Journal of Traumatic Stress December 2013, 26, 762–766
BRIEF REPORT
Psychological Effects of the Marathon Bombing on Boston-Area Veterans With Posttraumatic Stress Disorder Mark W. Miller,1,2 Erika J. Wolf,1,2 Christina Hein,1 Lauren Prince,1 and Annemarie F. Reardon1 1
2
National Center for PTSD at VA Boston Healthcare System, Boston, Massachusetts, USA Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
This study examined the psychological impact of the Boston Marathon bombing using data from an ongoing longitudinal study of Bostonarea veterans with posttraumatic stress disorder (PTSD; N = 71). Participants were assessed by telephone within 1 week of the end of the event; 42.3% of participants reported being personally affected by the bombings and/or the manhunt that followed. The majority of them reported that the bombing reminded them of their own traumas and/or caused other emotional distress. Examination of change in posttraumatic stress disorder (PTSD) symptoms from a prebombing assessment an average of 2 months earlier to 1 week after the event revealed no significant change in symptoms across the sample as a whole. However, examination of patterns of change at the individual level revealed significant correlations (r = .33; p = .005) between distress at the time of the event and change in total PTSD symptom severity, with this effect accounted for primarily by increases in intrusion and avoidance symptoms (rs = .35 and .31, ps = .002 and .008, respectively). Findings of this study should raise awareness of the potential impact of terror attacks, mass shootings, and other events of this type on the well-being of individuals with histories of trauma and/or pre-existing PTSD.
On Monday April 15, 2013, during the 117th running of the Boston Marathon, two bombs exploded near the finish line, killing 3 people and injuring 247. Thousands of runners, staff, and spectators witnessed the event, and tens of thousands of others likely knew a friend or relative who was there. Four days later, police engaged a pair of suspects in a firefight in suburban Watertown during the middle of the night. One suspect was killed and the other escaped, triggering a manhunt of unprecedented scope and intensity that included a day-long “shelter in place” order from the governor of Massachusetts for residents of Boston and surrounding communities. The surviving suspect was arrested that night. The experience will likely be recalled as one of the darkest moments of Boston’s nearly 400-year-old history. A substantial proportion of individuals who were directly affected by the bombing and/or had a close friend or relative who was killed or injured in it will be at risk for the devel-
opment of posttraumatic stress disorder (PTSD). Others who were less directly exposed may also be vulnerable to adverse psychological consequences by virtue of their prior histories of exposure to traumas of a similar nature and/or pre-existing PTSD. For Boston-area combat veterans with PTSD, similarities between aspects of the Marathon bombing and their own experiences in the warzone may reactivate trauma memories and exacerbate symptoms. However, though anecdotal clinical evidence suggests this to be the case, very few studies have examined this phenomenon directly and very little is known about the proportion of patients who might be affected, the severity of their reactions, or individual difference factors that predict them. In this report, we describe findings from a study of the psychological impact of the Boston Marathon bombing based on an ongoing longitudinal study of Boston-area veterans with histories of trauma and PTSD. From a methodological standpoint, the optimal approach to examining the effects of a new adverse life event on pre-existing PTSD is to examine symptom changes from pre- to postevent; however, doing so requires an established longitudinal cohort or a previously studied sample available for recontact. We are aware of only two published studies of this type. Niles, Wolf, and Kutter (2003) followed a small sample (N = 17) of Vietnam veterans with chronic PTSD in a 2-year longitudinal study using biweekly telephone assessments that captured intervals before and after the September 11, 2001 (9/11) attacks. Results showed a significant increase in PTSD severity during the 6
Funding for this study was provided by VA Merit Review Grant MHBA-01210F awarded to Mark Miller and a VA Career Development Award to Erika Wolf. Correspondence concerning this article should be addressed to Mark W. Miller, National Center for PTSD (116B-2), VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA 02130. E-mail: [email protected] Published 2013. This article is a US Government work and is in the public domain in the USA. View this article online at wileyonlinelibrary.com DOI: 10.1002/jts.21865
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weeks after 9/11 compared to the 6 weeks before it, with symptoms returning to baseline levels thereafter. Similarly, Rosen, Tiet, Cavella, Finney, and Lee (2005) surveyed 178 veterans from Veterans Affairs (VA) medical centers on the west coast of the United States with pre-existing PTSD 0–5 months before 9/11 and again 6 months after the attacks. In that study, mean levels of PTSD symptomatology did not change across the two time points, but a subsample of participants reported difficulties in functioning that they attributed to the 9/11 attacks. These findings suggest that some patients with chronic PTSD may react to new-onset adverse life events with acute exacerbations of pre-existing symptoms. For the U.S. VA and other health care systems and clinics to properly prepare for, and respond to, the mental health care needs of these patients, further research is needed to clarify how and to what extent they are affected.
