The Effects of Terrorist Attacks on Symptom Clusters of PTSD: a Comparison with Victims of Other Traumatic Events

  • Andrea Pozza
  • Letizia Bossini
  • Fabio FerrettiEmail author
  • Miriam Olivola
  • Laura Del Matto
  • Serena Desantis
  • Andrea Fagiolini
  • Anna Coluccia
Original Paper


In the Post-Traumatic Stress Disorder (PTSD) literature, no study assessed differences in symptom clusters among victims of terrorist attacks (TA) as compared with victims of other traumatic events. Due to the intentional nature of the harm infliction, TA may be expected to produce more severe symptoms, particularly avoidance, since this cluster was found to be a severity marker and a maintenance factor of the disorder. As several patients delay treatment-seeking, duration of untreated illness (DUI) is another problem potentially influencing PTSD severity. The current study explored differences in PTSD symptom clusters as a function of the traumatic event type (TA compared with other events), DUI, and sex. One hundred-eight patients with primary PTSD were administered The Clinician Administered PTSD Scale. Mean DUI was approximately 12 years, irrespective of the event type. Patients who had experienced TA had significantly more severe Avoidance/Numbing symptoms and general PTSD severity than those who had experienced other events. No significant effects emerged for DUI and sex on all clusters. Timely recognition and intervention on PTSD may include community psychoeducation programs about its symptoms. Tailored intervention on TA-related PTSD may focus on Avoidance/Numbing by including medication and psychotherapeutic approaches for this symptom cluster.


Terrorism Trauma Avoidance Stress Victims Numbing 


Compliance with Ethical Standards

Conflict of Interest

Andrea Pozza declares that he has no conflict of interest.

Letizia Bossini declares that she has no conflict of interest.

Fabio Ferretti declares that he has no conflict of interest.

Miriam Olivola declares that she has no conflict of interest.

Laura Del Matto declares that she has no conflict of interest.

Serena Desantis declares that she has no conflict of interest.

Andrea Fagiolini declares that he has no conflict of interest.

