Bleich A, Gelkopf M, Solomon Z. Exposure to Terrorism, Stress-Related Mental Health Symptoms, and Coping Behaviors Among a Nationally Representative Sample in Israel. JAMA. 2003;290(5):612-620. doi:10.1001/jama.290.5.612
Author Affiliations: Lev-Hasharon Mental Health Center, affiliated with Tel-Aviv University Sackler School of Medicine, Tel-Aviv, Israel (Drs Bleich and Gelkopf); Department of Psychiatry, Tel-Aviv Sackler School of Medicine and Israel Trauma Center for Victims of Terror and War (NATAL) (Dr Bleich); Shappel School of Social Work and Adler Research Center, Tel-Aviv University (Dr Solomon).
Context The terrorist attacks on Israeli society have been ongoing since September
2000. However, few studies have examined the impact of terrorism on nationally
representative population samples, and no study has examined the psychological
impact of ongoing terrorism in Israel.
Objectives To determine the level of exposure to terrorist attacks and the prevalence
of traumatic stress–related (TSR) symptoms, symptoms of posttraumatic
stress disorder (PTSD), and sense of safety after 19 months of terrorism in
Israel, and to identify correlates of the psychological sequelae and the modes
of coping with the terrorism.
Design, Setting, and Participants Telephone survey conducted April-May 2002, using a strata sampling method,
of 902 eligible households and a representative sample of 742 Israeli residents
older than 18 years (82% contact rate) and a final participation of 512 (57%).
Main Outcome Measures Number of TSR symptoms, rates of those with symptom criteria for PTSD
and acute stress disorder assessed by the Stanford Acute Stress Reaction Questionnaire,
self-reported feelings of depression, optimism, sense of safety, help-seeking,
and modes of coping.
Results Of 512 survey participants, 84 (16.4%) had been directly exposed to
a terrorist attack and 191 (37.3%) had a family member or friend who had been
exposed. Of 510 participants who responded to questions about TSR symptoms,
391 (76.7%) had at least 1 TSR symptom (mean, 4.0 [SD, 4.5]; range, 0-23;
mean intensity, 0.8; range, 0-4). Symptom criteria for PTSD were met by 48
participants (9.4%) and criteria for acute stress disorder, by 1 participant;
299 (58.6%) reported feeling depressed. The majority of respondents expressed
optimism about their personal future (421/512 [82.2%]) and the future of Israel
(307/509 [66.8%]), and expressed self-efficacy with regard to their ability
to function in a terrorist attack (322/431 [74.6%]). Most expressed a low
sense of safety with respect to themselves (307/509 [60.4%]) and their relatives
(345/507 [67.9%]). Few reported a need for professional help (27/506 [5.3%]).
Female sex, sense of safety, and use of tranquilizers, alcohol, and cigarettes
to cope were associated with TSR symptoms and symptom criteria for PTSD; level
of exposure and objective risk were not. The most prevalent coping mechanisms
were active information search about loved ones and social support.
Conclusions Considering the nature and length of the Israeli traumatic experience,
the psychological impact may be considered moderate. Although the survey participants
showed distress and lowered sense of safety, they did not develop high levels
of psychiatric distress, which may be related to a habituation process and
to coping mechanisms.
Since the beginning of the Al-Aqsa intifada in late September 2000,
Israeli society has been confronted by continual terrorism, including knife
or gun attacks, drive-by shootings, intrusions into homes, and suicide bombings.
By April 30, 2002, 472 persons (318 civilians) had been killed in terrorist
attacks and 3846 persons (2708 civilians) had been injured (totaling 0.067%
of the population of 6.4 million). Five hundred sixty of the terrorist attacks
(out of more than 13 000), with a death toll of 185, had been carried
out within Israel's 1967 borders.1
With the exception of a number of telephone and Web-based surveys conducted
following the September 11, 2001, attacks in the United States, few studies
have examined the impact of modern forms of terrorism on nationally representative
samples of developed countries. These post–September 11 studies examined
such matters as persons' sense of safety2,3 and
the prevalence of symptoms of posttraumatic stress disorder (PTSD), and traumatic
stress–related (TSR) symptoms.4,5
No study, however, has examined the psychological impact of the ongoing
terrorism in Israel. Herein we report the results of a nationally representative
telephone-based survey of Israeli residents conducted in April through May
2002, to determine the prevalence of symptoms of PTSD and to identify correlates
of these psychological sequelae and the coping modes used to deal with exposure
to terrorism and its ongoing threat.
