrated biopsychosocial approach.

Our proposal has strong historical precedent. By 1992, the concept of trauma-inflicted personality changes had been well studied, as described by Herman and colleagues

 and later confirmed by many others, including Beltran and Silove,

 In an effort to distinguish personality changes as a result of catastrophic events from those with other causes, the ICD-10 task force decided on the inclusion of EPCACE. Personality traits such as hostile or distrustful attitude toward the world and social withdrawal, chronic feelings of emptiness or hopelessness, of being on edge as if constantly threatened, and estrangement distinguished EPCACE from related disorders.

With catastrophic genocidal trauma that includes extreme helplessness, humiliation, and the destruction of a validating community, resulting in aloneness, there is also a potentially lifelong vulnerability to shame.

 Such personality traits may emerge post-catastrophe and then become dormant. Nonetheless, they may reemerge with disruptive life-cycle events such as helplessness, humiliation, separation, loss, and grief or with news events, such as can occur for Holocaust survivors when anti-Semitism reemerges. Similar events may result in seemingly divergent personality traits emerging among survivors or even within a survivor, such as when there is an intensification of efforts to avoid massive grief concurrent with a counterphobic adaptation.

To test the validity of such an EPCACE diagnosis, Beltran and colleagues

 undertook a comprehensive survey of clinical psychologists and psychiatrists: 89% of respondents agreed that personality can be altered by trauma occurring in adulthood. Of those 89% of respondents, torture and concentration camp exposure were identified by 91% and 90% respectively as likely to produce changes to personality, followed by 72% for war exposure, 66% for sexual assault, 57% for hostage situations, 52% for domestic violence, 25% for natural disasters, and 24% for motor vehicle accidents.

Despite this substantial evidence, only 16% of clinicians had ever used EPCACE as a diagnosis for their patients, although it had been a valid ICD-10 diagnosis for 7 years before Beltran’s survey. Those who responded to the survey also cited issues of symptom overlap between EPCACE and more commonly used diagnoses, specifically depressive disorders and borderline personality disorder. However, EPCACE is marked by stable changes in personality, whereas borderline and depressive disorders are marked by instability in mood and affect.

It is foreseeable that post-traumatic avoidance of reminders by both patient and clinician is even more pronounced in catastrophic trauma. This may be another factor that contributed to the underutilization of EPCACE in its debut as a diagnosis. Alas, the underutilization of EPCACE is a loss for a significant proportion of patients who might otherwise have united as a treatment community. This loss is compounded by the fact that aloneness is often seen in the transgenerational transmission of EPCACE-related suffering. Group therapy is therefore a vital modality in EPCACE treatment across generations and in fostering the transgenerational transmission of resilience.

A follow-up study of the validity and utility of EPCACE in 2008 by Beltran attempted to redefine the broad aspects of the diagnosis and identify the key criteria that described a person with EPCACE. Twenty-four mental health clinicians who worked with patients who had experienced war and sexual assault as well as recently displaced refugees provided valuable feedback. Not only were the key attributes of “A hostile or mistrustful attitude toward the world, social withdrawal, feelings of emptiness or hopelessness, a chronic feeling of being ‘on edge,’ as if constantly threatened, and estrangement” identified, but mental health practitioners felt significant features were excluded from EPCACE’s operational definition. These include “somatization, self-injurious/self-damaging behaviors, sexual dysfunction, and enduring guilt,” which if included would differentiate EPCACE from complex PTSD and strengthen the operational validity of the diagnosis.

 Since then, no changes to criteria or follow-up studies have been conducted to improve the utility of EPCACE.

Research into EPCACE has been limited, as manifestations of the core symptoms can often differ depending on viewpoints and type of trauma. A core feature of EPCACE such as “a hostile or mistrustful attitude toward the world” can be operationally expressed by multiple symptoms such as anger, aggression, and other countless variations.

