Truck attack: Fear of ISIS and reminder of truck attacks in Europe as associated with psychological distress and PTSD symptoms

Psychiatry Research 267 (2018) 306–312

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Truck attack: Fear of ISIS and reminder of truck attacks in Europe as associated with psychological distress and PTSD symptoms

T

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Michal Mahat-Shamira, , Yaakov Hoffmanb, Shani Pitcho-Prelorentzosa, Yaira Hamama-Raza, Osnat Lavendaa, Lia Ringa, Uzia Halevia, Eytan Ellenbergc, Ishay Ostfeldc, Menachem Ben-Ezraa a

School of Social Work, Ariel University, Israel Interdisciplinary Department of Social Sciences, Bar-Ilan University, Israel c Bureau of Medical Affairs, National Insurance Institute of Israel, Israel b

A R T I C LE I N FO

A B S T R A C T

Keywords: ISIS attack Psychological distress Severe stress symptoms

Following an ISIS attack, the present study examined the association between psychological distress and severe stress symptoms with vulnerability variables: i.e. Physical proximity to the site of the terror attack, Associative memory of prior events, Danger perception and ISIS anxiety. Using an online survey, 397 adult participants were recruited, Seventy-two hours after an ISIS terror attack, and filled out Psychological distress Patient Health Questionnaire 4 and severe stress symptoms questionnaire as well as physical proximity to the site of the terror attack, associative memory of prior events, danger perception and ISIS anxiety scales. Physical proximity to the site of the terror attack and ISIS anxiety were found to be significantly associated of both psychological distress and severe stress symptoms. Regarding danger perception, only danger perception of terror attacks was associated with both psychological distress and with severe stress symptoms. Lastly, whereas being reminded of the 2014 Jerusalem tractor attack (tapping to association via location) was neither associated with psychological distress nor with severe stress symptom, the reminder of the truck attack in Berlin (tapping into association by recency and similarity) was associated with psychological distress but not with severe stress symptoms. The importance of the findings is discussed.

1. Introduction In recent years the Islamic state of Iraq and Syria (ISIS) has fought its wars predominantly in Muslim countries, while focusing to a lesser extent on terror attacks in western countries (Byman, 2016). Yet over a 1000 persons have been killed in ISIS terror attacks in Western countries during the past three years (see Hoffman, 2017). These attacks are broadcasted on worldwide media, with ISIS releasing media content typically claiming responsibility and warning of future attacks. The impact of this media campaign is massive (Lowe, 2015). Hoffman and Shrira (2017) note several reasons for the salience of the ISIS threat to Israeli society. First, ISIS fighting and militia are felt on two out of three of Israel's borders. Second, ISIS has made direct threats to Israel both in Arabic and in Hebrew that echo the Holocaust by explicitly stating its aim of destroying Israel.1 The genocidal ISIS tendency was actualized against Yazidi's in Iraq (Abdel-Razek and Puttick, 2016). Third, Israeli media covers ISIS fighting and terror very intensely, for example, in a search conducted this past summer in YNET, ⁎

Corresponding author. E-mail address: [email protected] (M. Mahat-Shamir). http://www.investigativeproject.org/4446/isis-threatens-holocaust-against-jews 2 http://www.vocativ.com/world/isis-2/israelis-fighting-isis/ 1

https://doi.org/10.1016/j.psychres.2018.06.021 Received 19 January 2018; Received in revised form 19 May 2018; Accepted 7 June 2018 Available online 18 June 2018 0165-1781/ © 2018 Elsevier B.V. All rights reserved.