Because Israel is a heterogeneous country with many subpopulations,
the sample was obtained by a within-strata random-sampling method using a
large database maintained by the DAHAF Institute. This database contains basic
demographic data on owners of telephones that has been gathered and updated
for more than 40 years for polling purposes. This method uses pools of stratified
household telephone numbers. These numbers are randomly chosen by computer
until the size criteria of each strata is attained. Strata were identified
by the following criteria: age, residence (towns and communities), new immigrants
from the former Soviet Union, kibbutz members, ultraorthodox Jews, Israeli
Arabs, and Jews either born or whose fathers were born in western Europe or
North America vs those born or whose fathers were born in Asia or Africa (new
immigrants included). The size of each stratum was deduced from information
drawn from the Israel Central Bureau of Statistics.6 The
target population consisted of all adult Israeli residents aged 18 years or
older. Accordingly, 902 households were telephoned and 742 individuals (each
representing 1 household) were randomly reached by telephone (82% contact
rate). Of these, 512 (69%) agreed to participate in the study, yielding a
final participation rate of 57% and a representative sample of the Israeli
population with a maximum sampling error of 4.5%.
Demographic characteristics of participants are shown in Table 1. The sample consisted of 250 men (48.9%) and 262 women (51.1%).
Ages ranged from 18 to 66 (mean, 38.35; SD, 15.8) years. There were 444 Jews
(86.8%) and 68 Arabs (13.2%). In terms of education, 243 (48.4%) had a year
or more of education after high school, 236 (46.9%) had completed high school,
and 24 (4.7%) had attended only elementary school. With respect to religiosity,
48 of the 444 Jews in the sample (11%) reported that they were religious (ie,
attempted to follow most of the religious rules, such as wearing a "cap" within
secular society), 134 (30.5%) that they were traditional (ie, followed most
of the religious rules of their respective ethnic tradition, usually only
within the confines of their homes and places of prayer), 21 (4.9%) that they
were orthodox (ie, lived in a religious community and followed the religious
rules socially as well as personally), and 235 (53.6%) that they were atheist.
Most of the sample lived in urban areas. Of the 444 Jews in the sample, 56.7%
were born in Israel and 43.3% were immigrants. All Arab participants were
born in Israel. With respect to income, 179 (49.3%) reported a net family
income below the mean (about $2000 per month), 145 (31.7%) reported a mean
family income, and 132 (28.9%) reported a family income higher than the mean.
The sample was representative of the Israeli population: no differences were
observed between the above distribution and data provided by the Israel Central
Bureau of Statistics, 2001.6
Participants (n = 512) and nonparticipants (n = 230) did not differ
on sex, income, residence, new immigrants from the former Soviet Union, kibbutz
members, ultraorthodox Jews, Israeli Arabs, and Jews being first- or second-generation
immigrants from western Europe or North America vs those from Asia or Africa.
Nonparticipants were significantly younger (mean age, 35.7 [SD, 15.4] years)
than participants (mean age, 38.2 [SD, 14.2] years; t740 = 2.1; P = .04).
Interviews were carried out by telephone using a structured questionnaire.
Three attempts were made to contact an adult at each telephone number. Whenever
5 questions were not responded to, the individual was considered a nonparticipant
and the interview was stopped (n = 5). Interviews were carried out on April
30 and May 1, 2002, by which time Israeli residents had experienced 19 months
Oral informed consent was obtained at the beginning of the interview,
when participants were asked whether they agreed to participate in the study.
The Helsinki Ethics Committee of the Lev-Hasharon Mental Health Center, affiliated
with the Sackler School of Medicine of the Tel-Aviv University, approved the
The interviewers were telephone-survey professionals with at least 1
year of experience who received training by a psychologist (M.G.) and a graduate
psychologist with experience in conducting telephone surveys. Trained interviewers
conducted telephone interviews in Hebrew, Russian, or Arabic; interviewers
speaking other languages were available but not used. A pilot study (see "Instruments"
section) was carried out in which a pool of interviewers best suited for this
survey was chosen based on their interview performance in the pilot study.
