Physical injury and posttraumatic stress reactions. A study of the survivors of the 2011 shooting massacre on Utøya Island, Norway
Introduction
Physical injury contributes substantially to the global burden of disease, particularly among adolescents and young adults [1]. A growing amount of research indicates that physically injured survivors exhibit higher levels of posttraumatic stress reactions (PTSR) than do non-injured survivors after traumatic mass events [2], [3]. A substantial number of studies have been conducted on clinical samples of mostly severely injured survivors of traffic accidents. These studies indicate that the degree of injury based on a clinical assessment of type, bodily location and severity is not significantly associated with posttraumatic stress [4], [5].
However, knowledge is sparse concerning how PTSR may be distributed among coarser categories of injury degree describing survivors with a broad variety of injury levels. Furthermore, there are few studies on the factors that may explain the elevated levels of PTSR among injured survivors compared with non-injured survivors, and the findings are disputed [6], [7], [8]. Therefore, when experiencing traumatic mass incidents resulting in physical injuries of all degrees, the aforementioned research does not supply health workers and decision-makers with sufficient information to target adequate psychosocial interventions for the different groups of injured survivors.
Information gained from the mass shooting at Utøya Island might help to reduce this knowledge gap. The current study investigated how the degree of injury, including no, moderate and severe injury, would be associated with PTSR 4–5 months after the attack, after adjusting for plausible confounding factors.
Section snippets
The terror attack
On 22 July 2011, Norway experienced two terrorist attacks. One man dressed as a policeman left a bomb outside the main government building in Oslo. The bomb exploded and killed eight people. Ten injured survivors were admitted to the hospital, and many were treated in a casualty clinic [9]. The perpetrator then left for Utøya Island outside the city, which at the time was hosting a summer camp for the Norwegian Labor Party's youth organization. Armed with a gun, he pursued and targeted the 564
The objective of the study
The objective of this study was to investigate the relationship between injury (no, moderate and severe) and posttraumatic stress reactions in survivors of the terror attack on Utøya Island, Norway, 22 July 2011, after adjusting for sociodemographic, psychosocial and trauma-related factors.
Methods
The present study is an observational study of survivors from the terror attack at the Utøya Island in Norway, 22 July 2011 using data from the Utøya Study conducted by the Norwegian Centre for Violence and Traumatic stress studies. In the aftermath of the terror attack, 495 survivors were registered by the police. Three months after the attack, the 490 survivors aged 13 or older were invited to participate in the first part (T1) of the Utøya Study. Most (95%) interviews at T1 took place in
Participants
Of the 490 invited, 165 could not be reached or declined to participate, and 325 (66%) accepted and were subsequently interviewed at T1. At T2, 285 (58%) survivors were interviewed, and 255 participated at both T1 and T2. The participation rate among the severely injured corresponded well with the overall response rate. There were no significant differences in sex or age between participants and non-participants at T1 or T2 [10], [11].
The physical injuries among survivors ranged from bruises to
Sociodemographic factors and psychosocial background
Sociodemographic factors were assessed at T1 (See Fig.1). Non-Norwegian origin was defined as having parents who were both born abroad. A previous study of the Utøya population showed that non-Norwegian origin was a risk factor for developing posttraumatic stress reactions [11]. Current economic situation was rated on a 5-item scale ranging from much better than that of most people = 1, to much worse than that of most people = 5. Participants living alone reported on their own economic situation,
Statistical analyses
Exact Pearson's χ2-tests were used to assess group differences for categorical variables, and ANOVA and Student's t-tests for continuous variables. Tukey's HSD procedure in ANOVAs and the Holm procedure in other analyses were used to adjust for multiple testing in post hoc analyses. A permutation t-test was performed for the substantially skewed variable ‘peritraumatic pain related to injury’. Permutation tests make no distributional assumptions and test whether the variable has the same
Results
The survivors' mean age was 19.4 years (SD 4.6) at the time of the shooting: 153 (47%) were females and 172 (53%) were males (Table 1). The majority was ethnic Norwegians; 12% were of non-Norwegian origin, and 22% reported having a current economy below average.
A substantial minority (19%) of the survivors was physically injured during the attack: 23 (7%) were severely injured and required hospitalization and 37 (11%) were moderately injured and required other medical help. No significant
Discussion
Physical injury sustained on Utøya Island on 22 July 2011 was associated with higher levels of posttraumatic stress reactions (PTSR) 4–5 months later. In particular, those moderately injured exhibited significantly higher levels of total PTSR compared with the non-injured. The injured survivors experienced particularly high levels of peritraumatic events and loss of close, which may explain their high levels of posttraumatic stress reactions.
Knowledge about the association between physical
Clinical implications
The findings in this study suggest that focusing on physical injury may be one important and clinically meaningful way of detecting survivors with particularly high levels of peritraumatic exposure and who are, therefore, at a high risk of posttraumatic stress reactions after traumatic mass events such as terror attacks. The findings also contribute to nuance how posttraumatic stress reactions may be differentially distributed among the injured and, in particular, to expand our focus also to
Conclusion
Physical injury was associated with posttraumatic stress reactions 4–5 months after the terror attacks at Utøya on July 22, 2011. The level of symptoms did not differ significantly between the moderately and severely injured.
Conflict of interests
The authors have no competing interests to report.
Acknowledgments
We would specifically like to thank the participants in the Utøya study and the Norwegian Centre for Violence and Traumatic stress studies for their collaboration. The study was funded by Helse Sør-Øst HF: PhD scholarship; project no 2012106 and the Norwegian Centre for Violence and Traumatic stress studies and supported by Oslo University Hospital: Equipment; project no 531300 and Vestre Viken HF.
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