Biomedical Engineering Reference
In-Depth Information
help people to begin to regain the ability to think
calmly and clearly.
exposure to physical harm. As is evident from
the Tokyo sarin incident—but also equally in
other terrorist incidents with higher magnitudes
of lethality (e.g., September 11th, 2001)—most
victims of terrorism are not severely physically
injured or harmed. Physical injury does increase
the risk of subsequent psychological impairment
(e.g., post-traumatic stress disorder, PTSD, or
depression), but others also are at risk for PTSD
if they: (a) could have been severely harmed but
were not, or (b) witnessed devastating incidents
in which others were harmed, or witnessed others
experiencing pain and suffering in the aftermath of
disaster [1,2]. Credible threats that do not occur,
and close calls and near misses, can be as psycho-
logically traumatic as direct exposure to severe
physical harm—and may potentially have an even
greater shock value, due to the ability of people to
imagine even greater catastrophes than those that
actually happen. Witnessing pain and suffering, or
the horrors of dismemberment or massive prop-
erty destruction, also can be traumatic—indeed
even when witnessing terrorism occurs primarily
through media, the effects can be traumatizing
for children [11] or adults [12]. In the medical
arena, a major unrecognized source of psycholog-
ical trauma in the wake of terrorism is witnessing
the suffering of others while awaiting emergency
medical care.
Individuals who have experienced other psycho-
logical traumas or socioeconomic adversities or
life stressors (e.g., poverty, immigration, racial
discrimination [12]) prior to terrorism exposure are
at elevated risk for developing PTSD [13] and other
forms of persistent psychological impairment [12].
Prior traumatization does not appear to have an
inoculation effect, but rather a sensitization effect
which is consistent with the alterations in critical
areas of brain functioning related to stress reac-
tivity and stress management that have been found
in PTSD [14]. However, living with the persistent
and immediate threat of terrorism on a daily basis
does not necessarily lead to PTSD: a survey of
a large community sample of Israeli adults found
that few (9%) had PTSD and most were optimistic
about their own future (82%), their ability to cope
with terrorist incidents (75%), and their country's
11.1.1.3 Reversing the invisibility
and violation of terrorism
When a sense of being able to anticipate and have
some meaningful control over at least some impor-
tant upcoming events has been re-established, there
is a further challenge involved in sustaining this
newly restored (and still fragile, after the shock
of having been blindsided by terrorism) sense of
control and hope. Terrorism is particularly trau-
matic because the agent or its mechanism of action
is invisible (e.g., toxic gas, but also instruments of
destruction that are hidden in plain sight by terror-
ists who cannot be distinguished from ordinary
people, such as in the use of improvised explosive
devices). Further, the harm that terrorism causes
is not just frightening but moreover a pernicious
and pervasive violation of the integrity of people's
bodies (e.g., poisoning, disfiguration, and ampu-
tation) and of the trust that people place in one
another [8]. These effects cannot be fully reversed,
and should not be minimized, but they can be miti-
gated by communicating information that helps the
patient understand what is happening to their body
in a manner that is open and transparent (rather
than rendered invisible by the cloak of silence or
technical terminology), and that explicitly demon-
strates the provider's trustworthiness by involving
the patient in a collaborative relationships as a fully
informed consumer and an equal and respected
partner in decision making. Although this may
seem like nothing more than the basic founda-
tion for establishing a positive “working alliance”
with any patient [10], this collaborative stance is
particularly crucial in treating persons affected by
terrorism in order to reduce rather than inadver-
tently exacerbate a sense of helplessness in the face
threats that are invisible and profound violations.
11.1.2 Recognizing Acute and Repeated
Exposure to Traumatic Stress: Direct,
Threatened, and Witnessed
Terrorism unfortunately very clearly illustrates
why psychological trauma is not limited to direct