The research instrument was a structured questionnaire consisting of
51 questions drawn from several questionnaires used in the study of reactions
to trauma and coping.7- 9 These
questionnaires measure TSR symptoms, means of coping, sense of safety, and
orientation to the future. In addition, we added questions used in previous
surveys to assess reactions to major stressful events3 as
well as questions developed specifically for this study.
Except as otherwise indicated below, the participants were asked to
reply to the questions with respect to the "last year and a half since the
beginning of the events," which is approximately the time that had elapsed
since the beginning of the intifada. All items were self-referential. Following
a pilot study of 50 individuals, the questionnaire was modified to make it
telephone-friendly, remove items that were difficult to understand, and combine
some questions to reduce their number. Eighty-eight percent of the questionnaires
were answered in 12 to 15 minutes.
For the purpose of this study a "terrorist attack" was operationally
defined as any armed attack by a self-proclaimed terrorist group, as categorized
by the Israel Defense Forces.10
Exposure was assessed by participants being asked whether they had been
exposed to a terrorist attack, whether they had a friend or family member
who had been exposed to an attack, and whether they or their friend or family
member were injured or died in the attack. Based on these 3 questions, we
divided the participants into 6 exposure score groups: (1) no exposure; (2)
friend/family-only exposure, uninjured; (3) friend/family-only exposure (not
personal), injured or killed; (4) personal exposure only; (5) personal and
friend/family exposure, without injuries; and (6) personal and friend/family
exposure, with injuries and/or death of a relative or friend.
Trauma- and stress-related mental health symptoms were measured using
a modified version of the Stanford Acute Stress Reaction Questionnaire (SASRQ).7 The SASRQ has acceptable statistical properties7 and has been used in trauma-related surveys2 to assess TSR symptoms and symptoms of acute stress
disorder (ASD) and PTSD. Our modified SASRQ had a Cronbach α score of
0.91. The questionnaire consists of 5 groups of questions representing the
5 PTSD clusters as defined by Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria. It was composed of 23 statements, each referring to a particular
stress-related symptom or behavior. For this study, we used 4 persistent reexperiencing
items (cluster B), 6 avoidance/numbing items (cluster C), 6 hyperarousal items
(cluster D), 4 dissociative items (ie, depersonalization, derealization, emotional
numbing, amnesia), 2 impairment-cluster items (1 work-related and 1 social-related),
and 1 distress item. Participants were asked to rate their agreement with
each stress symptom on a 5-point Likert scale (0 = disagree, 1 = agree somewhat,
2 = agree, 3 = strongly agree, 4 = agree completely), and to report how long
they had felt or behaved in the stated manner (1 = 2 days or less; 2 = less
than 1 month; 3 = 1 month or more).
A symptom was considered relevant for TSR and PTSD if the individual
at least "agreed" (third choice out of 5) with the item and declared having
had the symptom for at least 1 month. This standard was used for the analyses
of the number of TSR symptoms and symptom criteria for PTSD and ASD. Because
not all participants met the full DSM-IV criteria
for PTSD (eg, actual exposure vs indirect exposure to a traumatic event) and
because our observations were made on the basis of screening instruments and
not comprehensive clinical evaluations, the participants were not considered
to have a clinical diagnosis of PTSD or ASD but an aggregation of symptom
criteria for PTSD and ASD.5
The survey included a single question regarding depression. Participants
were asked whether they felt "depressed" or "gloomy."
Coping was assessed using a modified version of the COPE8 questionnaire.
This questionnaire has acceptable statistical properties for the assessment
of coping mechanisms and has been used in other trauma-related studies.2,8 A telephone pilot study using a student
sample showed good test-retest properties over 2 weeks (Pearson r = 0.83-0.98; n = 30). The questionnaire consisted of 14 questions.
