Adverse childhood experiences, education, and involvement in terrorist violence: Examining mediation and moderation.

Most perpetrators of terrorist violence have had some level of post-secondary school education, with many enrolled in education at the time of their attacks. Exploring this premise in the context of prevention, this article draws from data gathered on a purposive sample (N = 206) of radicalized individuals from Europe and North America, half of whom became involved in terrorist violence at the end of their radicalization trajectories. Through a lens of educational participation, we propose novel, non-linear frameworks for understanding radicalization outcomes. To do so, two factors are explored that uniquely intersect when an individual enters a school setting: Adverse childhood experiences (ACE) and the human capital provided by education. As hypothesized, exposure to ACE was found to be associated with radicalization trajectories culminating in terrorist violence at the bivariate level (OR = 2.08). Consistent with the developmental-assets framework, it was further hypothesized that this relationship would be mediated by enrollment in education; however, results did not support this hypothesis. Instead, consistent with resiliency-based models, it was found that the relationship between ACE and involvement in terrorist violence was significant for those who abandoned education during radicalization (OR = 2.07). As well as contributing to theoretical models of radicalization to terrorist violence, identifying the furtherance of education as a moderator of risk may signal an important preventative strategy for violent extremism. Keeping enrolled students engaged in their programs, even if only nominally, may also forego the need for educators to engage in potentially controversial practices such as alerting the authorities to students who display signs of radicalization.

Violent extremism in the U.S.: Causes and consequences for youth, families, schools, and communities.

Violent extremism in the United States has surged over the past 25 years, with attacks on and threats to major governmental and other institutions, infrastructure (e.g., electric grid), and specific segments of the population, including immigrant and BIPOC (Black, Indigenous, and other People of Color) communities. Violent extremism can take multiple and diverse forms, such as bombings in public spaces or specific sites (e.g., house of worship, governmental office), mass and more targeted types of shootings, bombings, fire setting, and vehicle-based ramming attacks. This article provides an overview of key issues surrounding terrorism and violent extremism, especially as they can impact youth, schools, and families. Characteristics of violent extremism, radicalization processes, subsequent types of harm, and prevention approaches are discussed. Issues impacting students and schools and the work of school psychologists are also considered. The article closes with broader recommendations for moving forward.

Understanding and preventing violent extremism in school settings.

Violent extremism (VE; i.e., terrorism) is an issue of increasing relevance in school settings. Worldwide, terrorist actors have increasingly targeted youth in schools both for victimization via attacks as well for radicalization and recruitment to their ranks. Although violent extremism as an ideologically motivated act can be distinguished from mass shootings in school settings in that most school-based mass shootings are not ideologically motivated, there is obvious overlap. The threat of violent extremism, however, also represents a distinct issue that warrants increased attention from school professionals. We present an overview of several related issues before exploring strategies to mitigate the threat of targeted violence in school settings, including opportunities for school personnel to assist in identifying, assessing, and managing threats of violent extremism. In the final section, we focus specifically on ways that school psychologists can increase awareness and help bring about individual and systemic changes to prevent violent extremism in schools.

The Perinatal Outcomes Following the October 7th Hamas-led Attack on Israel.

BACKGROUND: On 7 October 2023, Hamas lunched a massive terror attack against Israel. The first weeks after were characterized with great uncertainty, insecurity, and fear. OBJECTIVES: To evaluate the effect of the first 2 months of the Iron Swords war on obstetrical emergency attendance and the corresponding perinatal outcomes. METHODS: We conducted a single center retrospective cohort study of all singleton births between 7 October and 7 December 2023. Prenatal emergency labor ward admission numbers and obstetric outcomes during the first 2 months of the war were compared to the combined corresponding periods for the years 2018-2022. RESULTS: During the initial 2 months of the conflict 1379 births were documented. The control group consisted of 7304 deliveries between 2018 and 2022. There was a decrease in daily emergency admissions to the labor ward during the first 5 weeks of the conflict compared to the corresponding periods in the preceding years (51.8 ± 15.0 vs. 57.0 ± 13.0, P = 0.0458). A notable increase in stillbirth rates was observed in the study group compared to the control group (5/1379 [0.36%] vs. 7/7304 [0.1%]; P = 0.014). Both groups exhibited similar gestational ages at birth, rates of preterm and post-term delivery, neonatal birthweights, mode of delivery, and induction of labor rates. CONCLUSIONS: In the initial weeks following Hamas's attack on Israel, there was a notable decrease in admissions to the prenatal emergency labor ward. This decline coincided with an increase in the rate of stillbirths among a population not directly involved in the conflict.

