What does the news industry need to know about the science related to survivors, the public and news consumption?

General Background. One of the cardinal symptoms of traumatic reactions, and specific symptoms of posttraumatic stress disorder, is both an avoidance of trauma-related cues and psychological and physiological distress upon exposure to such trauma-related cues.

Clearly, news reports regularly contain such trauma-related cues (sounds, images). This type of exposure to reminders of the event(s) can be extremely distressing to survivors, and many find it quite difficult to calm down after such exposure. This is the basis of the traumatic response that is supported by ample theoretical, clinical and empirical evidence.

Media Exposure and Psychological Symptoms in Trauma Survivors. To date, there is limited scientific data about the effects of terrorism and media exposure upon survivors, although the consensus among clinicians is that survivors should monitor their consumption of trauma-related media and prepare for such exposure with a plan about how to reduce resulting symptoms that may be triggered.

For example, experts suggested that survivors limit viewing of news after September 11, 2001, and many experts currently are suggesting to survivors that they tape anniversary programs so that survivors may regulate their exposure and decide if, when and how to watch these programs later.

Among the few studies conducted, the following scientific evidence is available:

• In a cross-sectional random digit dial survey of adult residents of Manhattan, New York City, living south of 110th Street, from October 16 to November 15, 2001, frequency of viewing "people falling or jumping from the towers of the World Trade Center" was associated with greater rates of PTSD and depression among those who directly experienced loss or witnessed the event.
  
  Specifically, among those respondents who were directly affected by the attacks, those who frequently watched this image were more likely to have PTSD (22.5%) and depression (21.3%) than those who did not (3.6% and 11.7% respectively). (Ahern, Galea , Resnick, Kilpatrick, Bucuvalas, Gold and Vlahov, 2002)
  
  
• In a nationally representative sample of 2,773 adults, clinically significant distress was associated with hours of terrorism-related television watched per day and number of different types of graphic terrorism-related content watched. It should be noted that the prevalence of general distress was not greater than that typically seen in community samples.
  
  Furthermore, in a subset of 691 New York City dwellers, number of hours of terrorism-related TV coverage watched was significantly associated with higher PTSD symptom endorsement but the content index was not (Schlenger et al., 2002).
  
  
• In a sample of Oklahoman children, in grades 6-12, who lost a relative in the bombing, those who watched more bomb-related television reported more PTSD symptoms seven weeks post-bombing than those who watched less bomb-related PTSD television.
  
  However the prevalence of those experiencing PTSD symptoms was not related to viewing time (Pfefferbaum, Moore, McDonald, Maynard, Gurwitch, & Nixon, 1999; Pfefferbaum, Nixon, Tucker, Tivis, Morre, Gurwitch, Pynoos, & Geis, 1999; Pfefferbaum, Nixon, Tivis, Doughty, Pynoos, Gurwitch, and Foy, 2001).
  
  
• Oklahoman children related to a person who was killed in the bombing, also were found to have considerably more difficulty settling down after watching bomb-related television than those who did not experience a personal loss (Pfefferbaum, Moore, et al., 1999; Pfefferbaum, Nixon, et al., 1999).
  
  
• Among 51 Kuwaitan children and adolescents exposed to a military occupation, severity of PTSD was correlated with amount of television exposure to graphic images of mutilation (Nader, Pynoos, Fairbanks, Al-Ajeel and Al-Asfour, 1993).

Media Exposure and Psychological Symptoms in Those Not Directly Affected by Terrorism

• Among a random sample of adult Manhattan-dwelling respondents not directly affected by the September 11 attacks, prevalence of PTSD and depression was not associated with frequency of television image viewing during the months of October to November 2001 (Ahern et al., 2002).
  
  
• Two studies of Oklahoman children reveal that amount of viewing time of bomb-related news is correlated with higher reports of PTSD symptoms, even in those who did not personally experience a loss (Pfefferbaum, Moore, et al., 1999; Pfefferbaum, Nixon, Tucker, et al., 1999; Pfefferbaum, Nixon, Tivis, et al., 2001).
  
  
• Among Oklahoman children (grades 6-12) who did not lose a relative, those in grades 6-12 who watched more bomb-related television reported more PTSD symptoms seven weeks post-bombing than those who watched less bomb-related PTSD television.
  
  
• In a study of 2000 Oklahoman children, in grades 6-8, only among those in the sample who were not personally affected (lost a relative, witnessed it) by the OKC bombing was amount of bomb-related television watching and PTSD symptoms related.

Media Exposure and Psychological Symptoms in Samples Where Trauma History Was not Assessed ( but likely existed for some proportion of participants)

• Among 85 individuals seeking mental health services (for any reason) in OKC, the number of hours viewing OKC bombing-related TV was not related to increased PTSD symptoms (Tucker, Pferfferbaum, Nixon and Dickson, 2000).
  
  
• In a study of 237 Israeli adults, half the group was randomly selected to watch television news clips related to terrorism and the other half watched other news clips not related to terrorism. Individuals who watched the terrorism-related news clips reported more anxiety than those who watched other types of news clips. It should be noted that while statistically significant, the level of anxiety was not in the pathological range (Slone, 2000).

Other Related Factors
Evidence shows that victims and survivors of traumatic events struggle with profound feelings of helplessness both at the time of the event (e.g., Brewin, Andrews, & Rose, 2000) and after the event (e.g., Roth and Newman, 1992). This helplessness comes from experiencing a lack of control and predictability during the event(s) and after the event(s).

