Chapter finds little for the communities affected directly form

Chapter
2: Literature Review

The chapter
will represent the theoretical stance of this study and literature review of
related studies. This study is primarily rooted in core concepts of psychology
of terrorism and its effect on psychological and emotional health and
wellbeing. An internal dislocation has been around different parts of the world
since its creation. Much has been focus on the issues but literature finds
little for the communities affected directly form a man-made disaster or the
effects on survivors of a particular incident regarding their physical or
psychological health, who found it unavoidable rethinking or relieving of a
previous havocs incident and the circumstances of that incident on their
present life. Traumatic experiences often top to psychiatric circumstances mostly
in the form of Post-Traumatic Stress Disorder and other mood disorders such as
Emotion Deregulation.

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2.1       Context, Trauma and Types

“Trauma”
usually means an extremely shocking and disturbing event. For example, to
understand the traumatic events the basic key is that it states the extreme
stress after a violent or heartbreaking event and it effect individual’s
ability to survive. Trauma, stress, and adaptation are not dived clearly,
whereas, stress responses are noticeably physiological in nature. Psychological
trauma is defined differently by various experts. It is basically the effect of
some traumatic experience encountered by an individual that proves how
traumatic the incident is. It is the kind of experience that makes victim
incapable of integrating his/her emotions or is a long-term condition which can
be life threatening, sanity or bodily honesty (Pearlman & Saakvitne, 1995).

Trauma has a
wide range of meanings containing the aftereffects of shocking incidents like
natural or accidental deaths, severe crimes, encountering violence, natural
disasters, etc. Chronic or repetitive experiences are also part of it such as
neglect, struggle, domestic or urban violence, fight, abusive relationship,
child abuse, concentration camps and long term deprivation. The survivor’s
experience and aftereffects on his/her life determines whether a specific event
is more or less traumatic. Traumatic incident is described in two components
subjective and objective. The personal experience of objective incident constitutes
the trauma. Traumatization will be high if a person is highly endangered. Psychologically
traumas mean feeling of complete helplessness and devastating emotion. It may
or may not include body injuries but psychological traumas are involved in
physiological disruptions that play a role in long lasting effects and later on
trauma become an experience of the survivor. The harmful event may affect two
people at the same time; one person may not even get a scratch and other may be
getting affected badly and get traumatized. The specific traumatic aspect of an
event can be different from one person to other. The details or meaning of the
events can’t be assumed, such as terrorist or violent attack; if it is distressing
for one individual it isn’t necessary to be as or at all distressing for other
individual and its aftereffects may vary from one another.

2.2       Single Blow vs. Repeated Trauma

Lenore Terr described
and differentiated about single blow and repeated traumas in traumatized
children studies. In some people single shocking event may create trauma
reactions for example natural disaster which may include hurricanes, volcanoes,
floods, earthquakes etc. whereas, technological disasters such as chemical
spills, nuclear failures, plane and auto crashes are closely related and are
socially troublesome because of finding faults and blaming others. Criminal
violence is also part of single blow traumas which may include rape homicide
and robbery that leaves great impact on victim’s life and their loved ones. These
traumatic event develop their effects on victim’s life day by day. The most
serious and common mental health problems of victims of trauma exposure are
that they are repeated, sustained and sometimes develop over years.

2.3       Natural vs.
Human Made

There is a difference
in natural and human prepared stressors that are arranged consciously on
individual and its effect also vary. Mostly, victims of violence and injury
given by any person or a group of people seek mental health treatment; if it’s done
to stop any cause, the problem may increase. Man-made violence is immense in
scale they are repeated, prolonged, severe or unpredictable; it is also threatening
for witnesses’ lives but also treating others violently. It embraces the
identity of a killer; human rights are being violated and abused by torture,
kidnapping, terrorist massive killing without any reason. Criminal violence
has been done by killing the innocent people of a community, specially
targeting one group, adding up exposure of war and political violence.
Including the U.S. incidents Oklahoma City bombing, the 9/11 attacks, or the Peshawar
attack on 12 December at APS School; apart from continuous violence in Syria,
Palestine, Burma and Afghanistan, Exterior U.S. such as bombardment, violence, raiding,
or any accidents that results in terrorist activities and persons acting in
isolation if they are considered political in nature.