Perceptions of Afghan and Ukrainian refugees in Europe.

The Russian invasion of Ukraine led to a major humanitarian crisis resulting in many Ukrainians seeking refugee status in European countries. Unlike the positive attitudes towards Ukrainian refugees, Afghan refugees who were also required to leave their country following the Taliban's takeover of Afghanistan, received a negative reaction from the same European countries. Examining similar crises, a year apart, where people fled perilous situations in their countries, reveals contrasting reactions that emphasize the need to understand factors driving diverse public attitudes. Integrated Threat Theory (ITT), which posits that perceived threats can lead to prejudice and negative attitudes, may elucidate mechanisms behind opposing reactions towards Ukrainian and Afghan refugees. This study explores whether symbolic threats, intergroup anxiety, fear of terrorism, and political orientation are differentially related to attitudes towards Afghan and Ukrainian refugees in 250 European participants. Results demonstrate that participants hold more positive attitudes towards Ukrainian refugees compared to Afghan refugees. All the aforementioned factors predicted attitudes towards Afghan refugees, but only symbolic threats predicted attitudes towards Ukrainian refugees. Ethnicity and religiosity explain the relationship between symbolic threats and attitudes towards Afghan refugees. Western European participants show a stronger link between terrorism fear and negative views on Afghan refugees than Eastern Europeans, possibly due to higher terrorism rates in the West. Thus, attitudes towards refugees are intricate, but the study emphasizes the role of ITT, terrorism fear, politics, ethnicity, religiosity, and region. The findings could refine policies, stressing the need to address these factors for fostering inclusive, empathetic European societies.

Analyzing unmanned aerial vehicle (drone) attacks; a disaster medicine perspective.

INTRODUCTION: Unmanned aerial vehicles (UAVs), more commonly known as drones, have rapidly become more diverse in capabilities and utilization through technology advancements and affordability. While drones have had significant positive impact on healthcare and consumer delivery particularly in remote and austere environments, Violent Non-State Actors (VNSAs) have increasingly used drones as weapons in planning and executing terrorist attacks resulting in significant morbidity and mortality. We aim to analyze drone-related attacks globally against civilians and critical infrastructure for more effective hospital and prehospital care preparedness. METHODS: We retrospectively reviewed the Global Terrorism Database (GTD) from 1970 to 2020 to analyze the worldwide prevalence of drone-related attacks against civilians and critical infrastructure. Cases were excluded if they had insufficient information regarding a drone involvement, and if attacks were conducted by the government entities. The trends in the number of attacks per month, as well as the number of fatalities and injuries, were examined using time series and trend analysis. RESULTS: The database search yielded 253 drone-related incidents, 173 of which met inclusion criteria. These incidents resulted in 92 fatalities and 215 injuries with civilian targets most commonly attacked by drones (76 events, 43.9%), followed by military (46 events, 26.5-%). The Middle East region was most affected (168 events, 97% of attacks) and the Islamic state of Iraq was the most common perpetrator (106 events, 61.2%). Almost all attacks were by explosive devices attached to drones (172 events, 99.4%). Time series with linear trend analyses suggested an upward trends of drone attacks by VNSAs, resulting in a greater number of injuries and fatalities, that became more frequent over the years. CONCLUSIONS: Overtime, there were upward trends of drone attacks, with higher lethality and morbidity. There were more injuries compared to fatalities. Most common region affected was the Middle East, and most common type of weapon employed by drone technology was explosive weapon. Investment in medical personnel training, security, and research is crucial for an effective mass-casualty incident response after the drone attacks.

[THE USE OF AMBULATORY PSYCHIATRIC SERVICES AMONG THE ISRAELI POPULATION FOLLOWING THE OCTOBER 7 TERROR ATTACKS AND IRON SWORDS WAR].

