Skip to main content

Verified by Psychology Today

Post-Traumatic Stress Disorder

What Makes PTSD From Mass Killings and War Stand Out?

New research shows how chronic trauma affects civilian populations.

Research on PTSD has tended to focus on the impact of single or short-term episodes of trauma, in part because it is easier to acknowledge and study. Let's not review the statistics on trauma here, as they are commonly available. While we have developed a better understanding of how childhood trauma can show up as complex PTSD and related issues later in life, there is a less clear understanding about PTSD related to chronic exposure to war, terror and political violence in civilian populations—"ongoing exposure to political conflict," or OEPC. Unfortunately, this question is increasingly important because of the accelerating pace of terrorist attacks, mass casualty events, war and the specter of more conflict on the horizon, political violence, and various other forms of exposure to potentially traumatizing material.

While such exposure may lead to PTSD and PTSD-like syndromes (which may not meet full diagnostic criteria for PTSD), most stress responses are normal, and the majority of people do not develop a medical condition in response to trauma exposure. It is important to respond to reactions as normal-until-proven-otherwise and provide supportive measures to maintain or reestablish routines and bolster resilience while thoughtfully monitoring for the emergence of more serious symptoms. There are risks to both over-diagnosing and under-diagnosing, and assessment itself must be done carefully so as not to provoke unnecessary stress.

Exposure to Collective Trauma

Despite expert recommendations to limit exposure to traumatic material while using the media appropriately as a source of useful information, and increasing understanding of the effects of media exposure on us, the media continues to broadcast high doses of potentially traumatizing material. In addition, people are likely to discuss disturbing and frightening current events, raising the level of awareness of such potential threats to the safety of oneself and loved ones.

Furthermore, because OEPC has become the norm and periods of calm are shorter and shorter, expectation of safety and stability in day-to-day life is undermined. While limiting self-exposure to the media can help to reduce the impact, many people have difficulty restraining themselves. We are therefore more likely to have a sense of ongoing significant threat on many levels, in addition to moral strain.

The effect of chronic threat on civilian populations needs to be better understood. If we don't address these concerns early on, there is reason to believe that negative consequences in the future may be even more problematic.

Researching OEPC As Seen By Experienced Mental Health Providers

To better understand the effect of chronic exposure to collective trauma, researchers (Goral, Lahad, & Aharonson-Daniel, 2017) decided to study Israeli civilians, who unfortunately represent a "natural laboratory" for OEPC. In one phase of a broader study, researchers carefully developed a survey for psychotherapists to complete regarding their observations of symptoms of single or short-term trauma exposure and OEPC.

They sought to better understand whether there were differences in severity or patterns of symptoms, whether post-traumatic symptoms get better when the source of distress lets up, and whether therapists perceived qualitative differences between single and short-term exposure and OEPC-related PTSD.

Standard PTSD symptoms include:

  • intrusion (nightmares, flashbacks, re-experiencing)
  • avoidance (of reminders, places, thoughts)
  • negative alterations in cognition and mood (difficulty with concentration, memory, depressive symptoms)
  • alternations in arousal and reactivity (feeling panicky, physical symptoms of elevated tension, being easily startled, feeling fearful)

In addition to looking at PTSD symptoms included in the standard medical definition, the researchers' 75-item questionnaire covered a broader range of possible symptoms based on other familiar post-traumatic characteristics. Examples include "mental exhaustion," "increased morbidity," "feeling lack of control about the future," a "sense of danger," a "low frustration threshold," and difficulties in relationships and with children.

The research team surveyed whether therapists observe that symptoms of OEPC are relieved during calm times, whether OEPC-related PTSD looks different from the standard diagnostic profile for PTSD, and whether current assessment tools are a good fit for OEPC.

The 66 survey participants were 67 percent female, with an average age of 51.4 years old. Half were social workers, 30 percent were psychologists, 20 percent were therapists with other backgrounds (e.g. art therapists), and only one was a psychiatrist. Most reported having over 11 years of professional experience and most had recently worked with traumatized patients.

For the broader set of post-traumatic symptoms, severity was higher in OEPC-related PTSD for all items. The only one rated as severe in single or short-term PTSD, in contrast, was "sense of danger/lack of protection."

For the standard diagnostic model of PTSD, OEPC had more severe symptoms to a significant extent for intrusion, negative alternations in cognition and mood, and arousal and reactivity, but not avoidance. For functional impairment, most measures were worse for OEPC.

Nearly 60 percent of therapists reported that they expected relief from OEPC symptoms when conflict was not present and when there was no immediate threat to the individual. A little over a quarter of therapists thought that there would be no relief regardless of whether a threat was present or nearby. There was no difference in these perceptions based on demographics.

Nearly 60 percent of therapists said that OEPC-related PTSD resembled PTSD per the DSM-5 definition. Nearly 25 percent thought that they were different syndromes, and the rest did not have a clear position. Interestingly, therapists in southern Israel were more likely to see them as different syndromes. Most therapists did not think current assessment tools were very appropriate—half said they were "fairly appropriate" and over 30 percent said they were not at all appropriate.

Additional Considerations

Higher "doses" of traumatic experience are typically correlated with more severe and higher rates of PTSD, so it is not surprising from that point of view that OEPC, which is by definition more prolonged exposure, is associated with more severe symptoms in most symptom areas. Interestingly, OEPC is not more strongly associated with avoidant symptoms, perhaps because it is difficult to completely avoid conflict-related trauma, and people who are avoidant of OEPC might be less likely to leave areas of perceived safety to go to a therapist's office. If that is the case, telemedicine might offer help for those who do not want to travel.

On the other hand, in addition to severity, the current data suggests a different symptom pattern with OEPC when considering the broader range of post-traumatic symptoms, which notably include greater personality change and shift in outlook on life, emotional regulation difficulty, existential concerns, increased social isolation and mistrust, and symptoms reminiscent of burnout. Similar changes are seen with complex PTSD and other forms of chronic trauma exposure as well. However, with complex PTSD related to childhood trauma, ongoing exposure is partially regenerated by internalized developmentally traumatic experience, making periods of calm and distance from threat more difficult in general.

These broader symptoms are not typically assessed with common PTSD screening and assessment rating scales and require additional attention to properly identify them. Mental exhaustion, a feature of burnout, was more severe with OEPC and is of special note because of the constant onslaught of tragic violent events nowadays and the impact it may have on wellbeing and overall function, as well as on a societal level—as collective mental fatigue may increase the challenge of responding resiliently.

Given that Israel has a long history of OEPC, the findings from the present study (and subsequent studies by the same research group) will be of interest for America, and other countries, where OEPC is a comparatively new phenomena to which we are still adjusting. Differences in culture and type of OEPC (e.g. domestic mass casualty events as in the USA as contrasted with political violence from international conflicts) are likely to result in important differences in the impact on civilians and society. It is likely that many of the findings will overlap, and therefore may help to inform us on how we can begin to think about coping with the disturbing, potential new-normal of escalating violence in our own country.

For guidelines regarding the Las Vegas shooting, please take a moment to review this resource from the Center for the Study of Traumatic Stress


Goral, A., Lahad, M. and Aharonson-Daniel, L. (2017). Differences in Posttraumatic Stress Characteristics by Duration of Exposure to Trauma, Psychiatry Research, Sept. 25.