Disruption results
in more severe exploitation which includes long duration, forced perception
fear of injury or death and helplessness. Viewing physical abuse can be
stressful and as much the victim is attached the stress will be. Particularly, watching
violence directed towards a close relative or friend is sadistic. Interpersonal
violence is considered as a passionate eruption, whereas, the most horrible
form of it is consciously inflicted.  In
settings such as prostitution, pornography rings, concentration camps, and in
some families powerful control is used.

In the field of
trauma the greatest predictable research findings are dose response, it depends
on dose, the more the dose trauma it will produce more damaging effects. Also
it is noticed that in greater stress, PTSD is more likely to be develop.  Psychological effect will understated greatly
if trauma is prompted, unpredictable, sadistic, repeated and complex by human
or is bad childhood experience given by any human.

2.4       Terrorism and Trauma

There is harsh
change in the world since September 11, 2001. First incident occur in 1993
which was bombardment over world trade center which was almost a wakeup call
but only few people took that seriously alarming situation related to peace in
world. The impending attack focused against the innocent children and common
people of society just to create the element of fear in a society. Impact of
terrorism on children and communities dispirit, terrify and traumatize the public
(Vasquez et al. (2008). These horrifying terroristic attacks incidents have
become common and are increasing day by day. The terrorists started to provoke
war state by targeting the school children, such as the incident in 2006 in
Afghanistan, another group of 20 children were attacked while playing soccer
and a suicidal attack Baghdad college; both incidences took place in February
2007. In March 2007 32 children and teachers were taken as prisoner in Manila forced
at gun point. Terroristic bombardment attacks also took place on 7th
of July, 2005 in London subway, another attack on Paris on 13th of
November 2015. Pakistan is amongst the sufferers of being a target of terrorist
activities. Within six days just after Malala Yousafzai was honored the Nobel
peace prize the terrorist attack was faced on 16th December 2014 in Peshawar targeting
school children. An estimated 145 innocent lives along with teachers was
killed; however, the exact numbers of lives lost are still unknown. Children
were shooting in their classrooms. The so called Tehreek-i-Taliban Pakistan
(TTP) took the responsibility of this attack and claimed it to be a revenge
from Pakistan Army for attacking the North Waziristan tribal areas in June
2014. It was deadly attacks ever on a school in any country. However, according
to GCPEA report Colombia, Pakistan, Afghanistan, Syria, Sudan and Somalia were
worst affected. These places had experienced more than a 1,000 attacks on
universities, schools, staff and students. The emphasis is to discuss impacts
of terrorism on Pakistani youth amongst the countries affected by complicated
terrorism. The reason behind terroristic attacks on educational institutions is
difficult to understand because there are varying reasons. Violence produces
long-term effects than any natural disaster or accidents (Schenlger et al.,
2002). Maximum experience of the traumatic incident and threat to life or any
constant violence causes damaging effect to the psychological health of
individual and mostly in Pakistani society (Khalily et al., 2010; Galea et al.,
2003). In Pakistani society psychological trauma is on the rise and is
prevailing in whole country (Medicines Sans Frontiers, 2008), due to which
people are effected badly and they are helpless, powerless and paralyzed (Herman,
1992; Abdel-hamid et al., 2004). It is documented that severe exposure to
psychological traumas outcome in physical health problems and psychological
problems (Boscarino, 1997). According to Alexander and Klein (2005) the purpose
behind terrorist activities is to build anxiety, fear and panic and developing
a sense of helplessness and hopelessness to destroy the sense of security and
safety and representing the ineffectiveness of the authorities.

Alexander and
Klein (2005) stated that reaction of terrorist events have not documented
properly therefore there is large literature and research work on reaction of
communities and individuals to major traumas. General reaction to terrorist
attacks often include emotional trauma, lack of sensation, denial, terror, nervousness,
helplessness and hopelessness, cognitive disorientation, confusion, disturbing
thoughts, images, high alert, impaired concentration and memory, social
withdrawal, irritability, loss of trust and faith, avoidant behavior, insomnia,
and loss of energy.