Israel's most popular news site, the term ISIS was mentioned 2666 times vs. the local terrorist group Hamas which was mentioned only 853 times. Finally, more than 100 Israeli Arabs have joined ISIS,2 and there is actual danger of them re-entering this region as sleeper agents (see also Byman, 2015). However, only recently (January 8, 2017) has Israel experienced its first ISIS attack, in the heart of Jerusalem, where a truck rammed into a group of soldiers killing four soldiers and wounding tens of soldiers. As this is the first time that an ISIS terror incident occurred in Israel, we wished to gauge how Israeli civilians responded. On the one hand, during 70 years of existence, Israel has literally experienced thousands of terror attacks and thus this current ISIS attack may be just one more. On the other hand, given the above reasons explicating why ISIS terror may be unique to Israelis, following this first ISIS attack in Israel, we were interested to examine the associations between vulnerability variables, known to be associated with stress-related conditions, with both psychological distress and severe stress symptoms. We focus on psychological distress and on severe stress symptoms

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utility of acute stress disorder diagnosis has found it to be highly predictive of post-traumatic stress disorder status, 3 to 6 months after the trauma. This finding was found valid either in cases with high likelihood of diagnosing post-traumatic stress disorder (i.e. full acute stress disorder criteria were met) or in cases with low likelihood of diagnosing post-traumatic stress disorder (i.e. at least two acute stress disorder criteria were not met) (Cahill and Pontoski, 2005). Thus, the current research seeks to examine the association between psychological distress and severe stress symptoms with vulnerability variables: i.e. Physical proximity to the site of the terror attack, Associative memory of prior events, Danger perception and ISIS anxiety. The rational for choosing each vulnerability variable will be discussed below.

since these two disorders were found to be associated with mass trauma events that are incomprehensible and have obvious human intent, such as terrorist events (Norris et al., 2002; Tucker et al., 2016). Regarding psychological distress, it is known that the most common mental disorders in the general population are depression and anxiety, which frequently coexist (Kroenke et al., 2009). In the current study we wish to examine the association between vulnerability variables and psychological distress (depression and anxiety) in the aftermath of an ISIS attack and to indicate whether a participant is predominantly affected by anxiety or depressive symptoms. It is evident that terrorism induces psychological distress among individuals both directly and indirectly exposed to the attacks (Hobfoll et al., 2008, 2006). Importantly, as the world is increasingly becoming a ``global village'', virtually everyone is exposed to images of terror through the media, which often provides a wide-ranged and detailed coverage of terror incidents, thereby exposing people around the world to the possibility of experiencing psychological distress (Goodwin et al., 2015; Ring et al., 2018). Our findings will serve as a screener, as an elevated PHQ– 4 score, serves an indicator for further inquiry to establish the presence or absence of a clinical disorder warranting treatment (Kroenke et al., 2009). Regarding severe stress symptoms, studies on the psychological implications of terrorist attacks in the United States (Galea et al., 2002), Spain (Miguel-Tobal et al., 2006), and Israel (Shalev and Freedman, 2005), have pointed to posttraumatic stress disorder (PTSD) as one of the most prominent and prevalent expressions of psychological distress following terror attacks. PTSD according to the ICD-11 is a disorder that develops following exposure to an extremely threatening or horrific event or series of events characterized by: (1) re-experiencing the traumatic event(s) in the present in the form of vivid intrusive memories accompanied by fear or horror, flashbacks, or nightmares; (2) avoidance of thoughts and memories of the event(s), or avoidance of activities or situations reminiscent of the event(s); and (3) a state of perceived current threat in the form of excessive hyper-vigilance or enhanced startle reactions. The symptoms must last for at least several weeks and cause significant impairment in functioning (Maercker et al., 2013). Notably, Contrary to the DSM-5, which requires a time frame for the diagnosis of PTSD, this is not a requirement in the proposed ICD-11. Because of the multiple diagnostic criteria along with the duration of time (few weeks) needed for the diagnosis, many exposed individuals may not be diagnosed as suffering from PTSD, yet may still display related symptoms and experience severe stress symptoms. In this study, we use the degree to which individuals experience symptoms of PTSD, (i.e., re-experiencing the traumatic event; avoidance, or hyper-vigilance which are more severe than depression and anxiety as expressed in psychological distress) as an indicator of severe stress symptoms experienced in response to terrorism, regardless of whether they meet PTSD diagnostic criteria. Importantly, we use the term severe stress symptoms and not Acute Stress Disorder (ASD), since ASD differs from PTSD in that it includes a greater emphasis on dissociative symptoms (Gibson, 2014). An ASD diagnosis requires that a person experience three symptoms of dissociation (e.g., numbing, reduced awareness, depersonalization, derealization, or amnesia) while the PTSD diagnosis does not include a dissociative symptom cluster. (Please see Bryant and Harvey's comprehensive text on ASD1 for a thorough discussion of the differences between ASD and PTSD (Bryant and Harvey, 2000)). Previous studies have also used terminology such as ``probable PTSD'' (e.g., Hobfoll et al., 2008) or ``clinically significant PTSD-like symptoms'' (Gidron et al., 2004) and suggest that the reported difficulties can be understood within the broad spectrum of PTSD pathology. Victims of traumatic events, such as the current ISIS attack, may develop psychological distress and severe stress symptoms according to vulnerability variables associated with the attack. Revealing the association between vulnerability variables associated with the terror attack and reports of psychological distress and severe stress symptoms may be useful for health care professionals as the up to date research on the