Anna Coluccia declares that she has no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). Washington, DC: American Psychiatric Publishing; 2013.Google Scholar
  2. 2.
    Steinert C, Hofmann M, Leichsenring F, Kruse J. The course of PTSD in naturalistic long-term studies: high variability of outcomes. A systematic review. Nord J Psychiatry. 2015;69:483–96.CrossRefGoogle Scholar
  3. 3.
    Dunmore E, Clark DM, Ehlers A. A prospective investigation of the role of cognitive factors in persistent posttraumatic stress disorder (PTSD) after physical or sexual assault. Behav Res Ther. 2001;39:1063–84.CrossRefGoogle Scholar
  4. 4.
    Mowrer OH. Two-factor learning theory: summary and comment. Psychol Rev. 1951;58:350–4.CrossRefGoogle Scholar
  5. 5.
    Ehlers A, Clark DM. A cognitive model of posttraumatic stress disorder. Behav Res Ther. 2000;38:319–45.CrossRefGoogle Scholar
  6. 6.
    Ditlevsen DN, Elklit A. Gender, trauma type, and PTSD prevalence: a re-analysis of 18 nordic convenience samples. Ann General Psychiatry. 2012;11:26.CrossRefGoogle Scholar
  7. 7.
    Birkeland MS, Heir T. Making connections: exploring the centrality of posttraumatic stress symptoms and covariates after a terrorist attack. Eur J Psychotraumatol. 2017;8:1333387.CrossRefGoogle Scholar
  8. 8.
    Breslau N, Chilcoat HD, Kessler RC, Davis GC. Previous exposure to trauma and PTSD effects of subsequent trauma: results from the Detroit area survey of trauma. Am J Psychiatry. 1999;156:902–7.CrossRefGoogle Scholar
  9. 9.
    Farhood L, Dimassi H, Lehtinen T. Exposure to war-related traumatic events, prevalence of PTSD, and general psychiatric morbidity in a civilian population from southern Lebanon. J Transcult Nurs. 2006;17:333–40.CrossRefGoogle Scholar
  10. 10.
    Bowler RM, Adams SW, Gocheva VV, Li J, Mergler D, Brackbill R, et al. Posttraumatic stress disorder, gender, and risk factors: world trade center tower survivors 10 to 11 years after the September 11, 2001 attacks. J Trauma Stress. 2017;30:564–70.CrossRefGoogle Scholar
  11. 11.
    Perrin M, Vandeleur CL, Castelao E, Rothen S, Glaus J, Vollenweider P, et al. Determinants of the development of post-traumatic stress disorder, in the general population. Soc Psychiatry Psychiatr Epidemiol. 2014;49:447–57.CrossRefGoogle Scholar
  12. 12.
    Kolassa IT, Ertl V, Eckart C, Kolassa S, Onyut LP, Elbert T. Spontaneous remission from PTSD depends on the number of traumatic event types experienced. Psychol Trauma. 2010;2:169–74.CrossRefGoogle Scholar
  13. 13.
    Robinson JS, Larson C. Are traumatic events necessary to elicit symptoms of posttraumatic stress. Psychol Trauma. 2010;2:71–6.CrossRefGoogle Scholar
  14. 14.
    Galea S, Nandi A, Vlahov D. The epidemiology of post-traumatic stress disorder after disasters. Epidemiol Rev. 2005;27:78–91.CrossRefGoogle Scholar
  15. 15.
    Neria Y, DiGrande L, Adams BG. Posttraumatic stress disorder following the September 11, 2001, terrorist attacks: a review of the literature among highly exposed populations. Am Psychol. 2011;66:429–46.CrossRefGoogle Scholar
  16. 16.
    Wittchen HU, Gloster A, Beesdo K, Schonfeld S, Perkonigg A. Posttraumatic stress disorder: diagnostic and epidemiological perspectives. CNS Spectr. 2009;14:5–12.Google Scholar
  17. 17.
    Heir T, Blix I, Knatten CK. Thinking that one's life was in danger: perceived life threat in individuals directly or indirectly exposed to terror. Br J Psychiatry. 2016;209:306–10.CrossRefGoogle Scholar
  18. 18.
    Shalev AY, Freedman S. PTSD following terrorist attacks: a prospective evaluation. Am J Psychiatry. 2005;162:1188–91.CrossRefGoogle Scholar
  19. 19.
    Hansen MB, Birkeland MS, Nissen A, Blix I, Solberg Ø, Heir T. Prevalence and course of symptom-defined PTSD in individuals directly or indirectly exposed to terror: a longitudinal study. Psychiatry. 2017;80:171–83.CrossRefGoogle Scholar
  20. 20.
    Kessler RC. Posttraumatic stress disorder: the burden to the individual and to society. J Clin Psychiatry. 2000;61:4–12.Google Scholar