Universally the
effects of carelessness and violence are intense and extensive. Survivors can
suffer from any psychiatric diagnosis or individual with frequent trauma
exposure carry many diagnoses on other end they may have grown and achieved
PTG. Due to cultural domains it has been difficult for men to get help for
psychological counseling which is also due to cultural gender bias. There is
difference between boys and girls exposure to terror and posttraumatic symptoms
which was explored by Solomon (2009) in a sample of 2,999 Israeli adolescents.
His study concluded that the female have more posttraumatic symptoms than males
and male reported very few symptoms.

Huddy et al.
(2008) explored the public reactions to terrorism and his results showed that
women responded higher on the personal helplessness, threat and anxiety in reaction
to terrorist events. According to Farooqi (1981) male students have or
experience less anxiety as compare to female. Pridemore et al. (2008) pointed
out that there is major suggestion that disastrous events which also include
terrorist attacks and it is indications of posttraumatic stress and especially for
the communities that are directly exposed to the incident.

From
meta-analytic (e. g., DiMaggio & Galea, 2006; DiMaggio, Galea, & Li,
2009) also narrative reviews (e.g., Bills et al., 2008; García-Vera &Sanz,
2008) happening the psychopathological consequences of terrorist attacks, it
derives that, after terrorist attacks, an important percentage of direct victims
(around 20-30%) will develop a posttraumatic stress disorder (PTSD) as well as
other mental disorders, mainly, major depression disorder, panic disorder,
generalized anxiety disorder, agoraphobia, and alcohol and other substance
dependence/abuse disorders as compared to indirect victims.

Trauma is
different from normal stress experience in childhood. Trauma usually occurs
suddenly and it is unpredictable, unusual and out of the range of any
experience and child or any victim feels inability and helplessness to cope
with traumas. Moreover unpredictability, overwhelming and suddenness nature of
the event form a terror response in survivors. Most common reaction to any
danger has labeled as fight or flight reaction (Monahon 1993). According to
Monahon (1997) early studies those experiences which involve emotions leave
impact on individual life for forever and trauma is outcome of any experiences
related to violence. Traumatic events influences relationships with others,
self, environments and communities and often lead to the feeling of guilt,
self-blame, panic, rage and disconnection from everyone (SAMSHA, 2011). Symptoms
of trauma includes terror and fear, crying, spontaneous behavior, regression,
insecurity and unable to regulate any emotions or feelings. Several things that
effect the impact of any trauma is victim’s age, relation with perpetrator,
trauma type, exposure duration, severity and trauma chronicity most important
aspect for healing from traumatic event is self-care.

According to
SAMHSA, (2010), for the journey of healing it is important that one
participates in the activities of that process so individual can feel the needs
of survivor of traumatic event. Healing is the process in which
cognitive-behavioral components should be effective. According to SAMHSA it is
important to involve in positive self-talk, make accomplishment and one should
be confident and pro-active for preventing to stay healthy and to heal.
Negative impact or after effects of trauma may include depression, posttraumatic
stress disorder, hopelessness (Bostock, Sheikh, & Barton, 2009; Calhoun
& Tedeschi, 2001; Linley, Joseph, , 2008).

2.5       Post-Traumatic stress disorder and
Terrorism

After
the experience of any traumatic event the survivor may suffer from the disorder
that is PTSD (DiMaggio , 2006; García-Vera , 2008; Norris,
Friedman, Watson, Byrne, Diaz, , 2002). Mostly people are exposing
to violent or threating events once in a lifetime (Ozer, Best, Lipsey, &
Weiss, 2003). Victims who have experience traumatic events reported PTSD
symptoms while few survivors show severe symptoms and they develop chronic PTSD
(Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). According to NCTC 2010
report 2670 innocent people were killed by terrorist attacks on Pakistan in
2009, in Afghanistan 2778 were killed and in Iraq 3654 were killed. It is
possible that severe PTSD may be caused due to terrorist attacks due to
multiple reasons. These attacks can lead to high level of PTSD than other
traumas. Whereas, these terroristic attacks result in large number of life
losses and
engage exposure to extreme scenes for emergency workforce. The workforce works nonstop for hours risking their lives for
their loved ones during and after the attacks.