 Holocaust survivors who were identified as “feeling as if the Holocaust experience was continuing” were more likely to suffer symptoms of mental disorder, whereas those who avoided the traumatic memories altogether had a higher mortality rate due to illness.

 Patients with a diagnosis of EPCACE may isolate themselves not only from their communities, but also from proper mental health care.

Alternatives to inclusion of EPCACE as a distinct diagnosis

Critics of the inclusion of EPCACE in diagnostic taxonomy claim that it lacks specificity and is insufficiently utilized. To address these concerns, Maercker and colleagues

 proposed to reconceive EPCACE as part of cPTSD in ICD-11. Following this recommendation, the World Health Organization trauma team eliminated the diagnosis of EPCACE.

 cPTSD incorporates patients with personality changes as a result of exposure to single or multiple traumatic experiences, as long as the requirement of three core features of PTSD is met; these core features include changes in affect, self-concept, and relational function.

Alas, modifying the diagnostic criteria for cPTSD to consolidate EPCACE and other trauma-related disorders may also lead to mislabeling and downgrading the seriousness of personality changes, as well as overlooking potentially transgenerational personality changes. Because different experiences may produce different neurological and behavioral effects, it would be unwise to disregard the type of event and its impact on affect.

A later study noted a more specific set of criteria that must be met, as well as additional symptoms such as changes to somatization, self-injurious/self-damaging behaviors, and sexual dysfunction that would largely be left out of the criteria for cPTSD.

 The current criteria for cPTSD-which encompass the majority of EPCACE cases tested by Keeley and colleagues18-faced diagnostic issues when practitioners became aware of the origin of the trauma.

Another argument against the diagnostic inclusion of EPCACE is symptom overlap between EPCACE and cPTSD. While there is a spectrum of post-traumatic disorders, with overlap among diagnostic categories, the presence of such similarities does not invalidate the clinical usefulness of an EPCACE-inclusive categorical approach in the initial process of clinical reasoning, differential diagnosis, treatment planning, and prognosis. Therefore, future ICD workgroups should reconsider EPCACE’s inclusion into cPTSD, given the weight mental health professionals place on traumatic origin, and restore EPCACE as a distinct diagnosis.

The American Psychiatric Association has opted for a more conservative route in DSM-5 by incorporating elements of cPTSD and EPCACE into the diagnosis of PTSD. DSM-IV had largely suffered from “poor interrater reliability of personality disorder diagnoses, poor stability over time, poor discriminant validity, and poor general coverage of personality disorder as well as poor clinical utility.”

 DSM-5 requires that adult patients being evaluated for stress disorders meet eight symptomatic criteria following exposure to trauma. Galatzer-Levy and Bryant

 found that the current diagnosis for PTSD could arise from 636,120 unique combinations of the eight criteria listed in the newly formulated definition. With so many combinations, PTSD has been utilized as an all-encompassing definition that lacks the specificity needed to adequately diagnose trauma. The diagnosis of trauma-related disorder should not be done on a one-size-fits-all basis, but rather should consider the elements of trauma and its disparate effects on individuals.

Why EPCACE should be reborn as a distinct diagnosis

As it currently stands, EPCACE has lost its core values in the newly revised ICD-11 and the previously published DSM-5. Given that EPCACE is marked by hostile attitudes toward society, withdrawal, emptiness, and hopelessness as well as constant vigilance and estrangement, the salient characteristic of the disorder is the sense of aloneness that leads to massive social disconnection. EPCACE has significant features in common with the kinds of compounding trauma seen in autism spectrum disorder or adolescent-onset psychosis as a person becomes isolated and marginalized. With EPCACE, patients suffer a loss of community and trust with the outside world. With the loss of community, as in the Holocaust, there is an ever-greater risk of the transgenerational transmission of trauma and far fewer transgenerational resources for resilience such as loving grandparents or an extended healthy family.