Method Participants and Procedure Participants were drawn from a cohort of 120 veterans who were enrolled in an ongoing longitudinal study of PTSD and related conditions in the VA Boston Healthcare System. They were recruited originally from a database of veterans who had consented to be contacted for future research studies and through flyers posted around the medical center. At the time of enrollment, all participants screened positive for current PTSD according to the Diagnostic and Statistical Manual of Mental Disorder (4th ed.; DSM-IV; American Psychiatric Association, 1994) scoring algorithm based on responses to the PTSD Checklist (Weathers, Litz, Herman, Huska, & Keane, 1993) administered over the phone. All later completed a Clinician Administered PTSD Scale (CAPS; Blake et al., 1995) administered in-person by a doctoral-level clinical psychologist within 2 years prior to the Marathon bombing. All participants had also completed at least one self-report assessment of PTSD symptoms within 3 months prior to the bombing using the same measure that was readministered after it (described below). Sixty-eight (56.7%) of the original 120 met criteria for current PTSD according to the CAPS; 79 (65.8%) reported that they were receiving mental health services at that time. Analyses for this study were based on 71 participants (59.2%) who could be reached by telephone within 1 week of the date of the Marathon bombing suspect’s arrest. Of those 71, 36 (50.7%) met criteria for current PTSD at the previous interview and all endorsed histories of trauma and had experienced symptoms of PTSD in the past. Comparison of participants who completed the postbombing assessment with those who did not revealed no significant differences in PTSD severity, race, gender, or employment status, though completers were slightly older than noncompleters (M = 56.99 vs. M = 53.22, respectively), t(118) = −2.09, p = .039. Eighty-six percent (n = 61) of the sample was male and the mean age was 56.99 years (standard deviation [SD] = 9.50,
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range 27–70 years). Self-reported race and ethnicity were as follows: 55 (77.5%) White, 17 (23.9%) Black or African American, 7 (9.9%) American Indian or Alaskan Native, and 3 (4.2%) were of unknown racial origin. (Totals for demographic categories may exceed 100% when categories were not mutually exclusive). Three (4.2%) participants described their ethnicity as Hispanic or Latino. A majority of the sample (n = 38, 53.5%) was unemployed or receiving disability payments, 19 (26.8%) worked full- or part-time, 13 (18.3%) were retired, and 1 (1.4%) was a student. Thirty-four (47.9%) reported serving in the Army, 12 (16.9%) in the Navy, 18 (25.4%) in the Marines, 9 (12.7%) in the Air Force, and 1 (1.4%) in other branches of the military. Reported eras of military service were Vietnam War (n = 41; 57.7%), Operation Desert Storm (n = 5; 7.0%), Operation Iraqi Freedom or Operation Enduring Freedom (n = 8; 11.3%), and other deployments or peacetime (n = 17; 23.9%). PTSD assessments were based on an index trauma determined by a clinician during administration of the CAPS. Thirty (42.3%) participants endorsed combat as their index trauma, 7 (9.9%) endorsed the sudden death of a friend or loved one, 7 (9.9%) endorsed being assaulted by an acquaintance or a stranger, 5 (7.0%) endorsed being threatened with death or serious harm, 4 (5.6%) endorsed childhood physical abuse, and 4 (5.6%) endorsed being sexually assaulted as an adult. Several other types of index traumas were also reported (e.g., natural disaster or serious accident), each occurring in less than 5.0% of the sample. Measures The study was approved and reviewed annually by the institutional review board at the VA Boston Healthcare System. During the week after the Marathon bombing, study participants were contacted by telephone by a Bachelor’s-level research assistant for a PTSD-symptom assessment. At the beginning of the call, participants were asked, “Were you, or was anyone close to you, personally affected by the bombing or the manhunt that followed, and if so, how?” Participants’ free verbal response to this query was recorded in writing by the research assistants with no further prompting or follow-up questions. Participants were then administered a 20-item DSM-5 referenced PTSD checklist based on the language and rating scale used in the National Stressful Events Web Survey (Kilpatrick, Resnick, Baber, Guille, & Gros, 2011; Miller et al., 2012). Participants were instructed to rate their symptoms in reference to the index trauma on which their prior CAPS assessment had been based and they were reminded of which event that was by the interviewer. For the pre-Marathon bombing assessment, participants were instructed to rate how bothered they had been by each symptom during the past month using a Likert scale with verbal anchors that ranged from 1 = not at all to 5 = extremely. For the post-Marathon bombing assessment, participants were instructed to rate how bothered they had been by each symptom since the bombing using the same scale. Alpha coefficients for the pre- and postbombing assessments were .85
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
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Table 1 Examples of Veterans’ Accounts of the Psychological Impact of the Boston Marathon Bombings and Their Qualitative Categorizations Exposure/response category
Veterans’ accounts “I was in the grandstands in front of the library; went into action, helped out as much as I could. After, I felt very drained and kind of fearful. Reality hits after the fact and that’s when the feelings and the physical symptoms come in. And I drank after—I’m alcoholic—had been dry for a couple weeks before then.” “My youngest daughter was heading to the Red Sox game—in the general area at the time—and we couldn’t reach her. I could only picture the damage made by similar bombs at war, could only picture finding her body in the rubble like at war.” “When the people lost their legs, it reminded me and I flashed back to my friend getting cut in half, it made me angry.” “I’ve had a couple nightmares, especially because of the pictures of the bloody sidewalks. I’ve had flashbacks, but the pictures just kept making me picture war again and again.” “It bothered me a lot, brought back combat memories—a lot worse than my reaction to 9/11.” “I felt personally and physically detached—like I wasn’t here anymore.” “It really affected me—a trigger for me. I had cousins down there. I had to call out of work for several days.”