The factors
include family background and family history of psychopathology (Inslicht
et al., 2010), childhood emotional abuse (McCaslin et al., 2006), and high
level of anxiety (Asmundson and Stapleton, 2008), and alexithymia (McCaslin et
al., 2006) including anger as personality trait (Meffert et al., 2008). The response
to a traumatic event has been found to be predictive such as high levels of
peri-traumatic distress (Marmar et al., 2006; Lilly et al., 2009; Inslicht et
al., 2010) and dissociation (Marmar et al., 2006; McCaslin et al., 2008; Lilly
et al., 2009; Martin et al., 2009). Other factors include repetitive work
stress (Marmar et al., 2006; Maguen et al., 2009) and less social support
(Marmar et al., 2006; Martin et al., 2009), are related to the severity of PTSD
symptoms. The aftereffects of terroristic attacks are
long-term among young children and youngsters. Some researchers found out that
before the age of 18 children suffer from trauma events.

The terror attacks resulted in feeling
of hopelessness and uncertainty among the mass in Pakistan. These feelings come
up with psychological problem including anxiety, depression and PTSD. The
trauma not only is being faced in person but can be experienced through media
exposure. The rate of experiencing trauma through media is high around 91%. The
trauma exposure effects psychological as well as physical health of youth (Boscarino,
1997). Other psychological disorders include depression, anxiety, obsessive
compulsive disorder, posttraumatic disorder (PTSD) and substance abuse disorder
common in Pakistan (Khalily 2010) including the negative impacts  life have become common in Pakistan (Khalily,
2011). Another study found out that around 65% of youth in Pakistan has mild to
moderate stress.

2.6       Post-Traumatic
Stress Disorder and Emotion Regulation

Emotion
regulation (ER) is seen to be a perilous factor in the development and
preservation of posttraumatic stress symptoms PTS (Bardeen, Kumpula, & Orcutt,
2013; Marx & Sloan, 2005; Nightingale & Williams, 2000). It is also the
main factor in the development of PTSD symptoms following trauma exposure in
emotion regulation ER (Bardeen, Kumpula, & Orcutt, 2013; Marx & Sloan,
2005; Nightingale & Williams 2000). ER is the conscious or unconscious attempt
to affect the probability, intensity, or duration of an emotion (Gross, 1998).
Traumatic event exposure provokes a variety of strong, emotional responses (Resick
& Gerrol, 1988). Moreover, intrusive re-experiencing symptoms, and supplementary
distress, are common following trauma exposure (Rothbaum et al., 1992).

As a result,
this delicate emotional distress following trauma exposure places increased
demands on efforts to regulate emotion. Individuals with PTSD often experience
a state of emotional freezing; so it is comparatively difficult for them to
experience both positive and negative emotions e.g., fear, horror, anger (APA,
2013). Likewise, individuals with PTSD often experience marked, chronic
emotions, such as guilt and shame (Resick & Schnicke, 1992). Collectively,
these PTSD characters indicate a disturbance in efforts to modulate emotional
responding. One of the aspects of ER is avoidance. Emotion regulation is the
concept which is highly complex to study about; nonetheless, in this study
based on integrative conceptualization of the term ER and how it can be synchronized
or to study its regulating strategies after a traumatic incident and its effect
on the individual’s well-being. Early studies suggest that after a traumatic
incident, emotional and psychological problems may arise but the insight of
their emotion and how to control it personally is not yet studied.

2.7       School Terrorism and its Effect on
Mental Health

After
the error attacks or natural disasters, many survivors go through symptoms of suffering,
sorrow, and anxiety, which may resolve on their own (Norris, Friedman,Watson,
& Byrne, 2002).September 11, 2001, terror attacks, Galea and colleagues
(2002) found that 7.5% reported symptoms consistent with a diagnosis of
posttraumatic stress disorder (PTSD) is related to the attacks. Schools may or
may not be the targets of terrorism, but they are certain to be affected by
terrorism, directly or indirectly.