Ten questions were originally taken from the COPE questionnaire and referred
to distinct different means of coping: emotional social support/venting of
emotions, instrumental social support, faith in God, acceptance, mental disengagement,
denial, use of alcohol or cigarettes (to cope with the situation), use of
tranquilizers (to cope with the situation), humor, and engaging in activities.
Questions were added to discern whether the participants had checked on the
safety of relatives and/or friends when there had been an attack, whether
they listened to the television and radio to receive information (active coping),
whether they avoided television and radio news broadcasts (avoidance coping),
and whether they sought help from friends or family (actively seeking help/social
support). Participants were asked to indicate how often they used each means
of coping on a 5-point scale, ranging from 0 (not at all) to 4 (a great deal).
They also were asked whether they found each means of coping they endorsed
helpful (helpful or not).
Coping modes were presented in terms of type, the amount of coping mechanisms
used, and the frequency of usage in each case (0 = not used, 1 = used a little,
2 = used sometimes, 3 = used often, 4 = used always).
Future orientation was queried via 2 items modified from the Children's
Future Orientation Scale9; these 2 items assess
optimism about personal future and the future of Israel. Based on a telephone
interview of a student sample, test-retest correlation for these 2 items was r = 0.90 and r = 0.92, respectively
(n = 30). Participants were asked to indicate the degree to which they agreed
with the statements on a 6-point Likert scale ranging from 1 (very much agree)
to 6 (do not agree at all). A response was considered positive if the participant
indicated at least moderate agreement.3
Sense of safety was assessed by 2 items created for the study, which
respectively queried respondents' sense of threat to themselves and their
relatives. Based on a telephone interview of a student sample, test-retest
correlation for these 2 items was r = 0.93 and r = 0.90, respectively (n = 30). These 2 questions were
rated on a 5-point Likert scale ranging from 0 (not at all) to 4 (very much).
These questions were combined for the regression analysis. A response was
considered positive if the participant indicated at least moderate agreement.2
Self-efficacy was assessed by a single item asking participants to indicate
how much they believed that they would know what best to do if they were caught
in a terrorist attack. Based on a telephone interview of a student sample,
test-retest correlation for this item was r = 0.90
(n = 30). This question was rated on a 5-point Likert scale ranging from 0
(not at all) to 4 (very much). A response was considered positive if the participant
indicated at least moderate agreement.2
Help-seeking behavior was examined by asking participants whether they
currently felt a need for psychological or psychiatric treatment and whether
they had called the telephone hotlines put in place to help people cope with
the distress caused by terrorism. If participants answered "yes" to the latter
question, they were asked whether the contact had been helpful and whether
they thought that they would use the hotlines in the future.
Three measures were used to assess objective threat. First, all individuals
who lived in either Jerusalem, Tel-Aviv, Netania, or Haifa (4 cities where
most of the suicide bombings occurred before the study was performed), as
well as those who lived in the disputed settlements, were grouped together
and compared with those who lived elsewhere. A comparison of those 2 groups
showed that individuals residing in higher-risk areas reported significantly
higher exposure scores than those residing in lower-risk areas (lower-risk
areas [n = 379]: 0.90 [SD, 1.4]; higher-risk areas [n = 133]: 1.50 [SD, 1.6]; t510 = −3.8; P =
.001). Second, individuals living in urban vs nonurban places were compared
after removing from this variable those living in the disputed settlements.
A comparison of these 2 groups showed the urban group to have been significantly
more exposed to terrorist attacks than the nonurban group (urban group [n
= 404]: 1.15 [SD, 1.5]; nonurban group [n = 98]: 0.72 [SD, 1.4]; t510 = 5.0; P = .008). Third, the
Jewish and Arab populations were compared. A comparison of these 2 groups
showed Jews to have been significantly more exposed than Arabs (Jews [n =
442]: 1.20 [SD, 1.5]; Arabs [n = 67]: 0.57 [SD, 1.4]; t507 = 7.9; P = .001]).
