Siri Thoresen

Post-traumatic stress reactions in survivors of the 2011 massacre on Utøya Island, Norway

BACKGROUND Although youths in many countries have been exposed to terrorism, few studies have examined early risk and protective factors for the subsequent development of mental health problems. AIMS To investigate the levels of post-traumatic stress in survivors of the 2011 massacre on Utøya Island compared with the general population in Norway, and to identify predictive factors. METHOD Four hundred and ninety survivors were invited to participate. Structured face-to-face interviews were performed 4-5 months after the attack. RESULTS There were 325 study participants (response rate 66%). Survivors had been highly exposed to danger and loss. Post-traumatic stress levels were more than six times higher in survivors than in the general population. Predictors were female gender, minority ethnic status, high level of trauma exposure, pain, the loss of someone close and social support. CONCLUSIONS Survivor characteristics that can be assessed in the early aftermath of a terrorist attack strongly predict the subsequent mental health problems of exposed youths. The highly elevated symptoms observed were largely attributable to the traumatic experience and reflect the mental health costs of the terrorist attack.

The day Norway cried: Proximity and distress in Norwegian citizens following the 22nd July 2011 terrorist attacks in Oslo and on Utøya Island

Background : Terrorism may create fear and stress reactions not only in the direct victims, but also in the general population. Objective : This study investigated emotional responses in the Norwegian population following the 22nd July 2011 terrorist attacks. We hypothesized that Oslo residents would report a higher level of fear responses compared with people living outside Oslo and that proximity would be associated with early distress and later post-traumatic stress reactions. Method : Representative samples were drawn from the Norwegian Population Registry. Telephone interviews were conducted 4–5 months after the attacks. The response rate for the Oslo sample (N=465) was 24% of the total sample, and 43% of those who were actually reached by phone and asked to participate. Corresponding figures for the sample living outside Oslo (N=716) were 19% and 30%. Results : Our results show strong immediate emotional responses, particularly sadness and a feeling of unreality, in both samples. Jumpiness and other fear responses were significantly higher among Oslo residents. Current level of risk perception was low 4–5 months after the attacks; however, a significant minority reported to feel less safe than before. Geographical and psychological proximity were associated with early emotional responses. Psychological proximity was significantly associated with post-traumatic stress reactions, while measures of geographical proximity were not. Immediate emotional responses, first-week reactions, and first-week jumpiness were uniquely and significantly associated with post-traumatic stress reactions. Post-traumatic stress reactions were elevated in ethnic minorities. Conclusions : The terrorist attacks seem to have had a significant effect on the Norwegian population, creating sadness and insecurity, at least in the short term. Proximity to the terrorist attacks was strongly associated with distress in the population, and early distress was strongly related to later post-traumatic stress reactions. Our results indicate that psychological proximity is more strongly associated with post-traumatic stress reactions than geographical proximity, and underline the importance of differentiated measurements of various aspects of early distress. For the abstract or full text in other languages, please see Supplementary files under Article Tools online

Suicide in peacekeepers: A cohort study of mortality from suicide in 22,275 Norwegian veterans from international peacekeeping operations

Abstract.Objective:Several studies have investigated post-traumatic stress reactions and other psychosocial problems in former peacekeepers. The question has also been raised as to whether such veterans might be at increased risk of suicide. This study investigated the suicide mortality in Norwegian former peacekeepers.Methods:Cause-specific mortality was identified in the population of Norwegian peacekeepers having participated in army missions in the years 1978–95. General population data were used for comparison. Standardized Mortality Ratios (SMRs) were calculated for different suicide methods and certain peacekeeping-related variables. Marital status was available for each year and controlled for by using separate suicide rates for unmarried, married and divorced.Results:A moderately, but significantly, increased SMR of 1.4 for suicide was found among the former peacekeepers (95% confidence interval = 1.1–1.8). After adjusting for marital status, the SMR was reduced to insignificance (SMR = 1.1, 95% confidence interval = 0.9–1.4). There was a significant increase in suicide by means of firearms and carbon monoxide poisoning.Conclusions:The increased risk of suicide in former peacekeepers was related to the peace-keepers’ lower marriage rate compared to the general population. This finding may indicate that the personnel were characterized by certain vulnerability factors before entering peacekeeping service, resulting in a reduced ability to enter into and remain in stable love relations. However, it cannot be excluded that stress reactions following peacekeeping may have contributed to possible strains on interpersonal relationships. Preventative work should, thus, include improved personnel selection routines and preferably also psychosocial support for veterans and their families. The increased number of suicides by use of firearms indicates that gun control might be an important prevention measure in this group.