A
B, C
C C C D D
Note. A = participant was directly affected by the bombing; B = participant had a close friend or relative who was in the vicinity of the bombing; C = participant indicated that the bombing reminded him or her of his or her own trauma; D = participant reported experiencing emotional distress that was not explicitly linked to his or her own trauma history.
and .93, respectively. The mean length of time between the two administrations was 59.42 days; the correlation between scores across this interval was r = .79. The content of participants’ free responses was later analyzed using a qualitative method in which each response was coded into one or more of the following nonmutually exclusive categories based on the consensus of the five authors of this report: (a) the participant was directly affected by the bombing, (b) the participant had a close friend or relative who was in the vicinity of the bombing, (c) the participant indicated that the bombing reminded him or her of his or her own trauma, and (d) the participant reported experiencing emotional distress that was not explicitly linked to his or her own trauma history (see examples in Table 1). Each category was coded as present or absent.
Data Analysis We began by examining mean PTSD symptom score change from pre- to postbombing using a paired sample t test. We then calculated difference scores by subtracting the prebombing PTSD total score from the postbombing score and analyzed the pattern of association between the difference score and each dichotomous bombing exposure/response category (with absent as the reference group) using point-biserial correlations. To correct for multiple comparisons, we adjusted the p-value threshold for statistical significance using the Holm (1978) correction. We then followedup significant results from the analysis of PTSD total scores by examining individual symptom clusters separately.
Results Examples of personal accounts of the psychological impact of the bombing and manhunt appear in Table 1. Thirty participants (42.25% of those assessed postbombing) reported being personally affected by the experience. Of those, five (16.67% of those affected) reported having been in close physical proximity to either the bombing or the shootings and manhunt that followed (Category A). Ten (33.33% of those affected) reported that a close friend or relative had been in the immediate vicinity of the bombing (Category B). Eleven (36.67% of those affected) reported that the bombing reminded them of their own trauma (Category C), and 27 (90.00% of those affected and 38.02% of those surveyed) indicated that the events caused other emotional distress (Category D). Only two participants described the type of exposure that could be classified as meeting Criterion A under DSM-5 criteria: one reported being near the finish line when the bombs exploded and witnessing the scene firsthand; the other witnessed casualties arriving at a local hospital. A paired-sample t test revealed no significant change in mean level of PTSD symptoms across the sample as a whole (prebombing: M = 38.94, SD = 25.66; postbombing: M = 36.35, SD = 26.08), t(70) = 1.29, p = .200. However, visual inspection of the distribution of change scores showed considerable individual variability, which led us to wonder what factors might predict individual differences in change trajectory. To address this, we calculated point-biserial correlations between each of the four response categories and change in PTSD symptom severity. As shown in Table 2, this revealed a significant correlation (which surpassed the Holm adjusted p-value threshold of .01) between distress at the time of the event (Category D) and change in total PTSD symptom severity (r = .33; p = .005). We
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
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Table 2 Point Biserial Correlations Between Marathon Bombing Exposure/Response Category and Change in PTSD Severity Exposure/response category
Change in PTSD symptom severity
Directly affected by bombing Close other in vicinity of bombing Bombing reminiscent of own trauma Emotional distress related to bombing
.04 .05 .13 .33**
Note. N = 71. Each bombing expose/response variable was a dichotomous variable reflecting presence/absence of that experience. The categories were nonmutually exclusive. ** p < .01.