Age, years of education, immigration year, and income were analyzed
as continuous data, and sex, ethnic background, religiosity, residence (town,
community, settlement, kibbutz, urban/nonurban), and place of birth (Israel/elsewhere)
as categorical data. Data were weighted to control for age and sex in the
descriptive analyses. t Tests for independent samples, χ2 tests, and Pearson correlations were performed, followed by 2 forward
stepwise linear regression for the continuous variables of TSR symptoms and
"feeling depressed," and a forward conditional logistic regression for the
variable of dichotomic symptoms of PTSD. In each regression analysis the significant
predictors from 7 groups of variables (demographics, exposure, objective risk,
coping, self-efficacy, future orientation, and sense of safety) were tested
for inclusion in the final models. Significance was set at P≤.05 (2-tailed). Nonsignificant variables were removed from analysis
to provide for the most parsimonious model. No imputation of missing values
was performed apart from the income score, which was replaced by the sample
mean for regression analyses. To control for the possibility that replacing
mean income scores for missing values biased our sample, regression analyses
were also performed on a smaller sample (n = 422) after removing all individuals
with missing income values. Results did not differ significantly from the
presented results of the original sample. Other cases were excluded from specific
analysis when information was missing relative to the content analyzed. This
did not affect the size and the integrity of the sample. SPSS-PC version 11.0
(SPSS Inc, Chicago, Ill) was used for all analyses.
The severity of exposure to terrorist attacks is shown in Table 2. More than half of respondents (285 [55.6%]) had not been
personally exposed or had a family member or friend who was exposed to an
attack. Thirty-six (7%) were exposed to an attack but had no family or friend
who was exposed; 17 (3.3%) were personally exposed and had a friend or family
member who was exposed without injury; and 31 (6%) were both personally exposed
to a terrorist attack and had a friend or family member killed or wounded
in an attack.
In total, 84 (16.4%) Israeli adults surveyed reported that they had
been personally involved in a terrorist attack in the year and a half prior
to the study; 113 (22.1%) reported that a friend or family member was wounded
or killed in an attack; and 78 (15.3%) reported that they knew someone who
survived an attack uninjured.
Participants endorsed a mean of 4.0 (SD, 4.5) stress-related items out
of the 23 that were queried (Table 3).
The mean level of TSR symptom intensity was 0.8 (range, 0-4; SD, 0.7), and
of 510 participants for whom TSR symptom intensity could be reported, 391
(76.7%) had at least 1 TSR symptom.
As shown in Table 2, 189
(37.1%) of the participants endorsed at least 1 re-experiencing item (cluster
B); 283 (55.5%) endorsed at least 1 avoidance/numbing symptom (cluster C);
252 (49.4%) of the participants endorsed at least 1 hyperarousal symptom (cluster
D); 116 (22.7%) of the participants endorsed at least 1 of the 2 impairment
items; and 236 (46.3%) endorsed the general distress item.
More than a quarter (138 [26.9%]) of the participants reported having
at least 1 of the 4 dissociative symptoms; the mean number of dissociative
symptoms endorsed was 0.4 (SD, 0.8). Depersonalization was reported by 58
(11.4%) of the participants, derealization by 42 (8.2%), emotional numbing
by 61 (12%), and amnesia by 46 (9%).
Symptom criteria for PTSD were met by 48 of the participants (9.4%).
More stringent standards (taking into consideration only answers of "strongly
agree" or higher) lowered the number to 14 (2.7%). Only 1 participant met
symptom criteria for ASD.
Of the 510 participants responding to the depression question, 299 (58.6%)
declared that they at least agreed with the statement "I feel depressed or
gloomy"; 152 (29.8%) stated that they "agreed very much" or "totally agreed"
with the statement.
The majority of participants (82.2% [421/512]) stated that they felt
optimistic about their personal future and 66.2% (337/509) that they felt
optimistic about the future of Israel. At the same time, 60.4% (307/509) declared
that they felt that their lives were in danger and 67.9% (345/507) that they
felt the lives of their family and/or acquaintances were in danger; 74.6%
(322/431) at least agreed they would function efficaciously in the event that
they were caught in a terrorist attack.
Only 5.3% (27/506) of the participants stated that they felt a need
for professional treatment; 12.2% (62/509) reported that they had called telephone
hotlines during the period queried; and 13.9% (66/475) thought they might
use them in the future. Of those who actually called the hotlines, 86.4% (57/66)
had not used them in the past and only 12.9% (8/62) found them helpful.