BACKGROUND: On October 7, 2023, operation "Iron Swords" erupted following a barbaric terror attack, resulting in over 1,200 casualties, with more than 250 individuals, abducted. The aftermath of this slaughter led to the evacuation of hundreds of thousands from their homes in both the south and north of Israel. This situation triggered an unprecedented surge in the request for mental health support as reported by health funds and helplines. Global observations of large-scale traumatic events indicate increased usage of mental health services. The question then arises regarding the scope of services required in response to the mega-atrocity of October 7. OBJECTIVES: To chart the utilization of psychiatric clinical treatment services in Israel in the aftermath of the October 7 attack. METHODS: This is a retrospective cohort analysis using the electronic database from the research division of Clalit Health Services. We performed a comparative charting of mental health clinic treatments among individuals aged 15 and above, focusing on October-December 2023. These data were then compared to corresponding months over the previous five years (2018-2022). RESULTS: From October to December 2023, there was a 23.2% increase in the requests for mental health clinic treatments, compared to the same period in 2022. This surge extends a continuing upward trend in the utilization of mental health services observed since 2018. CONCLUSIONS: The study results emphasize the necessity for a responsive and flexible mental health system, to address immediate and long-term psychiatric care needs. The insights derived from these data are crucial for policymakers and clinicians to restructure mental health services, aiming to enhance the quality and accessibility of care for the Israeli population. DISCUSSION: The consistent rise in utilization of clinical mental health services significantly intensified following October 7, 2023. This echoes trends observed in global studies, underscoring the profound and enduring effects of traumatic experiences on mental health. These insights highlight the necessity for ongoing, high-quality therapeutic services and underscores the critical need for strategic policy development and increased investment in mental health services.

[ACUTE MENTAL HEALTH INTERVENTIONS AFTER THE OCTOBER 7 ATTACKS AND THE IRON SWORDS WAR: CASE SERIES].

INTRODUCTION: On October 7, 2023, terrorist organizations led by Hamas, launched an extensive attack on Israel. Within days following the initial attack, there was a clear need to provide psychological support to individuals who were exposed to the horrors of the October 7 attacks. Hence, the Tel Aviv Sourasky Medical Center opened the "Ichilov Otef Nefesh" clinic to provide psychological first aid to the first-line victims of the war. As the fighting spread, the services were extended to the entire population. The guiding principle of the intervention was that it is crucial in the acute phase after exposure to significant trauma, and its main purpose is to support the natural course of one's recovery processes. This case series describes three representative cases from among the hundreds of people who applied to the clinic. The intervention provided was guided by an integrated approach that promotes introspection and connectedness to one's environment and community, enhancing cognitive functions, emotional regulation and utilizing available resources to reduce distress. The main themes that emerged shifted between feelings of helplessness and a sense of agency; a breach in basic trust and renewed trust, guilt and self-compassion; anger, abandonment and alienation versus solidarity and connecting to the present and the future, despair versus hope and loss versus acceptance and connectedness. In face of these, the therapists endorsed techniques of validation, restoring self-agency, promoting a sense of self-agency and self-compassion, creating a link between the past and present, and finding connection and hope.

[THE ROLE OF STRESS IN MANIC-PSYCHOTIC EPISODE DURING THE TERROR ATTACK OF OCTOBER 7 - CASE REPORT].

INTRODUCTION: The bio-psycho-social model is mostly used to understand the etiology and pathogenesis of psychiatric disorders. Even though in our era, the biological factors became more dominant in the field, the stress-diathesis model is quite acceptable to explain and understand the evolution of psychotic as well as affective disorders. BACKGROUND: In this case report we present a patient, in her late 40's, admitted to our department with a manic-psychotic episode for the first time in her life, after the massive terror attack of October 7, and in which we suggest that the signs and symptoms might be explained using the psycho-dynamic theory. CONCLUSIONS: We conclude suggesting that the equilibrium of the bio-psycho-social model, should be adjusted in the context of time and space, especially during a situation of catastrophic scale in the patient environment. DISCUSSION: Although stress is a risk factor for the development of affective disorders and especially manic-psychotic episodes, there is scarce literature to support it. On the other hand, psycho-dynamic theories sometimes consider stressful life events as a causative factor for the development of depressive as well as manic episodes.

Holocaust centrality, anxiety, and other risk factors associated with terror threat salience among descendants of Holocaust survivors.