1.1. Physical proximity to the site of the terror attack Previous findings indicate the significance of physical proximity to the site of the terror attack and its diverse impact on the extent to which individuals develop psychological distress (Galea et al., 2002). For example, Shaw's (2003) research has demonstrated significant positive relationships between physical proximity to a terrorist attack and increased psychological distress. There is also some evidence that proximity to a terror scene may increases the risk of PTSD symptoms (Schlenger et al., 2002) and that the closer one is to the terror scene, the more severe the stress symptom levels (Mahat-Shamir et al., 2017). Accordingly, as most previous ISIS knowledge was accrued via media exposure, it would be interesting to gauge the impact of proximity to the attack location. It is important to note that given that the world is much more connected today via smart phone and media, such an attack may be very detrimental even when people were far from the terror incident. Thus, we were also interested in measuring the impact of associative memory of previous traumatic events, including an associative memory driven by the media, on individuals stress levels. 1.2. Associative memory of prior events A broad outlook at contextual parameters such as worldviews that maybe associated with memory consolidation and priming indicate that these worldviews give the individual the basic framework in which exposure to traumatic event or priming for such event is being contextualized. In a previous study conducted among the Israeli population in the aftermath of a terror attack, it was found that those who focused their attention on both recent and similar terror events were associated with elevated levels of distress (Ben-Ezra et al., 2016). Hence, the ``associative memory'' play an important role in providing the framework in which an individual cognitively reacts to cue of prior traumatic events. Indeed, as human beings are more globally connected and networked via media and internet, a related question is, will psychological distress and severe stress symptoms be affected by similar ISIS reminders, i.e., an ISIS truck ramming into a crowd of people in Germany (December 19, 2016) which is geographically distant but very similar in the fact that it was perpetrated by ISIS using a truck. Alternatively, psychological distress and severe stress symptoms may be higher for persons reminded by a slightly different attack, i.e., a tractor ramming into civilians in the very same city Jerusalem, Israel, killing one civilian and wounding seven (August 4, 2014). The first incident is geographically distant but identical in terms of content and media; the latter is closer geographically but was not identical (tractor vs. truck; local terror vs. ISIS terror). Note also that as the truck incident was more recent there may have been a recency effect on the impact of following distress (see also Ben-Ezra et al., 2016). Essentially, the question then becomes whether associative memory of prior events following a terror attack abides by typical psychological rules of recency or will the identification of Jerusalemites with their kin Jerusalemites render memory of the tractor incident more relevant and salient (Holland and Kensinger, 2010). Notably, associative memory of 307

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associated with psychological distress and with severe stress symptoms. c) Danger perception of terror attacks will be positively associated with psychological distress and with severe stress symptoms. d) Fear of ISIS will be positively associated with psychological distress and with severe stress symptoms.

prior similar event may potentially prime future psychological distress following traumatic events (Ben-Ezra et al., 2013). For example, findings from a previous study show that associative memory of both recent and similar terror events was associated with psychological distress (Ben-Ezra et al., 2016). 1.3. Danger perception