Using independent-samples t tests, χ2 tests, and Pearson correlations, no significant associations were
found between objective threat (high vs low residency risk, urban vs nonurban,
and Jewish vs Arab population) or exposure levels, and number of TSR or PTSD
symptoms or feeling depressed. With a sample size of 48 participants meeting
symptom criteria for PTSD compared with 461 without PTSD, the analysis had
a power of 44.8% to yield a statistically significant result.
Similarly, no significant association was found between objective threat
(high vs low residency risk, urban vs nonurban, Jewish vs Arab Israeli), exposure
and future orientation, or sense of personal safety. Nor was a significant
association found between objective threat, level of exposure, and either
perceived need for treatment, being in treatment, use of hotline, or anticipated
use of hotline in the future. We found no significant association between
objective threat and any of the dependent variables. The only significant
association found with level of exposure was reduced sense of safety for friends
or family (n = 505; Pearson r = .13; P = .005).
The presence of a symptoms of PTSD was associated significantly with
being female (16.2% [42/260] women vs 2.4% [6/249] men with symptoms of PTSD; χ21 = 28.1; P<.001) and with lower
income (on a 1-5 scale, those with symptoms of PTSD [2.4; SD, 1.2] vs those
with no symptoms of PTSD [2.8; SD, 1.2] t454 = 2.01; P = .45). No other demographic feature
was found to be significantly associated with symptoms of PTSD.
A higher number of TSR symptoms was found in women (women: 5.2 [SD,
5.0]; men: 3.5 [SD, 3.5]; t510 = 6.2; P<.001). Number of TSR symptoms also was associated
with place of birth (inside of Israel: 3.7 [SD, 4.4]; outside of Israel: 4.6
[SD, 4.5]; t510 = −2.2; P = .03), religiosity (religious: 4.7 [SD, 5.1]; not religious: 3.6
[SD, 4.0]; t437 = −2.6; P = .01), and lower income (lower than average income: 4.67 [SD, 5.2];
average and higher income: 3.7 [SD, 4.2]; t454 = −2.1; P = .03). No other significant
association was found with demographic items. Feeling depressed was associated
with mean age (those feeling depressed: 41.2 [SD, 15.8]; those not feeling
depressed: 37.2 [SD, 15.6] years; t506 =
2.6; P = .009) and sex (women: 2.1 [SD, 1.2]; men:
1.4 [SD, 1.2]; t506 = 6.8; P<.001).
The frequency and helpfulness of coping modes used to deal with the
terrorist attacks are presented in Table
4. The most frequently used modes of coping were checking on whereabouts
of family and friends after an attack and instrumental and emotional social
support. Tranquilizers and alcohol or cigarettes were used less frequently
as a specific coping mechanism. We did not assess use of tranquilizers, alcohol,
and cigarettes that was not associated with coping. Self-distraction through
activity, active search for social support, faith in God, and checking on
the whereabouts of family or friends after attacks were considered the most
helpful modes for those who had ever used them.
Participants used a mean of 6.4 (SD, 1.9; range, 1-12) coping modes
"ever" and a mean of 1.3 (SD, 1.6; range, 0-8) coping modes "always."
Three regression analyses were performed to assess the relative contribution
of exposure to terrorist attack, demographic items, means of coping, future
orientation, sense of safety, and self-efficacy to symptoms of PTSD, number
of TSR symptoms, and feeling depressed. The final regression models are presented
in Table 5.
All the regression models showed associations between all 3 dependent
variables and female sex, low sense of safety (used here as a predictor variable),
coping via use of tranquilizers, and coping via use of alcohol or cigarettes.
In addition, the models showed that coping by avoiding television and radio
was associated with the number of TSR symptoms, that faith in God was associated
with the number of TSR symptoms and feeling depressed, and that older age
was associated with feeling depressed. Due to sample size considerations we
could not validate the logistic regression model for symptoms of PTSD (we
could not assess fit via external validation).