EPCACE should be a stand-alone diagnosis rather than a formulation because diagnoses are heuristics for formulations, which guide prognosis and treatment planning. Also, if diagnoses are missing key ideas, those will also be missing in formulations. Aloneness and vulnerability are distinct factors characteristic of EPCACE that are coherent only at the diagnostic level. Moreover, with catastrophic experiences the life cycle and transgenerational dimensions of trauma and resilience are more likely to be central.

The majority of mental health clinicians in active practice or completing graduate education will utilize either DSM-5 or ICD-11. When Evans and colleagues

 surveyed a global sample of psychologists, they noted that 78% of respondents opted for a diagnosis that is flexible enough to account for cultural differences. Severity of a diagnosis was highly rated as a goal of clinical care, as 88% of the respondents believed that it should take the form either of a subtype based on severity or degree of functional impairment or of a separate diagnosis.

Further research has linked trauma to quantifiable changes in personality. In a comparison of late-onset personality pathology due to wartime trauma with prior personality disorders, 24.3% of patients had a personality disorder develop only after exposure to catastrophic events. When compared with those who had preexisting personality disorders, those with late-onset personality pathology had a three-fold higher rate of PTSD symptoms. Moreover, there were higher rates of suicidal ideation and self-reported emotional distress compared with persons with pre-trauma pathology.

Additional research has shown not only physical changes to the brain but also transgenerational effects that pass from parent to offspring.

 Such a link between catastrophic experiences and personality necessitates the use of integrative criteria such as EPCACE, which will serve the interests of patients and empower clinicians in making treatment decisions.

Self-help networks for EPCACE patients not only ease personal growth but also offer a safe communal space for patient empowerment. For example, since the aftermath of World War II, displaced and persecuted populations have found themselves unified and united by their shared experiences. Illustrative are reports of suffering experienced throughout Europe by survivors of massive psychic trauma with loss of their nurturing emotional milieu. Having the capacity to identify such traumatized populations from various countries and backgrounds and to unite them under a self-help support network enables survivors to create community for one another and foster therapeutic approaches which, via an empowering community, seek transgenerationally to treat the transmission of trauma and encourage the transmission of resilience.

Aloneness, along with helplessness about being alone and feeling humiliated, has increasingly been found to be a major risk factor across the illness spectrum. Aloneness post-trauma and in the midst of grief, to which persons who suffer from EPCACE are highly vulnerable, can reasonably be expected to compound this risk factor. Therefore, the diagnosis of EPCACE can be an important step toward remediation rather than exacerbation of the aloneness, helplessness, and humiliation that, in a vicious cycle, can lead to further isolation.

To avoid the misuse of EPCACE, it is vital to be aware that some survivors of catastrophic experiences in which terror involves dehumanization, degradation, and humiliation may therefore experience a heightened sensitivity to helplessness and humiliation. Receiving any psychiatric diagnosis is humiliating; therefore, patients frequently avoid seeking clinically based help. However, a newly empowered population brought together by that very catastrophic experience can provide solace, rebuild self-esteem, and relieve ongoing collective suffering.

All too often, both the fragility of aging and disturbing news events bring home to EPCACE sufferers disturbing reminders of catastrophic trauma. When applied with care, EPCACE as a diagnosis is not only helpful in clinical formulation and treatment planning but also has the potential to support the creation of healing communities for life-cycle stressors and losses. EPCACE-informed development of additional treatment modalities, such as group bereavement therapy and support groups outside of the clinical context that are focused on supporting survivors’ agency, empowerment, self-respect, connectedness, and creativity, has the potential to reduce post-catastrophic isolation, demoralization, and suffering.

Dr Bursztajn is corresponding author and can be reached at 

Dr Bursztajn wishes to dedicate his contribution to this work to his family, friends, and patients, Shoah (Holocaust) survivors and resisters.

Dr Tanaka is Assistant Professor of Psychiatry, Oregon Health & Science University (OHSU) School of Medicine, Portland, OR; Mr Tang is MS-1, Pacific Northwest Health Sciences, Yakima, WA; Dr Haque is Lecturer on Global Health and Social Medicine, Harvard Medical School, Boston, MA; and Dr Bursztajn is Associate Professor of Psychiatry, Part-Time, Harvard Medical School, Boston, MA. The authors report no conflicts of interest concerning the subject matter of this article.