Traumatic stress and suicidal ideation in Norwegian male peacekeepers

To investigate the association between war zone stress exposure during international military operations and later suicidal ideation, a follow-up study of 1172 Norwegian male peacekeepers was conducted 7 years, on average, after redeployment. Suicidal ideation was reported in 6% of the veterans, while it was reported in 17% of the subsample of those who were prematurely repatriated. Suicidal ideation was significantly associated with service stress exposure level, even when background factors, repatriation status, negative life events, social support, alcohol consumption, and marital and occupational status were controlled for. Results indicate that the association between service stress exposure and suicidal ideation was mediated by posttraumatic stress symptoms and general mental health problems combined.

Violence against children, later victimisation, and mental health: a cross-sectional study of the general Norwegian population

Background Violence in childhood is associated with mental health problems and risk of revictimisation. Less is known about the relative importance of the various types of childhood and adult victimisation for adult mental health. Objective To estimate the associations between various types of childhood and adult violence exposure, and their combined associations to adult mental health. Method This study was a cross-sectional telephone survey of the Norwegian adult population; 2,435 women and 2,092 men aged 18–75 participated (19.3% of those we tried to call and 42.9% of those who answered the phone). The interview comprised a broad array of violence exposure in both childhood and adulthood. Anxiety/depression was measured by the Hopkins Symptom Check List (HSCL-10). Results Victimisation was commonly reported, for example, child sexual abuse (women: 10.2%, men: 3.5%), childhood–parental physical violence (women: 4.9%, men: 5.1%), and lifetime forcible rape (women: 9.4%, men: 1.1%). All categories of childhood violence were significantly associated with adult victimisation, with a 2.2–5.0 times higher occurrence in exposed children (p<0.05 for all associations). Anxiety/depression (HSCL-10) associated with adult abuse increased with the number of childhood violence categories experienced (p<0.001). All combinations of childhood violence were significantly associated with anxiety/depression (p<0.001 for all associations). Individuals reporting psychological violence/neglect had the highest levels of anxiety/depression. Conclusions Results should be interpreted in light of the low response rate. Childhood violence in all its forms was a risk factor for victimisation in adulthood. Adult anxiety/depression was associated with both the number of violence categories and the type of childhood violence experienced. A broad assessment of childhood and adult violence exposure is necessary both for research and prevention purposes. Psychological violence and neglect should receive more research attention, especially in combination with other types of violence.

Trauma Victim: Yes or No? Why It May Be Difficult to Answer Questions Regarding Violence, Sexual Abuse, and Other Traumatic Events

The aim of this study is to explore the reasons why it may be difficult to answer questions regarding violence, sexual abuse, and other potentially traumatic events (PTEs). Qualitative and quantitative methods are used with a nonrepresentative community sample of 628 women who respond to a Web survey. Altogether, 65% do not find it difficult to answer any PTE questions. Difficulties in answering occur more frequently with violence and sexual abuse items and are associated with exposure. Reasons for difficulties in answering include “event fit” (severity, frequency, force), “me as a victim” (responsibility, reactions, protection, memory), and “you as abuser” (intention, protection).

Social support barriers and mental health in terrorist attack survivors

BACKGROUND To expand our understanding of social support and mental health, we introduce a measure of social support barriers and investigate the relationship between these barriers, social support, mental health and gender in survivors of the terrorist attack on Utøya Island, Norway. METHODS Survivors (N=285) were interviewed face to face. We used confirmatory factor analysis (CFA) to assess the latent factor structure of the Social Support Barriers Scale and perceived social support (FSSQ), and linear regression analyses to investigate the associations between social support variables and mental health (PTSD-RI and HSCL-8). RESULTS The CFA indicated that social support barriers and perceived social support were two separable latent constructs. Social support barriers were highly associated with posttraumatic stress reactions (adjusted regression coefficient=0.38, 95% CI=0.29-0.47. p<0.001) as well as with psychological distress (adjusted regression coefficient=0.35, 95% CI=0.26-0.43, p<0.001). In contrast, neither perceived social support nor gender was associated with mental health after adjustment for barriers. LIMITATIONS Most analyses were based on cross-sectional data. This is the first study to use a quantitative measure of social support barriers. CONCLUSION Social support barriers may be a new opening to understand the relationship between social support and mental health and may have a role in explaining why women are at increased risk for mental health problems. Clinicians should explore not only perceived social support but also barriers to making use of these resources when consulting young people facing major life adversities.