then examined the association between distress at the time of the event and change in each of the individual PTSD symptom clusters. Results showed that that the largest changes were in the Criterion B (intrusions) and Criterion C (avoidance) symptoms (rs = .35 and .31, ps = .002 and .008, respectively). Criterion D (negative alterations in cognitions and mood) showed a significant, albeit weaker, association with event-related distress (r = .26, p = .032) and the association with Criterion E (alterations in arousal and reactivity) was nonsignificant (r = .11, p = .352). Finally, analyses that examined other individual difference factors (e.g., trauma history, combat experience, PTSD severity, and personality traits) revealed no significant associations with change in PTSD symptom severity. This included an analysis that addressed the question of whether effects were confined to those with PTSD. We accomplished this by comparing PTSD symptom scores for those with and without a previous CAPS-based PTSD diagnosis using repeated measures analysis of variance. Results showed a main effect of PTSD diagnosis (i.e., individuals with PTSD had higher mean scores), F(1, 69) = 34.22, p < .001, but no significant Diagnosis × Time interaction, F(1, 69) < 1, p = .619. Discussion Average levels of PTSD symptom severity did not change significantly from the pre- to postbombing assessments for this sample of Boston-area veterans as a whole; however, analysis of individual change scores revealed considerable heterogeneity in response to the Marathon bombing. Veterans who reported being emotionally distressed at the time of the event showed significant increases in PTSD symptomatology—particularly in the domains of the hallmark symptoms of intrusive memories and nightmares about, and avoidance of stimuli associated with their previous traumas. A qualitative analysis of participants’ verbal description of their reactions suggested that for many participants, similarities between the Boston Marathon bombing and their own war zone trauma experiences reactivated trauma-related memories and prompted symptom exacerbations. Participants reported being triggered by horrific images from the bomb scene, “flashing back” to their own war
zone experiences, and feeling angry, detached, and fearful. It is noteworthy, however, that although a substantial subsample (38% of those surveyed) reported being emotionally distressed and showed symptom increases, the majority of the veterans in this cohort indicated that they were not personally impacted by the experience. Though it is possible that our assessment method underestimated the degree of impact, these findings underscore the heterogeneity of reactions to new-onset adverse life events and highlight the considerable resilience of many veterans to such adversity, even those with trauma histories and longstanding symptoms of PTSD. These conclusions should be weighed in light of the study’s strengths and limitations. The primary strength was the longitudinal sample composed of Boston-area veterans who were already being followed prior to the bombing and a postbombing assessment that was completed within approximately a week of the end of the event. Limitations included the modest sample size, which likely limited our power to identify individual difference factors predictive of symptom exacerbation; a circumscribed assessment of reactions to the event based on free responses to a single interview question; a qualitative coding system designed specifically for this study; and the absence of a control group. Also, we have yet to determine the duration of observed changes. To conclude, findings of this study should raise awareness of the potential impact of terror attacks, mass shootings, and other manmade or natural catastrophes on the well-being of individuals with histories of trauma and/or pre-existing PTSD. Health care providers and systems should be prepared to offer services, not only to those directly impacted by the event, but also to those for whom the event triggers a recurrence of intrusive memories, avoidance, and other symptoms linked to a prior trauma. At the same time, providers should recognize that there is considerable variability in the nature of such responses and understand that many at risk individuals show remarkable resilience when confronted with new-onset adverse life events. Future research should aim to further clarify the impact of events of this type on pre-existing PTSD symptomatology and advance the understanding of the role that they play in serving to perpetuate or maintain chronic symptomatology. References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Gusman, F. D., Charney, D. S., & Keane, T. M. (1995). The development of a ClinicianAdministered PTSD Scale. Journal of Traumatic Stress, 8, 75–90. Holm, S. (1978). A simple sequentially rejective multiple test procedure. Scandinavian Journal of Statistics, 6, 65–70. Kilpatrick, D. G., Resnick, H. S., Baber, B., Guille, C., & Gros, K. (2011). The National Stressful Events Web Survey (NSES-W). Charleston, SC: Medical University of South Carolina. Miller, M. W., Wolf, E. J., Kilpatrick, D., Resnick, H., Marx, B. P., Holowka, D. W., . . . .Friedman, M. J. (2012). The prevalence and latent structure of
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proposed DSM-5 posttraumatic stress disorder symptoms in US national and veteran samples. Psychological Trauma: Theory, Research, Practice and Policy. Advance online publication. doi:10.1037/a0029730
Rosen, C., Tiet, Q., Cavella, S., Finney, J., & Lee, T. (2005). Chronic PTSD patients’ functioning before and after the September 11th attacks. Journal of Traumatic Stress, 18, 781–784. doi:10.1002/jts.20086
Niles, B. L., Wolf, E. J., & Kutter, C. J. (2003). Posttraumatic stress disorder symptomatology in Vietnam veterans before and after September 11. Journal of Nervous and Mental Disease, 191, 682–684. doi:10.1097/01.nmd.0000092178.45511.e6
Weathers, F. W., Litz, B. T., Herman, D. S., Huska, J. A., & Keane, T. M. (1993, October). The PTSD Checklist: Reliability, validity, & diagnostic utility. Paper presented at the Annual Meeting of the International Society for Traumatic Stress Studies, San Antonio, TX.
