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TUESDAY, Aug. 5, 2003 (HealthDayNews) -- Although Israelis are deeply affected by terrorist acts that occur in their daily life, the psychological impact "may be considered moderate."
The relatively muted psychiatric response may be related to a "habituation" process and to the wide use of coping mechanisms, say the authors of a survey appearing in the Aug. 6 issue of the Journal of the American Medical Association.
This edition of the journal is a theme issue devoted to violence and human rights.
The study was led by Dr. Avraham Bleich of Lev-Hasharon Mental Health Center of the Tel-Aviv University Sackler School of Medicine in Israel. He and his colleagues date the beginning of the current round of terrorism to September 2000, the start of the Al-Aqsa intifada. Between then and April 30, 2002, the time frame of their study, the authors say that knife and gun attacks, drive-by shootings and suicide bombings resulted in 472 dead (318 of them civilians) and 3,846 injured (2,708 of them civilians).
Despite the level of casualties, no studies had looked at the psychological impact of this violence until now, the authors assert.
Marc Gelkopf, co-author of the study and director of research at Lev-Hasharon Mental Health Center, was very surprised by the findings. "We knew that people would be stressed but we did not know that people would not be sick, that 19 months of extreme stress did not bring people to the brink," he says.
For this survey, the researchers contacted 512 people across Israel by telephone and asked them 51 questions related to trauma, coping, sense of safety and thoughts about the future. The study participants were representative of the national population, with 86.8 percent of them Jews, and 13.2 percent Arabs; roughly half of them men and half of them women; and most residents of urban areas.
Of the 512 respondents, 16 percent said they had been directly exposed to a terrorist attack, while 37 percent said a family member or friend had been exposed. Sixty percent of the people said they felt their lives were in danger, while almost 68 percent felt the lives of friends and family were in danger. More than half of the participants expressed a low sense of safety.
Almost 77 percent of respondents had at least one traumatic stress-related symptom, such as "general distress." And 9 percent met the criteria for symptoms of post traumatic stress disorder (PTSD). Fifty-eight percent reported feeling depressed or gloomy.
Women were more likely to have symptoms of post traumatic stress disorder. They were also more prone to a traumatic stress-related symptom, and to feel depressed.
Nevertheless, a high proportion of respondents reported feeling optimistic about their personal future (82 percent) and Israel's future (66 percent), a finding that seems to indicate that strong adaptive psychological mechanisms are at play, the researchers say.
"It has always been my understanding and experience that PTSD occurs when people are exposed to horrible experiences and then prevented from processing the experiences," says Steven M. Herman, director of the Psychiatry Ambulatory Care Clinic and director of the Out-Patient PTSD Clinic at Richard L. Roudebush VA Medical Center in Indianapolis.
"For example, soldiers in combat often don't have time to grieve for their losses because there's another battle to fight. Rape victims are often blamed by society. And children are embedded in their families -- the very support group they would need to process child abuse," he says.
"But it appears that Israelis are carefully utilizing their social support networks to deal with issues as they occur. Getting information is important to experience processing," Herman adds.
The survey found that 83 percent of participants actively searched for information about loved ones after an attack, and that 76 percent to 81 percent had some form of social support to deal with stress. Fewer people used self-distraction (38 percent), information avoidance (32 percent), tranquilizers (7 percent) or alcohol or cigarettes (5.3 percent) to cope.
The study authors also speculate that the adaptive responses may be due to an "accommodation effect," in which stress decreases as traumatic events recur. In other words, people become inured to certain violent events.
"Why didn't people freak out more? One of the reasons, we believe, is that here was really a habituation process," Gelkopf says. "Over time people just get used to it.
"We also must take into account the fact that this is not a personal trauma but a national trauma. You have this leveling phenomenon, which means that everybody was affected in the same way," Gelkopf says. "There's a kind of solidarity. It's everybody's story. It brings it more into the social sphere."
Dr. Israel Liberzon is director of the PTSD program and co-director of the Center for Trauma Stress and Anxiety at the University of Michigan Health System. He says the results of the survey were interesting but not surprising because the relative rates of full-blown diagnoses were low compared to those seen in the United States.
No one knows at this time why this is the case, Liberzon says. "Is it a culturally defined phenomenon? What's the role of the culture? Is it an issue of stress inoculation that people who live in a particular environment who are continuously exposed to stress learn to adjust and live with it without the same degree of symptoms that they would have in a different environment?" he asks.
Part of the answer may lie in the differences between Israeli and American society. "Israeli society is a less individualized society than the U.S. The social networks are tighter, the family is a much more extended family and everybody is located very close to each other," Liberzon says.
Another study in the same issue of the journal found that playing and tending animals were dangerous pursuits for children in Afghanistan.
Almost half (46 percent) of the people injured in Afghanistan by landmines or unexploded ordnance (including grenades, bombs, mortar shells and cluster munitions) were under the age of 16 and these children were most likely to be engaged in one of these two activities. The study authors also found that the highest number of injuries were seen among those aged 7 to 15 and that boys were most likely to be wounded.
An average of 102 new injuries were reported each month and the fatality rate was 9.4 percent, although these figures were likely to be low because of under-reporting, the authors reported.
More information
The American Psychological Association has information on coping with terrorism and on resiliency.