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Articles

This article explores why Enduring Personality Change After Catastrophic Experience (EPCACE) is a clinically useful diagnosis.

How Catastrophe Can Change Personality

[[{"type":"media","view_mode":"media_crop","fid":"41184","attributes":{"alt":"Young Westerners Drawn to Terrorist Organizations","class":"media-image media-image-right","id":"media_crop_9096784023397","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4310","media_crop_rotate":"0","media_crop_scale_h":"188","media_crop_scale_w":"150","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]The relatively sudden rise of the terrorist group ISIS in the Middle East has surprised many in the West. Equally surprising is that financially stable foreigners from the West are over-represented among ISIS fighters.

 As helpless observers of the inhumane and disproportionate violence that ISIS has exacted on the people of the Middle East and the rest of the world, it is easy to wonder: what could possibly be the appeal of such a murderous, intolerant, and authoritarian organization to so many young people in the West?

This question is easier to answer when imagining the motives and rationales of locals in Iraq and Syria. Perhaps these locals join in what they believe to be a righteous cause. They may want to fight their perceived enemy in a global war, just as many Americans join the US Armed Forces to fight ISIS and other perceived enemies. But what could possibly compel otherwise financially stable young Westerners (non-Muslim as well as Muslim) to leave their families, friends, and home culture, and take up an uncertain future by joining a terrorist organization like ISIS?

Clearly, poverty is not causing people to join ISIS, neither is religion. The vast majority of the West’s 50 million Muslims do not join terrorist groups.

 Even among those with radical Islamic beliefs, only a very few act on those beliefs and join a terrorist organization.

 Background beliefs do not explain the motivation that compels people to join such groups-even as fundamentalist organizations go, ISIS is particularly extreme. It has been roundly condemned by many prominent Islamic institutions across the world as illegitimate, in violation of Islamic Law, and as not a part of Islam; it has even been rejected by the quite radical group Al-Qaeda.

The true answer is more disturbing and psychological, and has little to do with evil psychopaths finding their true home in ISIS, or of innocent youths being brainwashed into mindless soldiers. Rather, it involves the interaction of conscious and unconscious processes with unique features of ideologies like ISIS, and existential (but not material) vulnerabilities inherent in contemporary American life. One way to summarize our answer is that as an ideology, ISIS provides existential fast food, and for some of the most spiritually hungry young Westerners, ISIS is like a Big Mac amidst a barren wasteland of an existence. Much of the worldview of ISIS appears intellectually vapid and brittle, even silly when seriously considered as religious or philosophical propositions. Just as a person can get lost, a religious movement can also get lost in a forest of bad ideas. But most people do not get a PhD in philosophy of religion before deciding what to believe. The heart’s longings lead the mind, and the existential filler of ISIS nourishes the desperate and vulnerable soul, however much one is surrounded by material comfort.

Who actually joins ISIS? Not psychopaths or the brainwashed, but rather everyday young people in social transition, on the margins of society, or amidst a crisis of identity. According to anthropologist and psychologist Scott Atran who has studied the motivations and demographics of terrorists, it is mostly youth in transitional stages in their lives-immigrants, students, those between jobs or girlfriends, or those who left their homes and are looking for new families. For the most part they have no traditional religious education and are “born again” to religion. They are self-seekers who have found their way to jihad in myriad ways.

Have you ever purchased junk food when tired, irritable, and jet-lagged at an airport? For lonely young people in transition, ISIS provides a quick fix to the perennial problems of human life. Vulnerable people don’t tend to fact check when existential relief is easily and cheaply attained with little effort. Specifically, the relief in question concerns the human desire for identity, certainty, social connection, meaning, the optimal amount of freedom, and glory.