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
BRIEF REPORT
Psychological Effects of the Marathon Bombing on Boston-Area Veterans With Posttraumatic Stress Disorder Mark W. Miller,1,2 Erika J. Wolf,1,2 Christina Hein,1 Lauren Prince,1 and Annemarie F. Reardon1 1
2
National Center for PTSD at VA Boston Healthcare System, Boston, Massachusetts, USA Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
This study examined the psychological impact of the Boston Marathon bombing using data from an ongoing longitudinal study of Bostonarea veterans with posttraumatic stress disorder (PTSD; N = 71). Participants were assessed by telephone within 1 week of the end of the event; 42.3% of participants reported being personally affected by the bombings and/or the manhunt that followed. The majority of them reported that the bombing reminded them of their own traumas and/or caused other emotional distress. Examination of change in posttraumatic stress disorder (PTSD) symptoms from a prebombing assessment an average of 2 months earlier to 1 week after the event revealed no significant change in symptoms across the sample as a whole. However, examination of patterns of change at the individual level revealed significant correlations (r = .33; p = .005) between distress at the time of the event and change in total PTSD symptom severity, with this effect accounted for primarily by increases in intrusion and avoidance symptoms (rs = .35 and .31, ps = .002 and .008, respectively). Findings of this study should raise awareness of the potential impact of terror attacks, mass shootings, and other events of this type on the well-being of individuals with histories of trauma and/or pre-existing PTSD.
On Monday April 15, 2013, during the 117th running of the Boston Marathon, two bombs exploded near the finish line, killing 3 people and injuring 247. Thousands of runners, staff, and spectators witnessed the event, and tens of thousands of others likely knew a friend or relative who was there. Four days later, police engaged a pair of suspects in a firefight in suburban Watertown during the middle of the night. One suspect was killed and the other escaped, triggering a manhunt of unprecedented scope and intensity that included a day-long “shelter in place” order from the governor of Massachusetts for residents of Boston and surrounding communities. The surviving suspect was arrested that night. The experience will likely be recalled as one of the darkest moments of Boston’s nearly 400-year-old history. A substantial proportion of individuals who were directly affected by the bombing and/or had a close friend or relative who was killed or injured in it will be at risk for the devel-
opment of posttraumatic stress disorder (PTSD). Others who were less directly exposed may also be vulnerable to adverse psychological consequences by virtue of their prior histories of exposure to traumas of a similar nature and/or pre-existing PTSD. For Boston-area combat veterans with PTSD, similarities between aspects of the Marathon bombing and their own experiences in the warzone may reactivate trauma memories and exacerbate symptoms. However, though anecdotal clinical evidence suggests this to be the case, very few studies have examined this phenomenon directly and very little is known about the proportion of patients who might be affected, the severity of their reactions, or individual difference factors that predict them. In this report, we describe findings from a study of the psychological impact of the Boston Marathon bombing based on an ongoing longitudinal study of Boston-area veterans with histories of trauma and PTSD. From a methodological standpoint, the optimal approach to examining the effects of a new adverse life event on pre-existing PTSD is to examine symptom changes from pre- to postevent; however, doing so requires an established longitudinal cohort or a previously studied sample available for recontact. We are aware of only two published studies of this type. Niles, Wolf, and Kutter (2003) followed a small sample (N = 17) of Vietnam veterans with chronic PTSD in a 2-year longitudinal study using biweekly telephone assessments that captured intervals before and after the September 11, 2001 (9/11) attacks. Results showed a significant increase in PTSD severity during the 6
Funding for this study was provided by VA Merit Review Grant MHBA-01210F awarded to Mark Miller and a VA Career Development Award to Erika Wolf. Correspondence concerning this article should be addressed to Mark W. Miller, National Center for PTSD (116B-2), VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA 02130. E-mail: [email protected] Published 2013. This article is a US Government work and is in the public domain in the USA. View this article online at wileyonlinelibrary.com DOI: 10.1002/jts.21865
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weeks after 9/11 compared to the 6 weeks before it, with symptoms returning to baseline levels thereafter. Similarly, Rosen, Tiet, Cavella, Finney, and Lee (2005) surveyed 178 veterans from Veterans Affairs (VA) medical centers on the west coast of the United States with pre-existing PTSD 0–5 months before 9/11 and again 6 months after the attacks. In that study, mean levels of PTSD symptomatology did not change across the two time points, but a subsample of participants reported difficulties in functioning that they attributed to the 9/11 attacks. These findings suggest that some patients with chronic PTSD may react to new-onset adverse life events with acute exacerbations of pre-existing symptoms. For the U.S. VA and other health care systems and clinics to properly prepare for, and respond to, the mental health care needs of these patients, further research is needed to clarify how and to what extent they are affected.