The study examined risk factors for sensitivity to terror threats among descendants of Holocaust survivors (Holocaust G1) during a significant rise in terrorist attacks in Israel. We examined the association of the number of familial Holocaust G1, trauma exposure, probable posttraumatic stress disorder (PTSD), anxiety symptoms, and Holocaust centrality with terror threat salience (TTS) in children and grandchildren of Holocaust G1 (Holocaust G2; G3). A web-based national sample included 297 Holocaust G2 (Mage=62.95, SD=10.25), 224 comparison G2 (Mage=61.79, SD=10.13), 379 Holocaust G3 (Mage=34.02, SD=8.65) and 171 comparison G3 (Mage=33.55, SD=8.26). Participants completed questionnaires on background characteristics, Holocaust background, trauma exposure, probable PTSD, anxiety symptoms, Holocaust centrality, and TTS. Findings showed that Holocaust G2 and G3 reported higher Holocaust centrality and TTS relative to comparisons, and Holocaust G3 reported higher levels of anxiety than comparison G3. The number of Holocaust G1, background characteristics, Holocaust centrality, and anxiety symptoms were associated with TTS in G2 and G3. Probable PTSD and trauma exposure were also associated with TTS in G2 and G3, respectively. Results highlight Holocaust centrality and anxiety among the factors associated with an increased preoccupation with terror threats in Holocaust descendants. Practitioners should implement interventions focusing on these factors, particularly at times of increased terrorism.

The impact of potentially morally injurious experience of betrayal on PTSD and depression following the October 7th terror attack.

With about 1200 individuals murdered, the massacre of October 7th was one of the deadliest terrorist attacks in modern history. The mental health consequences of terrorist attacks have been documented. However, little is known of the impact of the potentially morally injurious experience (PMIE) of betrayal--in which individuals feel betrayed by leaders they once trusted--on levels of psychological burden in the aftermath of such an attack. In this national prospective cohort study, we examined to what extent the PMIE of betrayal exacerbates the risk for posttraumatic stress disorder (PTSD) and depression in the wake of the October 7th terrorist attack. A representative sample of 710 Israeli adults (362 female, 51.1%), Jews (557, 79.9%) and Arabs (153, 20.1%), aged 18-85 (M = 41.01, SD = 13.72) completed validated self-report questionnaires assessing PTSD, depression, and PMIE-betrayal at two timepoints: T1, in August 2023 (6-7 weeks before the attack) and T2, in November 2023 (5-6 weeks after the attack). In two hierarchical logistic regressions, we found that experience of PMIE-betrayal predicted diagnoses of both PTSD (OR 1.92, 95% CI 1.26-2.92) and depression (OR 2.03, 95% CI 1.37-3.01) at T2, beyond probable PTSD/depression at T1 and demographic and trauma-related variables. Moreover, in two repeated-measure analyses predicting PTSD/depression symptoms, we found significant interactions between PTSD/depression trajectories and PMIE-betrayal, meaning that the increase of PTSD/depression symptoms was significantly higher among participants experiencing betrayal in the context of the attack. Our study highlights the impact of PMIE of betrayal on the dramatic increase in psychopathology following the October 7th terror attack on Israel's population. Clinicians treating individuals coping with PTSD and depression should attend to their patients' possible exposure to betrayal following the attack. Moreover, national leaders and policymakers should take significant steps to repair the public's betrayal experience.

DNA and fingerprint analyses of debris from improvised explosive device.

Improvised explosive devices (IEDs) can be assembled directly from daily items and are easily purchasable and distributable internationally, owing to the absence of government export permits. Hence, their origins are not readily revealed, and they can pose significant adverse effects despite their low manufacturing costs. In this study, the feasibility of identifying fingerprints and deoxyribo nucleic acid (DNA) profiles in various IEDs and samples is investigated. Additionally, the relative positions of debris are identified to set the scope of on-site inspection at terrorist scenes. All samples are categorized into porous and non-porous materials, and LMG test, extraction, quantification, and short tandem repeat (STR) analysis are conducted to view the DNA profile. For fingerprinting, 1,2-IND and CA are utilized for development, followed by quality-control analysis. Although sample acquisition is impossible in some experiments, DNA profiling and fingerprint analysis are possible for all, thus allowing mapping to be performed. This study shows that even when terrorist bombing occurs, if evidence with minimal damage is detected at the scene, then STR profiles and fingerprints can be obtained at a level suitable for AFIS usage. Furthermore, accumulating mapping results from numerous experiments significantly aids in determining the scope of evidence acquisition.