At crucial developmental periods in adolescence and early adulthood, the formation of one’s identity is a primary concern, and a riddle to be solved. These years are a time for figuring out who one is, where one belongs, what one values and finds meaningful, and what one can become and prove to the world.

 These years are also a time of increasing awareness of an exciting yet frightening internal world with conscious and unconscious conflicts around envy, competition, self-control, and self-esteem.

 For youths on the margins of Western society, and in transition from one community to the next, this process of identity formation can become a hopeless task. When one has become a fringe member of one’s home community in America during crucial phases of identity formation, it is very tempting to join what appears to be a righteous struggle against one’s oppressive community. Even superficial Internet exposure (much less direct marketing) can convince the young that they too may participate in a world-historical narrative in which the enemy of America is a beacon of hope for solidifying their emerging self. This may evolve into a counterphobic attitude toward the society in which they feel helplessness, with a full embrace of a cult of death such as ISIS.

Humans tend to live with a quest for certainty in their hearts, and uncertainty is experienced as aversive.

 Whatever its factual merits, a pluralistic worldview denies its adherents the delights of absolute certainty, and it takes much cognitive effort to maintain. ISIS provides an ideology in which the world is divided into absolute good and evil, no compromises are possible, radical Islam is the solution to all human problems, and any other interpretation of Islam is unthinkable. Why settle for shades of grey in a messy world when “The Truth” is packaged and delivered in under 30 seconds via Internet sound bites? This black and white picture of truth may seem simplistic for the critically minded, but it can provide epistemological crÃ¨me brÃ»lÃ©e for drifting and unanchored Western youths. These youths are looking for answers to existential questions within a home culture perceived to be permissive and relativistic. In the midst of all this, an ideology that does not compromise the quest for certainty can be very appealing to the most vulnerable.

Americans pride themselves on their individualism, but the underside of individualism is loneliness.

 The desire for social connection is a human need as basic as food and sex, and the most obvious source of terrorist seduction for the lonely hearted.

 Social networks construct the web by which individuals are drawn to action, and social connection is a common attraction for everyday wholesome clubs as well as nefarious cults of all persuasions. Terrorist organizations are no exception, and most people join due to the influence of friends, kin, and others in a social network.

Although joining based on the influence of one’s friends and kin is a primary factor, recruitment from ISIS also occurs. ISIS has initiated a number of systematic online efforts to target and respond effectively to young Westerners in transition at the margins of society, who can be easily tempted by the false allure of quick and easy social connections amidst an individualistic society from which they feel alienated.

 Rather than contemplating and deciding whether the ideas within the ideology of ISIS are rational and worthy of assent, the young are more likely to be drawn in by attachments to those already embedded in ISIS as a way to thwart loneliness.

By most accounts, Americans are happy people, and the pursuit of happiness is enshrined in the American Declaration of Independence. But Western definitions of happiness tend toward happiness as present pleasure and self-expression, rather than happiness as meaning, moral struggle and sacrifice, and aligning oneself with sacred purposes beyond the self.

 The latter meaning-oriented definition of happiness is more crucial for mental and physical health, but it is more common in non-secular cultures (and in the religious traditions within secular societies).

 For Western youths drifting between communities and belief systems amidst pluralistic America, the allure of a powerful, simple ideology with a crystal-clear elaboration of the transcendent meaning for their lives and struggles would be akin to an ice cream cone on a hot July afternoon. This desire for meaning-to be a part of something much larger than oneself, especially if it is transcendent-is a very deep wish in human nature, and not the same as routine motivations concerning status or in-group preferences (ethnicity, race, or religion).

 Thus the same need for meaning that propels a youngster to want to join ISIS can also lead an American businessman who achieves financial success to yearn for something beyond the accumulation of wealth, to something more meaningful and significant such as philanthropy, political office, or supporting a war.