Reminders that occur without warning are particularly troublesome because they contribute to a sense of helplessness, emotional imbalance and lack of control. In the face of these events, opportunities to anticipate and exercise choice and control with regard to exposure to potential triggers can aid them in regaining a sense of agency and control over their lives.

Summary
Although there are only a handful of studies that examine the relationship between news consumption and symptoms, these studies suggest that there is a relationship between consumption of terrorism-related media and reported distress level among child viewers (both survivors and non-survivors).

Second, among adults directly affected by terrorism, rates of PTSD and depression were correlated with frequency of viewing specific images of people jumping from the World Trade Center in the immediate months following the events. Among the general public, it appears that viewing such images was not associated with rates of disorder, although, there is data that suggest that temporary anxiety may be associated with viewing such news.

It is important to note, however, that although a relationship between the amount of terrorism-related news consumed (especially viewing broadcast images) and trauma-related distress clearly exists, the direction of causality remains unknown.

Specifically, it is unknown if watching terrorism-related television contributes to PTSD symptoms or if those with PTSD symptoms choose to watch more terrorism-related television. There also is a possibility of a reporting bias (or memory or attention bias) such that those who endorse PTSD symptoms also may endorse more exposure to media-related images.

Advice to Viewers
Despite the limitations of what is known, the following recommendations seem to be reasonable precautions. Among adult and child survivors, it seems prudent to limit exposure to these images as much as possible.

Children, regardless of relationship to the event, also should be encouraged to watch less terrorism-specific television. In addition, it makes sense to discuss with children their understanding of the events and try to make them feel as safe as possible.

Advice to networks
For journalists and network executives, consideration of a warning system for graphic imagery and sound appears warranted, especially for children. At a minimum, a visual warning on broadcast television would help a) reduce distress among survivors and children or b) possibly increase consumer satisfaction with the news among the large audience who watches terrorism-related news-those directly affected by the events.

Efforts to promote a sense of control are complicated by the fact that trauma-related cues can be quite specific to the individual, making it impossible to identify with certainty all reminders that might be emotional triggers for them. However, it is clear that many reminders are so potent or so much a part of a traumatic experience that they are nearly universal in their relevance to survivors.

Graphic imagery and sounds from the crash sites are likely to be of this type for the 9/11 survivors and surviving family members of those killed in the attacks. The viability of selecting universal images is bolstered since this technique has been successfully used in research paradigms studying attention bias and physiological responses among individuals with PTSD who have experienced specific types of trauma (Vietnam veterans, rape, war, etc.).

As noted above, providing victims with some degree of control over an otherwise uncontrollable time in their lives is likely be a tremendous comfort to them and may aid in their healing process. Furthermore, evidence shows that victims and survivors of traumatic events struggle with profound feelings of helplessness. In the face of these events, opportunities to exercise choice and control about triggers can aid them.

Sources

Ahern J, Galea S, Resnick H, Kilpatrick D, Bucuvalas M, Gold J, Vlahov D. Television Images and Psychological Symptoms after the September 11 Terrorist Attacks. Society for Epidemiologic Research Annual Meeting. [Poster presentation]. Palm Desert, CA; June 2002.

Brewin, C. R; Andrews, B.; Rose, S.. (2000). Fear, helplessness, and horror in posttraumatic stress disorder: investigating DSM-IV criterion A2 in victims of violent crime. Journal of Traumatic Stress, 13, 499-509.

Jessica Hamblen (2001). How the Community May Be Affected by Media Coverage of the Terrorist Attack A National Center for PTSD Fact Sheet. http://www.ncptsd.org/facts/disasters/fs_media_disaster.html

Nader, K., Pynoos, R., Fairbanks, L., Al-Ajeel, M., & Al-Asfour, A. (1993). A preliminary study of PTSD and grief among the children of Kuwait following the Gulf crisis. British Journal of Clinical Psychology, 32, 407-416.

Pfefferbaum, B., Moore, V., McDonald, N., Maynard, B., Gurwitch, R., & Nixon, S. (1999). The role of exposure in posttraumatic stress in youths following the 1995 bombing. Journal of the State Medical Association, 92, 164-167.

Pfefferbaum, B., Nixon, S., Tivis, R., Doughty, D., Pynoos, R., Gurwitch, R., & Foy, D. (2001). Television exposure in children after a terrorist incident. Psychiatry, 64, 202-211.

Pfefferbaum, B., Nixon, S., Tucker, P., Tivis, R., Morre, V., Gurwitch, R., Pynoos, R., & Geis, H. (1999). Posttraumatic stress response in bereaved children after the Oklahoma City bombing. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1372-1379.

Roth, S., & Newman, E. (1992). The role of helplessness in the recovery process for sexual trauma survivors. Canadian Journal of Behaviour Science, 24, 220- 232.

Schlenger, W.E., Caddell, J.M., Ebert, L., Jordan, B.K., Rourke, K.M., Wilson, D., Thalji, L., Dennis, J.M., Fairbank, J.A., & Kulka, R.A. (August 7, 2002). Psychological Reactions to Terrorist Attacks: Findings from the National Study of Americans' Reactions to September 11, Journal of American Medical Association, 288, 5, 581-588.

Sloan, M. (2000). Response to media coverage of terrorism. Journal of Conflict Resolution, 44, 508-522.

Tucker, P., Pfefferbaum, B., Nixon, S., & Dickson, W. (2000). Predictors of post-traumatic stress symptoms in Oklahoma City: Exposure, social support, peri-traumatic response. Journal of Behavioral Health Services and Research, 27, 406-416.