Impact of Terrorism on the Use of Healthcare Services in Burkina Faso Between 2015 and 2022.

Burkina Faso has been facing a security crisis due to terrorism since 2015. This study aims to assess the impact of the attacks on the use of healthcare services. This is a secondary study on data from the country's health data warehouse and the ACLED security data warehouse. After a description, generalized additive models were used to assess the impact of attacks on the use of health services. Between January 2015 and December 2022, 2449 kidnap/disappearance attacks, armed attacks, bombings and landmine explosions were perpetrated, causing 4965 deaths. The Sahel region was the most targeted (36.37% of attacks and 50.57% of deaths). Only population density had a significant impact on the use of health services (p<5%). The models were valid. Our study has shown that, despite the persistent insecurity in Burkina Faso, people are resilient and, above all, continue to seek out the most important healthcare services. It is therefore important to work to maintain the supply of these services.

Mass killing during terror attack at the Israel-Gaza border and the role of the Ministry of Health in identification of human remains and their release.

More than 1200 civilians and military were killed in cities and villages by the Hamas attack on October 7th, 2023. The bodies and body-parts had to be identified and released for burial. This report outlines the challenges and mode of operation of the massive disaster victim identification (DVI) efforts. Bodies were delivered to a central mortuary. Each body was coded and undressed for external inspection and documentation of physical elements. Digital fingerprints were recorded and blood or toenails sampled for DNA. Odontology exams were performed by dentists describing dentition, aided by computerized tomography (CT). Whole-body CT was performed in cases the bodies were disfigured or burned from the second week. Simultaneously, families of missing civilians provided physical elements to the police to extract the DNA for antemortem documentation. The police took the responsibility over the reconciliation, which was based on comparison of the ante-mortem and post-mortem fingerprints, aided by DNA profile matching, odontology examination, clinical and/or radiological findings performed by forensic practitioners. Secondary identification elements were used assure the families regarding the identification. Precise scientific identification a was a priority, even if it slowed the rate of bodies release. Families were allowed to view their relative either at the mortuary or before burial. The DVI process required cooperation between several governmental agencies and police. To maximize the effectiveness, a synchronized approach should be adopted, specifying communication channels between the partners and dividing the responsibilities. The DVI should be led by a single, experienced authority to ensure interdisciplinary teamwork. This catastrophe required personal resilience of the teams for rapid and efficient functioning and communication between the partners.

[Terror attacks : Recommendations for cooperation between police, hospitals and non-police security services]. / Lebensbedrohliche Einsatzlagen : Handlungsempfehlung zur Zusammenarbeit zwischen Polizei, Kliniken und nichtpolizeilicher Gefahrenabwehr.

BACKGROUND: The risk of terrorist attacks in the Federal Republic of Germany is present and is currently increasing. Publicly funded acute care hospitals and their owners are involved in disaster control as part of their remit and are responsible for taking comprehensive precautions to ensure their operational capability in the event of disasters. This mandate must also be ensured in the event of terrorist attacks and amok incidents. For this purpose, an optimal cooperation between preclinical and clinical care is indispensable. AIM: Recommended actions for collaboration between nonclinical and clinical planning to manage a mass casualty incident in terrorist life-threatening response situations are presented. MATERIAL AND METHODS: The Inter-Hospital Security Conference Baden-Württemberg (IHSC BW) is an association of representatives of acute hospitals in Baden-Württemberg, the Ministry of the Interior, Digitalization and Migration Baden-Württemberg, the Ministry of Social Affairs and Integration Baden-Württemberg, the State Police Headquarters Baden-Württemberg and the Baden-Württemberg Hospital Association. From 2018 to 2020, the IHSC BW developed recommendations for action on cooperation between police, hospitals and non-police emergency response. The recommendations for action were agreed by the group members in 6 working sessions and initialled in two subsequent video conferences. A recommendation was considered adopted when the IHSC BW plenary assembly finally gave its approval with an absolute majority. RESULTS AND DISCUSSION: Competence-based interface solutions for a smooth cooperation between prehospital and hospital management in the care of patients who have become victims of a terrorist attack are to be demanded. For preliminary planning, the establishment of a local safety conference at the county disaster control authority level with the following participants is recommended: disaster control authority, fire department, regional police headquarters, chief emergency physician, rescue services and disaster control officers of affected clinics. It is recommended to set up a joint command and situation center (CSC), where management personnel from the police, rescue service, fire department and disaster control can meet to organize the handling of the incident jointly, competently and without loss of time. From this CSC, a liaison officer should then provide the clinics with information at regular intervals. Exercises should take place regularly. Cross-organizational exercises are particularly important, and this is one of the tasks of the local safety conference.