Relatedly, as Atran notes, people join ISIS because they seek adventure and want glory. ISIS presents to the bored, secure, and the uninspired in Western liberal democracies a “thrilling cause and call to action that promises glory and esteem in the eyes of friends. Jihad is an egalitarian, equal-opportunity employer: fraternal, fast-breaking, glorious and cool. . . Many are just ‘vacationers’ for jihad, going to Syria over school breaks or holidays for the thrill of adventure and a semblance of glory.”

A seemingly paradoxical reason some Westerners join ISIS and other totalitarian organizations is that too much freedom can be experienced as burdensome. In 1941, the psychologist Erich Fromm in 

 explained why so many were attracted to the Nazi ideology in Germany by pointing to a feature of human nature that is afraid of being free and thus would rather submit to authority than be responsible for creating a life of one’s own. As in 1941 for Nazism, so also in 2015 for ISIS. Clearly, being a slave is no fun. But maximal freedom may also not be ideal, and humans vary in the degree to which additional freedom is experienced as beneficial. For someone who is socially integrated and stable, and more willful by nature, more autonomy can be a liberating means to self-create a life amidst hospitable institutions. In contrast, young adults in transition or on the margins of society may experience freedom as oppressive, since they lack the personal or social means for actually using a high degree of freedom to improve their lives. A totalitarian cult such as ISIS, which promises a strict ideology, rules, and a social order to which one can bind and submerge oneself, appeals to youths, especially those on the fringes of Western society for whom high amounts of freedom do not feel liberating but instead, oppressive.

Finally, these many vulnerabilities to joining terrorist organizations are combined with a deep but selective empathy. For example, an Iraqi-American youngster who perceives that Iraqis are persecuted by Americans might expand his empathy for suffering Iraqis over Americans and decide to join ISIS. Alternatively, a 5th-generation Italian-American youngster could find himself on the fringe of American society and start to develop deep empathy with the sufferings of America’s perceived enemies. Empathy is indeed a source of joining terrorist groups. The same empathy we may feel for the cherished victims of our favorite causes, others may feel for non-Americans. Empathy can be free of this paradoxical effect and fulfill its ethical possibilities only when empathy is generalized to all humans who suffer, not just to those in our in-group.

The reasons that youths join terrorist organizations such as ISIS have little to do with being poor, brainwashed, a Muslim, or a psychopath, and more to do with vulnerabilities in human nature exacerbated by aspects of Western societies. This diagnosis is echoed by journalists who have interviewed many ISIS fighters; a recent analysis of ISIS fighters remarks that “what draws people to ISIS could easily bring them to any number of cults or totalitarian movements, even those ideologically contradictory to Salafist Jihadism.”

If we Westerners are lucky, we have identities, certainties, social connections, meanings, generalized empathies, freedoms, and individual pursuits of glory that can be taken for granted. However, for those Westerners in transition, marginalized, lonely, lost, bored, uncertain, spiritually or existentially dispossessed, burdened by too much freedom, and empathically selective, ISIS and other shallow but contagious ideologies will remain tempting as quick fixes for the deep predicaments inherent to the human condition.

We would like to thank Dan Jones for helping us find some of the sources quoted in this article.

Dr Haque is Co-Director, UNESCO Chair in Bioethics, American Unit; Department of Psychiatry and Human Behavior, Brown University, Providence, RI; Program in Psychiatry and the Law and Department of Psychology, Harvard University, Cambridge, MA. Ms Choi is Associate at Nonprofit Finance Fund, Boston; Harvard Mediation Program, Harvard Law School. Mr Phillips is Co-Founder of Beyond Conflict, Cambridge, MA. Dr Bursztajn is President, UNESCO Chair in Bioethics, American Unit; Associate Clinical Professor of Psychiatry and Co-Founder of the Program in Psychiatry and the Law, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston. The authors report no conflicts of interest concerning the subject matter of this article.

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The authors explore possible reasons why young people in the West leave their families, friends, and home culture to join terrorist organizations.

Omar Sultan Haque, MD, PhD, MTS

Articles

How Catastrophe Can Change Personality

Why Are Young Westerners Drawn to Terrorist Organizations Like ISIS?