This survey provides qualitative confirmation of the extensive exposure
to terrorism that Israeli civilians have experienced during the violent intifada
that began in September 2000. In the 19 months between then and the time that
the survey was conducted, in April through May 2001, almost half the participants
in the sample were exposed to terrorism personally or through a friend or
family member: 16.4% of participants reported experiencing a terrorist attack
personally, and 37.4% reported that a friend or relative was caught in an
The findings suggest that the terrorism has had a substantial impact.
Almost two thirds of the sample (60%) reported that they felt that their lives
were in danger and more than two thirds (67.9%) that they felt that the lives
of their friends and family were in danger.
In addition, the participants reported trauma- and stress-related mental
health symptoms. More than one third (37.4%) of participants reported having
at least 1 TSR symptom for at least 1 month, with a mean of 4 symptoms reported
per person. The most frequently reported symptoms were avoidance/numbing,
endorsed by 55.5% of the participants, followed by hyperarousal symptoms (49.4%),
and reexperiencing trauma-related scenes (37.1%). Furthermore, 26.9% of the
participants endorsed at least 1 dissociative symptom, 46.3% reported being
distressed by the symptoms, and 22.7% reported that their work or social functioning
More than half of the participants (58.6%) reported feeling depressed
or gloomy and 28% that they felt "very" depressed or gloomy. A total of 9.4%
of participants met DSM-IV symptom criteria for PTSD.
Although any clinical implications of these results should be interpreted
with caution, the rate can be extrapolated to 610 000 of 6.4 million
Israelis who may have met symptom criteria for PTSD at the time of the study.
For all the distress, however, the emotional impact seems to have been
fairly moderate. At the time of the study, the participants had faced 19 months
of terrorist attacks marked by steadily increasing frequency. The terrorism
reached almost all parts of the country. In addition, news of the terrorist
attacks was repeatedly covered by television and radio. Considering the high
levels of direct and indirect exposure to trauma in the sample, much more
distress might have been expected than was actually found.
The mean number and intensity of TSR symptoms reported by this sample
are similar to the number and intensity found among a national sample of US
residents following the September 11 terrorist attack on the New York World
Trade Center,2 which, for all its devastation,
occurred on a single day and further from home for most US residents than
the recurrent attacks experienced by the Israeli population. The prevalence
of those with symptom criteria for PTSD in our sample (9.4%) was also similar
to that found after September 11 among New York residents (eg, the rate of
7.5% as reported by Galea et al4 and of 11.2%
as reported by Schlenger et al5). However,
the rate in Israel from this study is lower than the rates reported for persons
in the immediate vicinity of the World Trade Center 1 to 2 months after the
September 11 attack (20%),4 and for those outside
of New York City 2 months after the attack (17%).2 Indeed,
the rate of those with symptom criteria for PTSD in Israel seems especially
low in light of the fact that many Israelis have experienced previous traumatic
events (eg, wars, prior terrorist attacks, the Holocaust), which may increase
the pathogenicity of subsequent traumatic experiences.11- 13
Thus, despite high levels of distress and concerns about safety, a relatively
low rate of symptoms of PTSD was observed. In addition, a majority of participants
reported little demand for professional help in dealing with the symptoms
aroused by the attacks. A majority also expressed optimism about their personal
future and the future of Israel, and a sense of self-efficacy in the event
of a terrorist attack.
Moreover, the majority of the participants seem to have coped constructively
and flexibly with the terrorism. They used a mean of 6 modes of coping, the
most prevalent of which were seeking information (about loved ones or in the
news media) and getting (and apparently giving) emotional and instrumental
social support and seeking it where they did not have it. In addition, the
coping modes reported as always used were mostly instrumental ones, such as
checking on the whereabouts of family or friends, active gathering of information
from the news media, and social support. Such modes of coping have been reported
to be associated with emotional health.12,14,15 A
substantially smaller proportion of the participants reported using self-distraction
or information avoidance, and a smaller percentage reported using tranquilizers,
alcohol, or cigarettes as specific modes of coping. These results may help
dispel the belief that people exposed to terrorism behave irrationally and
that both ego control and the social fabric disintegrate. Our results might
be slightly optimistic compared with other studies of the impact of trauma
on large-scale populations. However, many previous relevant studies have been
done in very extreme situations, such as war and civil conflict, which was
not the case in Israel.16- 18
The adaptive responses seen in this study may be explained by an accommodation
effect, in which the stress and distress created by traumatic events decrease
as they recur. Accommodation effects were reported during the 1991 Gulf War
as Israelis became habituated to the repeated missile attacks to which they
were subjected,11,12 as well as
during the German blitz during World War II when Londoners endured long and
constant bombing.19 In fact, the behaviors
of the Israeli and British populations seem to have been similar: neither
had a substantial number of psychiatric casualties, and both became habituated
to the stress. Along with feelings of depression, low sense of safety, and
other TSR symptoms, both populations reported high levels of self-efficacy
In addition to examining the emotional and cognitive repercussions of
the ongoing terrorism, this study sought to identify predictors of distress.