Terror catastrophizing: association with anxiety, depression, and transgenerational effects.

Background & Objectives: Terror catastrophizing, defined as an ongoing fear of future terrorist attacks, is associated with a higher incidence of anxiety disorders, among other psychological impacts. However, previous studies examining terror catastrophizing's relationship to other mental health disorders are limited. The current study sought to determine if patients diagnosed with anxiety and depression would experience increased terror catastrophizing. Additionally, this study aimed to investigate whether parental terror catastrophizing increases children's internalizing symptoms.Design & Methods: Individuals were randomly drawn from the Danish Civil Registration System and invited to complete a series of questionnaires to measure terror catastrophizing tendency, lifetime parental trauma, and children's internalizing symptoms. In total, n = 4,175 invitees completed the survey of which 933 reported on a child between 6 and 18 years. Responses were analyzed using a generalized linear regression model.Results: Participants diagnosed with anxiety alone or comorbid with depression were more likely to experience symptoms of terror catastrophizing than undiagnosed participants (ß = 0.10, p < .001; ß = 0.07, p = .012). Furthermore, the parental tendency to catastrophize terror was associated with higher internalizing symptoms in children (ß = 0.09, p = .006), even after taking parental diagnoses, as well as lifetime and childhood trauma into account.Conclusion: The results can inform clinical practices to account for a patient's potential to exhibit increased terror catastrophizing tendencies or be more affected by traumatic events. Additionally, they can offer insights for designing novel preventative interventions for the whole family, due to the relation between parental tendencies for terror catastrophizing and the internalizing symptoms observed in children.

Diagnoses of comorbid anxiety and depression tend to have increased terror catastrophizing (TC); however, a sole anxiety diagnosis is associated with more TC, while sole depression is not.Informative for clinical practice to understand how patients with TC tendencies are more likely to be impacted by traumatic events.Parental TC symptoms are linked to internalizing symptoms in children; thus, this could inform the design of novel preventative interventions.

A longitudinal follow-up study of rescue and recovery narratives of Oklahoma City bombing responders nearly a quarter century later.

BACKGROUND: Most research examining first responders of terrorist incidents has been conducted in early post-disaster periods, utilized quantitative research methods, and focused on psychopathology such as post-traumatic stress. METHODS: Longitudinal follow-up assessments of 124 workers from 181 baseline volunteer rescue and recovery workers originally studied were completed nearly a quarter century after the terrorist bombing of the Murrah Federal Building in Oklahoma City. Open-ended qualitative interviews were used in the follow-up study. RESULTS: The rescue and recovery work, vividly described decades later, was gruesome. These workers' descriptions captured their mental toughness and their professional missions, as well as the emotional and mental health (MH) toll on their lives. CONCLUSIONS: The extreme nature of rescue and recovery work in the aftermath of terrorism suggests potential utility for MH interventions to address the psychological toll that can be expected of human beings under the most extraordinary circumstances.

Terrorism as Coalitional Predation: Explaining Definitional Ambiguities and Precautionary Responses.

Terrorism continues to be an enigmatic and contested concept, lacking a universally accepted definition despite extensive scholarly debate. Lay intuitions, however, demonstrate a notable convergence in identifying acts as "terrorism" when specific situational features are present, such as indiscriminate violence and out-group perpetration. These features elicit predictable and robust precautionary responses, raising the question: Is there a unified and parsimonious explanation for these phenomena? It is hypothesized that a situational template exists in the human mind, the coalitional predation template (CPT), which evolved not to detect modern-day terrorism, per se, but to identify and respond to situations of predatory coalitional conflict. The paper examines the potential cues and mechanisms that constitute the psychological systems activated by such threats, suggesting that matching the input cues of the CPT triggers well-documented precautionary responses to terrorism. However, this cue-based system may not align neatly with contemporary threats, leading to disproportionate responses to some threats while underestimating others. The model also posits that interpretations of violence can vary due to incomplete cues and the social position of the evaluator, leading to public disagreements and inconsistencies in defining terrorism. Consequently, arriving at an unambiguous and widely accepted definition of terrorism may not be possible. The model presented may account for a range of phenomena, including the inclination towards attributing mental illness to particular violent incidents and the uncanny surface similarities between terrorism and war crimes. The findings have significant implications for both the theoretical understanding of terrorism and practical policy responses.