Method Participants and Procedure Participants were drawn from a cohort of 120 veterans who were enrolled in an ongoing longitudinal study of PTSD and related conditions in the VA Boston Healthcare System. They were recruited originally from a database of veterans who had consented to be contacted for future research studies and through flyers posted around the medical center. At the time of enrollment, all participants screened positive for current PTSD according to the Diagnostic and Statistical Manual of Mental Disorder (4th ed.; DSM-IV; American Psychiatric Association, 1994) scoring algorithm based on responses to the PTSD Checklist (Weathers, Litz, Herman, Huska, & Keane, 1993) administered over the phone. All later completed a Clinician Administered PTSD Scale (CAPS; Blake et al., 1995) administered in-person by a doctoral-level clinical psychologist within 2 years prior to the Marathon bombing. All participants had also completed at least one self-report assessment of PTSD symptoms within 3 months prior to the bombing using the same measure that was readministered after it (described below). Sixty-eight (56.7%) of the original 120 met criteria for current PTSD according to the CAPS; 79 (65.8%) reported that they were receiving mental health services at that time. Analyses for this study were based on 71 participants (59.2%) who could be reached by telephone within 1 week of the date of the Marathon bombing suspect’s arrest. Of those 71, 36 (50.7%) met criteria for current PTSD at the previous interview and all endorsed histories of trauma and had experienced symptoms of PTSD in the past. Comparison of participants who completed the postbombing assessment with those who did not revealed no significant differences in PTSD severity, race, gender, or employment status, though completers were slightly older than noncompleters (M = 56.99 vs. M = 53.22, respectively), t(118) = −2.09, p = .039. Eighty-six percent (n = 61) of the sample was male and the mean age was 56.99 years (standard deviation [SD] = 9.50,
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range 27–70 years). Self-reported race and ethnicity were as follows: 55 (77.5%) White, 17 (23.9%) Black or African American, 7 (9.9%) American Indian or Alaskan Native, and 3 (4.2%) were of unknown racial origin. (Totals for demographic categories may exceed 100% when categories were not mutually exclusive). Three (4.2%) participants described their ethnicity as Hispanic or Latino. A majority of the sample (n = 38, 53.5%) was unemployed or receiving disability payments, 19 (26.8%) worked full- or part-time, 13 (18.3%) were retired, and 1 (1.4%) was a student. Thirty-four (47.9%) reported serving in the Army, 12 (16.9%) in the Navy, 18 (25.4%) in the Marines, 9 (12.7%) in the Air Force, and 1 (1.4%) in other branches of the military. Reported eras of military service were Vietnam War (n = 41; 57.7%), Operation Desert Storm (n = 5; 7.0%), Operation Iraqi Freedom or Operation Enduring Freedom (n = 8; 11.3%), and other deployments or peacetime (n = 17; 23.9%). PTSD assessments were based on an index trauma determined by a clinician during administration of the CAPS. Thirty (42.3%) participants endorsed combat as their index trauma, 7 (9.9%) endorsed the sudden death of a friend or loved one, 7 (9.9%) endorsed being assaulted by an acquaintance or a stranger, 5 (7.0%) endorsed being threatened with death or serious harm, 4 (5.6%) endorsed childhood physical abuse, and 4 (5.6%) endorsed being sexually assaulted as an adult. Several other types of index traumas were also reported (e.g., natural disaster or serious accident), each occurring in less than 5.0% of the sample. Measures The study was approved and reviewed annually by the institutional review board at the VA Boston Healthcare System. During the week after the Marathon bombing, study participants were contacted by telephone by a Bachelor’s-level research assistant for a PTSD-symptom assessment. At the beginning of the call, participants were asked, “Were you, or was anyone close to you, personally affected by the bombing or the manhunt that followed, and if so, how?” Participants’ free verbal response to this query was recorded in writing by the research assistants with no further prompting or follow-up questions. Participants were then administered a 20-item DSM-5 referenced PTSD checklist based on the language and rating scale used in the National Stressful Events Web Survey (Kilpatrick, Resnick, Baber, Guille, & Gros, 2011; Miller et al., 2012). Participants were instructed to rate their symptoms in reference to the index trauma on which their prior CAPS assessment had been based and they were reminded of which event that was by the interviewer. For the pre-Marathon bombing assessment, participants were instructed to rate how bothered they had been by each symptom during the past month using a Likert scale with verbal anchors that ranged from 1 = not at all to 5 = extremely. For the post-Marathon bombing assessment, participants were instructed to rate how bothered they had been by each symptom since the bombing using the same scale. Alpha coefficients for the pre- and postbombing assessments were .85
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
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Table 1 Examples of Veterans’ Accounts of the Psychological Impact of the Boston Marathon Bombings and Their Qualitative Categorizations Exposure/response category
Veterans’ accounts “I was in the grandstands in front of the library; went into action, helped out as much as I could. After, I felt very drained and kind of fearful. Reality hits after the fact and that’s when the feelings and the physical symptoms come in. And I drank after—I’m alcoholic—had been dry for a couple weeks before then.” “My youngest daughter was heading to the Red Sox game—in the general area at the time—and we couldn’t reach her. I could only picture the damage made by similar bombs at war, could only picture finding her body in the rubble like at war.” “When the people lost their legs, it reminded me and I flashed back to my friend getting cut in half, it made me angry.” “I’ve had a couple nightmares, especially because of the pictures of the bloody sidewalks. I’ve had flashbacks, but the pictures just kept making me picture war again and again.” “It bothered me a lot, brought back combat memories—a lot worse than my reaction to 9/11.” “I felt personally and physically detached—like I wasn’t here anymore.” “It really affected me—a trigger for me. I had cousins down there. I had to call out of work for several days.”