  21. 21.
    Santiago PN, Ursano RJ, Gray CL, Pynoos RS, Spiegel D, Lewis-Fernandez R, et al. A systematic review of PTSD prevalence and trajectories in DSM-5 defined trauma exposed populations: intentional and non-intentional traumatic events. PLoS One. 2013;8:e59236.CrossRefGoogle Scholar
  22. 22.
    Norman RM, Malla AK. Duration of untreated psychosis: a critical examination of the concept and its importance. Psychol Med. 2001;31:381–400.CrossRefGoogle Scholar
  23. 23.
    De Jong J, Komproe I, Van Ommeren M. Terrorism, human-made and natural disasters as a professional and ethical challenge to psychiatry. Int Psychiatry. 2003;1:8–9.CrossRefGoogle Scholar
  24. 24.
    Morina N, van Emmerik AA, Andrews B, Brewin CR. Comparison of DSM-IV and proposed ICD-11 formulations of PTSD among civilian survivors of war and war veterans. J Trauma Stress. 2014;27:647–54.CrossRefGoogle Scholar
  25. 25.
    Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52:1048–60.CrossRefGoogle Scholar
  26. 26.
    Kelley LP, Weathers FW, McDevitt-Murphy ME, Eakin DE, Flood AM. A comparison of PTSD symptom patterns in three types of civilian trauma. J Trauma Stress. 2009;22:227–35.CrossRefGoogle Scholar
  27. 27.
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: American Psychiatric Press; 2000.Google Scholar
  28. 28.
    General assembly of the world medical association. World medical association declaration of Helsinki: ethical principles for medical research involving human subjects. J Am Dent Assoc. 2014;81:14.Google Scholar
  29. 29.
    First MB, Spitzer RL, Gibbon M, Williams JB. Structured clinical interview for DSM-IV Axis I disorders-patient edition (SCID-I/P, version 2.0). New York, NY: Biometrics Research Department; 1995.Google Scholar
  30. 30.
    Mazzi F, Morosini P, De Girolamo G, Lussetti M, Guaraldi GP. SCID-I—structured clinical interview for DSM-IV Axis I disorders (Italian edition). Florence: Giunti OS; 2000.Google Scholar
  31. 31.
    First MB, Gibbon M, Spitzer RL, Williams JBW, Benjamin LS. Structured clinical interview for DSM-IV Axis II personality disorders (SCID-II). Washington, DC: American Psychiatric Press; 1997.Google Scholar
  32. 32.
    Maffei C, Fossati A, Agostoni I, Barraco A, Bagnato M, Donati D, et al. Interrater reliability and internal consistency of the structured clinical interview for DSM-IV Axis II personality disorders (SCID-II), version 2.0. J Personal Disord. 1997;11:279–84.CrossRefGoogle Scholar
  33. 33.
    Blake DD, Weathers FW, Nagy LM, Kaloupek DG, Gusman FD, Charney DS, et al. The development of a clinician-administered PTSD scale. J Trauma Stress. 1995;8:75–90.CrossRefGoogle Scholar
  34. 34.
    Weathers FW, Keane TM, Davidson JR. Clinician-administered PTSD scale: a review of the first ten years of research. Depress Anxiety. 2001;13:132–56.CrossRefGoogle Scholar
  35. 35.
    Cohen J. Statistical power analysis for the behavioral sciences. New York, NY: Routledge; 1988.Google Scholar
  36. 36.
    Olejnik S, Algina J. Generalized eta and omega squared statistics: measures of effect sizes for some common research designs. Psychol Methods. 2003;8:434–47.CrossRefGoogle Scholar
  37. 37.
    von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. STROBE Initiative (2007) The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet. 2007;37:1453–1457.Google Scholar
  38. 38.
    Friedman MJ, Wang S, Jalowiec JE, McHugo GJ, McDonagh-Coyle A. Thyroid hormone alterations among women with posttraumatic stress disorder due to childhood sexual abuse. Biol Psychiatry. 2005;57:1186–92.CrossRefGoogle Scholar
  39. 39.
    Amir M, Kaplan Z, Efroni R, Levine Y, Benjamin J, Kotler M. Coping styles in post-traumatic stress disorder (PTSD) patients. Pers Individ Dif. 1997;23:399–405.Google Scholar
  40. 40.
    Foa EB, Kozak MJ. Emotional processing of fear: exposure to corrective information. Psychol Bull. 1986;99:20–35.CrossRefGoogle Scholar
  41. 41.