Reported Increase in Substance Use Following Mass Terrorism and the Role of Psychosocial Factors.

Importance: Research has shown evidence of increased substance use (ISU) in populations affected by mass terrorism; however, less is known regarding how psychosocial factors interact to estimate ISU following such events. Objective: To examine which factors are associated with reporting ISU, test whether psychological distress (PD) mediated the association between exposure to trauma and reporting ISU, and whether the mediation effect differed among those with prior mental health (MH) difficulties and those without. Design, Setting, and Participants: A partially representative cross-sectional survey of the adult Jewish population in Israel (aged 18-70 years) was conducted 4 weeks after October 7, 2023 (October 31 to November 5, 2023). A national Web panel using quotas based on national distributions was used. Randomly chosen adult Jewish members were invited to participate until a predetermined sample size was reached. Main Outcomes and Measures: The study measures included reporting ISU (outcome), PD (mediator), exposure to terror events and sociodemographic characteristics (variables), and prior MH difficulties (moderator). Hypotheses regarding outcome and variables were formulated before data collection. Results: A total of 7000 invitations were distributed, 2679 individuals consented, 1432 were excluded owing to quota limits, 74 failed attention tests, and 205 opted out, resulting in 968 participants (490 women [50.6%]; mean [SD] age, 41.5 [14.6] years). Hierarchical regression analysis revealed that participants were significantly more likely to report ISU if they had experienced direct exposure (odds ratio [OR], 5.75; 95% CI, 2.53 to 13.05), indirect exposure (OR, 1.84; 95% CI, 1.27 to 2.67), media exposure (OR, 1.22; 95% CI, 1.09 to 1.36), PD (OR, 1.80; 95% CI, 1.44 to 2.25), or previous MH difficulties (OR, 2.76; 95% CI, 1.86 to 4.09). PD partially mediated the association between indirect exposure (b = 0.20; 95% CI, 0.11 to 0.31) and media exposure (b = 0.14; 95% CI, 0.10 to 0.19) and reporting ISU. No evidence was found to support previous MH difficulties as a moderator of these indirect effects (indirect exposure, b = -0.003; 95% CI, -0.28 to 0.28; media exposure, b = 0.01; 95% CI, -0.06 to 0.08). Conclusions and Relevance: This study contributes to the research on the association of mass terrorism with ISU while shedding important light on the role it may play in the self-medication of PD following exposure, even in those who might have no previous MH difficulties. These insights are crucial for planning essential health services and preventive measures.

It matters what you see: Graphic media images of war and terror may amplify distress.

Media exposure to graphic images of violence has proliferated in contemporary society, particularly with the advent of social media. Extensive exposure to media coverage immediately after the 9/11 attacks and the Boston Marathon bombings (BMB) was associated with more early traumatic stress symptoms; in fact, several hours of BMB-related daily media exposure was a stronger correlate of distress than being directly exposed to the bombings themselves. Researchers have replicated these findings across different traumatic events, extending this work to document that exposure to graphic images is independently and significantly associated with stress symptoms and poorer functioning. The media exposure-distress association also appears to be cyclical over time, with increased exposure predicting greater distress and greater distress predicting more media exposure following subsequent tragedies. The war in Israel and Gaza, which began on October 7, 2023, provides a current, real-time context to further explore these issues as journalists often share graphic images of death and destruction, making media-based graphic images once again ubiquitous and potentially challenging public well-being. For individuals sharing an identity with the victims or otherwise feeling emotionally connected to the Middle East, it may be difficult to avoid viewing these images. Through a review of research on the association between exposure to graphic images and public health, we discuss differing views on the societal implications of viewing such images and advocate for media literacy campaigns to educate the public to identify mis/disinformation and understand the risks of viewing and sharing graphic images with others.