2. Methods Experiencing a traumatic event, such as an exposure to an ISIS terror attack, may shatter people's most basic cognitive schemes about the world, other people and themselves (Janoff-Bulman, 1989). A perception of the world as a dangerous place and other people as dangerous to the individual is the end result of shattered assumptions and worldviews following traumatic event. Moreover, as traumatic schema creation of PTSD is maintained, one's trust of the world as core beliefs weakens (Foa and Rothbaum, 1998). Terrorism is distinguished from other threats and its corrosive impact on danger perception and on feelings of security is well-recognized. For example, a study aimed at assessing the psychological effects of different types of traumatic events, has ranked terrorism as one of “the most powerful and pervasive generators of psychiatric illness, distress, and disrupted community and social functioning” (Fullerton et al., 2003, p. 6). Moreover, previous research regarding fear of terror indicated that a wider range of emotional responses to trauma may result in more severe stress symptoms (Ben-Ezra et al., 2017).

2.1. Sample and procedure Seventy-two hours after the terror attack, we deployed an online survey to collect a sample of the Israeli population using social media (mainly Facebook), mobile application (mainly WhatsApp) as means to collect data in the immediate aftermath of the ISIS terror attack. Ethics approval was obtained from the ethics committee in the Faculty of Social Science and Humanities at the first author's university. The sample composed of 397 participants with mean age of 34.3 (SD = 10.55), 62.5% of the sample were women (n = 248), 66.2% were married or living in co-habitation (n = 263). 2.2. Measurements Beyond basic demographics, we used the following measures: 2.2.1. Physical proximity to the site of the attack Physical proximity to the site of the attack was indicated by the physical proximity of the participants to the site of the truck attack located in Armon Hanatziv promenade in southeastern Jerusalem. Participants were asked to report whether they were present at the site during the truck attack. Responses were 1 = `no’ ; 2 = `yes’. This variable was found to be associated with severe stress symptoms, as found in Tel-Aviv Sarona Market terror attack (Mahat-Shamir et al., 2017).

1.4. ISIS anxiety Given the massive impact of the ISIS media campaign, the putative ISIS‐related anxiety should be an important research focus (Hoffman, 2017). This is especially true when the terror attack is executed by ISIS, as ISIS attacks seem to combine both present and future elements of anxiety, thus creating fear of ISIS (Hoffman, 2017). This fear may bear psychological consequences, as for example those who were more fearful of ISIS terrorism were more likely to watch beheading videos and watching beheading videos was associated with psychological distress. Moreover, Hoffman (2017) revealed that higher levels of PTSD symptoms (to which we refer to as severe stress symptoms) are associated with ISIS anxiety.

2.2.2. Associative memory of prior events Participants’ associative memory was tested in relation to two events: “Since the truck attack, how often do you think of the 2014 Jerusalem tractor attack” (tapping to association via location) and “Since the truck attack, how often do you think of the 2016 Berlin truck attack” (tapping to association by similarity). Self-report of each event was rated on a five point Likert scale ranging from 1 ‘not at all’ to 5 ‘very much’. The mean score for the 2014 Jerusalem tractor attack was 3.06 (S.D = 1.24) and for the 2016 Berlin truck attack was 3.31 (S.D = 1.41).

1.5. Current study hypotheses The current study was conducted 72 h after a truck driven by ISIS perpetrator rammed into a group of soldiers adjacent to the Armon Hanatziv promenade in southeastern Jerusalem, leading to the death of four (three female soldiers and one male soldier) and wounding another fifteen. It is important to note that most studies exploring terror attacks, look at civilians reactions after a certain period of time (mostly a month or later). One lacuna in the literature is the immediate reactions to these events (up to 72 h). The rationale for it stems from two aspects that expand previous studies (Ben-Ezra et al., 2016): first, this examination is less affected by media and social environment. Second, it may provide a better understanding of the factors associated with consolidation of distressing memories. The current study presents an opportunity to look at behavioral and cognitive reactions to highly stressful event while people are still grasping and processing the event. In light of the ongoing Israeli–Palestinian conflict, the population in Israel has always been the target of terror attacks. Nevertheless and as noted, this was the first ISIS attack executed in Israel. Given the above we hypothesize the following:

2.2.3. Danger perception Danger perception was measured for the following potential events “Terror attacks”, “Missile attacks” and “War”. The phrasing for each event was similar: “Please rate the following events in terms of danger to yourself and to significant others” on a five point Likert scale ranging from 1 ‘no danger' to 5 `extremely dangerous'. The mean and SD for each event was: “Terror attacks” 4.28 (SD = 0.69), “Missile attacks” 3.87 (SD = 0.91) and “War” 4.27 (SD = 0.99). 2.2.4. ISIS anxiety The ISIS anxiety scale is a 5‐item scale specifically referred to one's subjective perception regarding the threat that ISIS poses. The items were as follows: “I am worried about ISIS more than most people”; “The threat of ISIS arouses a strong anxiety in me”; “I am more careful in my behavior due to the ISIS threat”; “The movies I saw (e.g., executions) caused me great anxiety”; and “I sometimes imagine what will happen if I will fall at the hands of ISIS.” Respondents were asked to indicate on a scale ranging from 1 (strongly disagree) to 5 (strongly agree) to what extent they agree with each statement (Hoffman, 2017). The five items were averaged with higher values indicating higher anxiety regarding

a) Physical proximity to the site of the attack will be positively associated with psychological distress and with severe stress symptoms. b) Reminder of previous terror attacks, i.e. the 2014 Jerusalem tractor attack and the 2016 truck attack in Berlin, will be positively 308

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proximity to the site of the attack, associative memory by similarity, danger perception of terror and missile attack and ISIS anxiety (r = 0.137; p = 0.007, r = 0.273; p < 0.001 , r = 0.310; p < 0.001 , r = 0.099; p = 0.048 , and r = 0.349; p < 0.001, respectively). Severe stress symptoms were also found to be significantly associated with proximity to the site of the attack, associative memory by similarity, danger perception of terror attack and ISIS anxiety (r = 0.253; p < 0.001 , r = 0.175; p < 0.001 , and r = 0.501; p < 0.001, respectively). As opposed to psychological distress, severe stress symptoms were also found to be significantly associated with danger perception of war (r = −0.111; p = 0.028). As indicated in Table 3, the variables’ model explained overall 22.7% of psychological distress. In step 1, socio-demographic variables and physical proximity to the site of the attack explained 3% of the variance (F (4392) = 3.328; p < 0.011). Associative memory, entered in step 2 accounted for 9.4% of the explained variance. This addition was statistically significant (F (2390) = 20.970; p < 0.001). Danger perception, entered in step 3, accounted for additional 6.6% of the explained variance (F (3387) = 10.601; p < 0.001) and ISIS anxiety, entered in step 4, accounted for additional 3.4% of the explained variance (F (1386) = 16.736; p < 0.001). For more information, please see Table 3. In the second model we regressed severe stress symptoms on the sociodemographic and vulnerability variables. As indicated in Table 4, the variables’ model explained overall 27.1% of severe stress symptoms. In step 1, socio-demographic variables and physical proximity to the site of the attack explained 6.2% of the variance (F (4392) = 6.463; p < 0.001). Associative memory, entered in step 2 accounted for 5.9% of the explained variance. This addition was statistically significant (F (2390) = 11.174; p < 0.001). Danger perception, entered in step 3, accounted for additional 9.9% of the explained variance (F (3387) = 9.181; p < 0.001) and ISIS anxiety, entered in step 4, accounted for additional 8.7% of the explained variance (F (1386) = 52.547; p < 0.001). For more information, please see Table 4. Almost all vulnerable variables were found to be statistically significant predictors of both psychological distress and severe stress symptoms. The following are the exceptions: Among the associative memory types, i.e. association via location vs. association by recency and similarity, the Berlin truck attack, tapping on the similarity association, was found to be a significant predictor of psychological distress but not for severe stress symptoms (B = 0.505 or better; t = 4.338 or better; p < 0.001 in model 1, B = 0.105 or better; t = 1.939 or better; p = 0.053 in model 2). In addition, among the danger perception events, i.e. terror attacks, missile attacks and war, only terror attacks were found to be significant predictors of both psychological distress and severe stress symptoms (B = 0.978 or better; t = 3.854 or better; p < 0.001 in model 1, B = 0.300 or better; t = 2.533 or better; p = 0.012 in model 2).