    Kliem S, Kröger C. Prevention of chronic PTSD with early cognitive behavioral therapy. A meta-analysis using mixed-effects modeling. Behav Res Ther. 2013;51:753–61.CrossRefGoogle Scholar
  42. 42.
    Bean RC, Ong CW, Lee J, Twohig MP. Acceptance and commitment therapy for PTSD and trauma: an empirical review. Behav Ther. 2017;40:145–50.Google Scholar
  43. 43.
    Paunović N. Prolonged exposure counterconditioning as a treatment for chronic posttraumatic stress disorder. J Anxiety Disord. 2003;17:479–99.CrossRefGoogle Scholar
  44. 44.
    Litz BT, Schlenger WE, Weathers FW, Caddell JM, Fairbank JA, LaVange LM. Predictors of emotional numbing in posttraumatic stress disorder. J Trauma Stress. 1997;10:607–18.Google Scholar
  45. 45.
    Kuriyama K, Honma M, Soshi T, Fujii T, Kim Y. Effect of D-cycloserine and valproic acid on the extinction of reinstated fear-conditioned responses and habituation of fear conditioning in healthy humans: a randomized controlled trial. Psychopharmacology. 2011;218:589–97.CrossRefGoogle Scholar
  46. 46.
    Kuriyama K, Honma M, Yoshiike T, Kim Y. Valproic acid but not D-cycloserine facilitates sleep-dependent offline learning of extinction and habituation of conditioned fear in humans. Neuropharmacology. 2013;64:424–31.CrossRefGoogle Scholar
  47. 47.
    Attari A, Rajabi F, Maracy MR. D-cycloserine for treatment of numbing and avoidance in chronic post-traumatic stress disorder: a randomized, double blind, clinical trial. J Res Med Sc. 2014;19:592–8.Google Scholar
  48. 48.
    Bean RC, Ong CW, Lee J, Twohig MP. Acceptance and commitment therapy for PTSD and trauma: an empirical review. The Behav Ther. 2017;40:145–50.Google Scholar
  49. 49.
    Haynes PL, Kelly M, Warner L, Quan SF, Krakow B, Bootzin RR. Cognitive behavioral social rhythm group therapy for veterans with posttraumatic stress disorder, depression, and sleep disturbance: results from an open trial. J Affect Disord. 2016;192:234–43.CrossRefGoogle Scholar
  50. 50.
    Pineles SL, Mostoufi SM, Ready CB, Street AE, Griffin MG, Resick PA. Trauma reactivity, avoidant coping, and PTSD symptoms: a moderating relationship? J Abnorm Psychol. 2011;120:240–6.CrossRefGoogle Scholar
  51. 51.
    Schell TL, Marshall GN, Jaycox LH. All symptoms are not created equal: the prominent role of hyperarousal in the natural course of posttraumatic psychological distress. J Abnorm Psychol. 2004;113:189–97.CrossRefGoogle Scholar
  52. 52.
    Scrimin S, Moscardino U, Capello F, Altoè G, Steinberg AM, Pynoos RS. Trauma reminders and PTSD symptoms in children three years after a terrorist attack in Beslan. Soc Sci Med. 2011;72:694–0.CrossRefGoogle Scholar
  53. 53.
    De Jong JT, Komproe IH, Van Ommeren M. Common mental disorders in postconflict settings. Lancet. 2003;361:2128–30.CrossRefGoogle Scholar
  54. 54.
    Solomon Z, Gelkopf M, Bleich A. Is terror gender-blind? Gender differences in reaction to terror events. Soc Psychiatry Psychiatr Epidemiol. 2005;40:947–54.CrossRefGoogle Scholar
  55. 55.
    ten Have M, de Graaf R, Ormel J, Vilagut G, Kovess V, Alonso J. Are attitudes towards mental health help-seeking associated with service use? Results from the European study of epidemiology of mental disorders. Soc Psychiatry and Psychiatric Epidemiology. 2010;45:153–63.CrossRefGoogle Scholar
  56. 56.
    DiMaggio C, Galea S. The behavioral consequences of terrorism: a meta-analysis. Acad Emerg Med. 2006;13:559–66.CrossRefGoogle Scholar
  57. 57.
    McFarlane AC, Lawrence-Wood E, Van Hooff M, Malhi GS, Yehuda R. The need to take a staging approach to the biological mechanisms of PTSD and its treatment. Curr Psychiatry Rep. 2017;19:10.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Medical Sciences, Surgery and NeurosciencesSanta Maria alle Scotte University HospitalSienaItaly
  2. 2.Department of Molecular Medicine, University of Siena School of Medicine and Department of Mental HealthUniversity of Siena Medical Center (AOUS)SienaItaly

Personalised recommendations