In contrast to the many studies that have found level of exposure to be associated
with symptoms of PTSD, TSR symptoms, and other psychosocial responses to traumatic
events,12,20 we found no association
between symptom criteria for PTSD and level of exposure. Nor was any association
found between level of exposure and the number or intensity of TSR symptoms
or any of the other indicators of distress. That is, persons who were actually
injured in a terrorist attack showed no more adverse emotional effects than
those who had not been exposed to an attack, either themselves or through
a family member or friend.
This finding may be accounted for in either of 2 ways. One is that those
who experience terrorism may understate their distress and continue with their
lives without being affected by it.12,21 The
other is that it reflects the wide-ranging impact of the pervasive traumatic
reality in Israel, which has either directly or indirectly (eg, through the
news media) affected virtually the entire population. This interpretation
is consistent with the conclusion of Silver et al2 that
the psychological impact of a major national trauma is not limited to those
who experience it directly.
Further support for the second interpretation is provided by the demographic
findings in our sample. These showed no difference in the traumatic sequelae
experienced by the urban and nonurban populations or by the Jewish and Arab
populations. Similarly, education did not buffer the impact of the terrorism
as it has been found to do for the impact of other traumatic experiences.12
Of all the demographic features studied, only female sex was significantly
associated with all mental health outcomes assessed (ie, symptoms of PTSD,
TSR symptoms, and "feeling depressed"). The regression analysis showed Israeli
women to be 5.54 times more likely than men to have symptom criteria for PTSD,
and a similar pattern also could be observed with TSR symptoms and feelings
of depression. Our findings support previous reports of women being more likely
than men to report having symptoms of PTSD.12,20,22 However,
sex bias in the reporting of symptoms cannot be ruled out.12 Further
study is warranted on the relationship between trauma, emotional coping, and
sex, and on the influence of this relationship on PTSD and TSR symptoms.
The study has a number of limitations, including the absence of data
from before the beginning of the intifada on the psychological repercussions
that were examined in this study. Without knowing the rate of symptoms of
PTSD in the population, the number and intensity of TSR symptoms, the sense
of safety, and feelings of depression in the period preceding the intifada,
we cannot properly ascertain the emotional impact of the terrorism. Another
limitation is that about a third of those contacted refused to be interviewed.
We cannot know whether or not their refusal was associated with a higher level
of distress. Furthermore, we cannot determine whether these self-reported
symptoms have clinical significance or if they simply reflect a heightened
awareness and arousal due to the terrorist threat.
In addition, one should be cautious in generalizing the findings to
various subpopulations that may or may not have been exposed to the threat
of terrorism and may not have been properly represented by strata sampling
(eg, those without homes or telephones). Furthermore, our results are not
generalizable to those younger than 18 years, who may in fact be at greater
risk of developing probable PTSD and stress-related symptoms.23 A
final limitation lies in the fact that we have not studied actual behavior.
The use of coping behaviors such as the avoidance of public places and public
transport might have given more insight into how Israelis reacted to the threat
Nonetheless, our study does show that after 19 months of unremitting
exposure to public terrorism, Israeli society was coping. Despite the limited
sense of safety and substantial distress, most Israelis reported adapting
to the situation without substantial mental health symptoms and impairment,
and most sought various ways of coping with terrorism and its ongoing threats.
This may be related to processes of adaptation and accommodation.