A
B, C
C C C D D
Note. A = participant was directly affected by the bombing; B = participant had a close friend or relative who was in the vicinity of the bombing; C = participant indicated that the bombing reminded him or her of his or her own trauma; D = participant reported experiencing emotional distress that was not explicitly linked to his or her own trauma history.
and .93, respectively. The mean length of time between the two administrations was 59.42 days; the correlation between scores across this interval was r = .79. The content of participants’ free responses was later analyzed using a qualitative method in which each response was coded into one or more of the following nonmutually exclusive categories based on the consensus of the five authors of this report: (a) the participant was directly affected by the bombing, (b) the participant had a close friend or relative who was in the vicinity of the bombing, (c) the participant indicated that the bombing reminded him or her of his or her own trauma, and (d) the participant reported experiencing emotional distress that was not explicitly linked to his or her own trauma history (see examples in Table 1). Each category was coded as present or absent.
Data Analysis We began by examining mean PTSD symptom score change from pre- to postbombing using a paired sample t test. We then calculated difference scores by subtracting the prebombing PTSD total score from the postbombing score and analyzed the pattern of association between the difference score and each dichotomous bombing exposure/response category (with absent as the reference group) using point-biserial correlations. To correct for multiple comparisons, we adjusted the p-value threshold for statistical significance using the Holm (1978) correction. We then followedup significant results from the analysis of PTSD total scores by examining individual symptom clusters separately.
Results Examples of personal accounts of the psychological impact of the bombing and manhunt appear in Table 1. Thirty participants (42.25% of those assessed postbombing) reported being personally affected by the experience. Of those, five (16.67% of those affected) reported having been in close physical proximity to either the bombing or the shootings and manhunt that followed (Category A). Ten (33.33% of those affected) reported that a close friend or relative had been in the immediate vicinity of the bombing (Category B). Eleven (36.67% of those affected) reported that the bombing reminded them of their own trauma (Category C), and 27 (90.00% of those affected and 38.02% of those surveyed) indicated that the events caused other emotional distress (Category D). Only two participants described the type of exposure that could be classified as meeting Criterion A under DSM-5 criteria: one reported being near the finish line when the bombs exploded and witnessing the scene firsthand; the other witnessed casualties arriving at a local hospital. A paired-sample t test revealed no significant change in mean level of PTSD symptoms across the sample as a whole (prebombing: M = 38.94, SD = 25.66; postbombing: M = 36.35, SD = 26.08), t(70) = 1.29, p = .200. However, visual inspection of the distribution of change scores showed considerable individual variability, which led us to wonder what factors might predict individual differences in change trajectory. To address this, we calculated point-biserial correlations between each of the four response categories and change in PTSD symptom severity. As shown in Table 2, this revealed a significant correlation (which surpassed the Holm adjusted p-value threshold of .01) between distress at the time of the event (Category D) and change in total PTSD symptom severity (r = .33; p = .005). We
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Table 2 Point Biserial Correlations Between Marathon Bombing Exposure/Response Category and Change in PTSD Severity Exposure/response category
Change in PTSD symptom severity
Directly affected by bombing Close other in vicinity of bombing Bombing reminiscent of own trauma Emotional distress related to bombing
.04 .05 .13 .33**
Note. N = 71. Each bombing expose/response variable was a dichotomous variable reflecting presence/absence of that experience. The categories were nonmutually exclusive. ** p < .01.