Familial factors and child characteristics as predictors of injuries in toddlers: a prospective cohort study

Objective To identify family and child characteristics that put toddlers at risk of injuries. Design A prospective cohort study. Setting This study was based on the Norwegian Mother and Child Cohort Study, conducted by the Norwegian Institute of Public Health. Participants The study sample consisted of 26 087 children and their mothers. Outcome measures Family and child characteristics measured before or at 18 months of age were investigated as potential predictors of hospital-attended injuries that occurred between 18 and 36 months of age. Results In the multivariable analysis, younger maternal age (OR 0.93, 95% CI 0.86 to 1.00), financial problems (OR 1.18, 95% CI 1.01 to 1.39), maternal mental distress (OR 1.09, 95% CI 1.03 to 1.16), having older siblings (OR 1.22, 95% CI 1.08 to 1.39), increased gestational age at birth (OR 1.04, 95% CI 1.00 to 1.07) and male gender (OR 1.26, 95% CI 1.11 to 1.42) were risk factors for hospital-attended injuries. Children with impaired gross motor development had a decreased risk of injury (OR 0.65, 95% CI 0.42 to 0.99), whereas those with impaired fine motor development had an increased risk (OR 1.55, 95% CI 1.22 to 1.97). Shyness was a protective factor (OR 0.92, 95% CI 0.86 to 0.98). Children with three reported attention problems had a slightly increased risk of hospital-attended injuries (OR 1.33, 95% CI 1.02 to 1.72; p=0.035); otherwise, behaviour was not a significant risk factor. Conclusions This study demonstrated that a wide variety of factors were in play as predictors of injuries in young children. Both child-related factors (gender, gestational age at birth, child motor development, shyness and attention) and familial factors (having older siblings, maternal age, financial difficulties and maternal mental health problems) were associated with injuries in toddlers.

Maternal childhood abuse predicts externalizing behaviour in toddlers: A prospective cohort study

Aims: To investigate the impact of maternal childhood abuse on toddlers’ behaviour and assess the potential mediation of maternal mental distress for this pathway. Methods: This study was based on the Norwegian Mother and Child Cohort Study, conducted by the Norwegian Institute of Public Health. The study sample consisted of 25,452 children and their mothers. Maternal childhood abuse was investigated as a potential predictor for child externalizing behaviour at 36 months of age. Maternal mental distress at child age 18 months was assessed as a potential mediator. Hierarchical linear regressions were used for analyses. Results: Childhood emotional abuse alone was reported by 8.3% of the mothers and physical and/or sexual abuse by 8.9%. Mothers with childhood abuse experiences were younger, less educated, more at risk for adult abuse and mental distress, and fewer were married or lived with a partner compared with women not reporting childhood abuse. Children of mothers with childhood abuse experiences showed significantly more externalizing behaviour even after adjusting for maternal age, education, single motherhood, gender and adult abuse experiences. When maternal mental health was entered into the model, the associations remained statistically significant, but were substantially attenuated. Conclusions: Maternal childhood abuse consistently predicted increased externalizing behaviour in the offspring, and this study suggests that childhood abuse impacts subsequent generations. Multiple pathways are possible, but this study identified increased maternal mental distress as a possible pathway between maternal childhood abuse and increased externalizing behaviour in the offspring.

Early outreach to survivors of the shootings in Norway on the 22nd of July 2011

Background Under-treatment and unmet needs among survivors have been documented years after terror attacks. Improved early and proactive outreach strategies, including targeted interventions for individuals in need, are required. After the terrorist attacks in Norway on 22 July 2011, a national, proactive outreach strategy was developed and implemented to help those who were directly affected. Objectives The aims of this study were threefold: (1) to investigate whether the survivors at the island of Utøya had received proactive outreach from the municipalities, (2) to examine the relationships between received health services and the survivors’ level of exposure and post-trauma health problems, and (3) to explore the level of unmet needs among survivors 5 months post-terror. Methods Three hundred and twenty five survivors (M age=19.4, SD=4.6, 47.1% females, response rate 66%) of the 2011 massacre on Utøya Island, Norway, were interviewed face-to-face 4–5 months post-terror. The survivors were asked if they had received proactive outreach from their municipality, and what type of health services they had received. Survivors’ level of peri-trauma exposure, loss and injury, posttraumatic stress reactions, symptoms of anxiety and depression, somatic health problems, and sick leave, were assessed. Results Most participants (87%) reported that they had received early and proactive outreach, and most (84%) had a contact person. In addition a majority of the survivors has received support from their general practitioner (63%), or other municipal help services (66%). Specialized mental health services by psychiatrists or psychologists had been provided to 73.1% of the survivors. Survivors who had been referred to specialized mental health services reported higher levels of exposure to trauma, posttraumatic stress reactions, depression and anxiety, and somatic health problems, compared to non-receivers of such services. Forty-three survivors (14%) reported unmet needs for services. Conclusion In accordance with the national strategy, the vast majority of the participants in this study had received an early and proactive outreach and targeted responses from specialized mental health services had been provided to survivors in need of more extensive help. However, an important minority of the participants had not been reached as planned. The knowledge from this study may guide professionals and decision makers in planning for future disasters and improve the levels of care.