then examined the association between distress at the time of the event and change in each of the individual PTSD symptom clusters. Results showed that that the largest changes were in the Criterion B (intrusions) and Criterion C (avoidance) symptoms (rs = .35 and .31, ps = .002 and .008, respectively). Criterion D (negative alterations in cognitions and mood) showed a significant, albeit weaker, association with event-related distress (r = .26, p = .032) and the association with Criterion E (alterations in arousal and reactivity) was nonsignificant (r = .11, p = .352). Finally, analyses that examined other individual difference factors (e.g., trauma history, combat experience, PTSD severity, and personality traits) revealed no significant associations with change in PTSD symptom severity. This included an analysis that addressed the question of whether effects were confined to those with PTSD. We accomplished this by comparing PTSD symptom scores for those with and without a previous CAPS-based PTSD diagnosis using repeated measures analysis of variance. Results showed a main effect of PTSD diagnosis (i.e., individuals with PTSD had higher mean scores), F(1, 69) = 34.22, p < .001, but no significant Diagnosis × Time interaction, F(1, 69) < 1, p = .619. Discussion Average levels of PTSD symptom severity did not change significantly from the pre- to postbombing assessments for this sample of Boston-area veterans as a whole; however, analysis of individual change scores revealed considerable heterogeneity in response to the Marathon bombing. Veterans who reported being emotionally distressed at the time of the event showed significant increases in PTSD symptomatology—particularly in the domains of the hallmark symptoms of intrusive memories and nightmares about, and avoidance of stimuli associated with their previous traumas. A qualitative analysis of participants’ verbal description of their reactions suggested that for many participants, similarities between the Boston Marathon bombing and their own war zone trauma experiences reactivated trauma-related memories and prompted symptom exacerbations. Participants reported being triggered by horrific images from the bomb scene, “flashing back” to their own war
zone experiences, and feeling angry, detached, and fearful. It is noteworthy, however, that although a substantial subsample (38% of those surveyed) reported being emotionally distressed and showed symptom increases, the majority of the veterans in this cohort indicated that they were not personally impacted by the experience. Though it is possible that our assessment method underestimated the degree of impact, these findings underscore the heterogeneity of reactions to new-onset adverse life events and highlight the considerable resilience of many veterans to such adversity, even those with trauma histories and longstanding symptoms of PTSD. These conclusions should be weighed in light of the study’s strengths and limitations. The primary strength was the longitudinal sample composed of Boston-area veterans who were already being followed prior to the bombing and a postbombing assessment that was completed within approximately a week of the end of the event. Limitations included the modest sample size, which likely limited our power to identify individual difference factors predictive of symptom exacerbation; a circumscribed assessment of reactions to the event based on free responses to a single interview question; a qualitative coding system designed specifically for this study; and the absence of a control group. Also, we have yet to determine the duration of observed changes. To conclude, findings of this study should raise awareness of the potential impact of terror attacks, mass shootings, and other manmade or natural catastrophes on the well-being of individuals with histories of trauma and/or pre-existing PTSD. Health care providers and systems should be prepared to offer services, not only to those directly impacted by the event, but also to those for whom the event triggers a recurrence of intrusive memories, avoidance, and other symptoms linked to a prior trauma. At the same time, providers should recognize that there is considerable variability in the nature of such responses and understand that many at risk individuals show remarkable resilience when confronted with new-onset adverse life events. Future research should aim to further clarify the impact of events of this type on pre-existing PTSD symptomatology and advance the understanding of the role that they play in serving to perpetuate or maintain chronic symptomatology. References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Gusman, F. D., Charney, D. S., & Keane, T. M. (1995). The development of a ClinicianAdministered PTSD Scale. Journal of Traumatic Stress, 8, 75–90. Holm, S. (1978). A simple sequentially rejective multiple test procedure. Scandinavian Journal of Statistics, 6, 65–70. Kilpatrick, D. G., Resnick, H. S., Baber, B., Guille, C., & Gros, K. (2011). The National Stressful Events Web Survey (NSES-W). Charleston, SC: Medical University of South Carolina. Miller, M. W., Wolf, E. J., Kilpatrick, D., Resnick, H., Marx, B. P., Holowka, D. W., . . . .Friedman, M. J. (2012). The prevalence and latent structure of
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proposed DSM-5 posttraumatic stress disorder symptoms in US national and veteran samples. Psychological Trauma: Theory, Research, Practice and Policy. Advance online publication. doi:10.1037/a0029730
Rosen, C., Tiet, Q., Cavella, S., Finney, J., & Lee, T. (2005). Chronic PTSD patients’ functioning before and after the September 11th attacks. Journal of Traumatic Stress, 18, 781–784. doi:10.1002/jts.20086
Niles, B. L., Wolf, E. J., & Kutter, C. J. (2003). Posttraumatic stress disorder symptomatology in Vietnam veterans before and after September 11. Journal of Nervous and Mental Disease, 191, 682–684. doi:10.1097/01.nmd.0000092178.45511.e6
Weathers, F. W., Litz, B. T., Herman, D. S., Huska, J. A., & Keane, T. M. (1993, October). The PTSD Checklist: Reliability, validity, & diagnostic utility. Paper presented at the Annual Meeting of the International Society for Traumatic Stress Studies, San Antonio, TX.
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