the ISIS threat. Cronbach's Alpha for the ISIS scale was 0.91. Dependent variables – Mental health indices 2.2.5. Psychological distress patient health questionnaire 4 (PHQ-4) The PHQ-4 is a 4-item scale for measuring psychological distress with two subscales tapping for anxiety and depression. The PHQ-4 focus on symptoms in the last two weeks (Kroenke et al., 2009). Each of the items is rated on a four-point Likert scale ranging from 0 `not at all' to 3 `nearly every day'. This scale is also widely used among the general population (Wolfe et al., 2013). Cronbach's Alpha for the PHQ-4 scale was 0.81. 2.2.6. Severe stress symptoms Severity of Stress Symptoms was measured according the proposed ICD-11 criteria (6 items addressing three clusters) on a scale of `1' not at all to `5' extremely. Each participant rated the response on a 5-point rating scale where a score of 3 or higher represented a positive symptom rating (Knefel and Lueger-Schuster, 2013). Cronbach's Alpha for the severe stress symptoms scale was 0.89. 2.3. Statistical analyses A four-step hierarchical regression analyses was carried out to examine the unique contribution of each vulnerability variable. In the first step, we inserted the socio-demographic factors (age, sex, marital status) and physical proximity to the site of the attack, as it refers to the physical proximity of the participants from the scene of the event. The rest of the vulnerability variables were inserted separately from the most cognitive and internal variable to the emotional and circumstantial variable. Therefore, in the second step, we have inserted the associative memory of prior events (tractor attack in Jerusalem, truck attack in Berlin). In the third step, we have inserted danger perception (terror attacks, missile attacks, war). And finally, in the fourth step, we inserted the ISIS anxiety variable, which is the less studied variable among the vulnerability variables. Psychological distress (Model 1) and severity of stress (Model 2) symptoms were regressed on these four variables. We examined potential multicollinearity between the study variables, and found no indication of multicollinearity, as tolerance levels ranged from 0.662 to 0.955 (O'Brien, 2007). 3. Results Table 1 summarizes the descriptive statistics of the study's variables and Table 2 provide information regarding the correlations found between the study's variables. As indicated in Table 2, Psychological distress was found to be positively and significantly associated with Table 1 Ranges, mean scores, standard deviations and prevalence of study variables.

Age Associative memory by location (Jerusalem tractor attack in 2014) Associative memory by similarity (Berlin truck attack in 2016) Danger perception of terror attacks Danger perception of missile attack Danger perception of war ISIS anxiety Psychological distress Sex (male) Marital status (in a committed relationship) Physical proximity to the site (present at the vicinity of the attack) Severe stress symptoms

Minimum

Maximum

Mean

S.D.

18 1

65 5

34.30 3.06

10.55 1.24

1

5

3.31

1.41

2 1 1 6 4 N 149 265

5 5 5 30 20 % 37.34 66.42

4.28 3.87 4.27 11.31 7.88

0.69 0.91 0.98 5.62 3.22

62

15.54

32

8.02

4. Discussion The current study focused on risk factors associated with psychological distress and severe stress symptoms. In particular, following an ISIS terror attack, the present study examined the association between the independent variables physical proximity to the site of the attack, associative memory of prior events, danger perception and ISIS anxiety with each of the dependent variables, namely, psychological distress and severe stress symptoms. In line with our first hypotheses, physical proximity to the site of the attack was found to be a highly associated with both psychological distress and severe stress symptoms. One way to explain these findings is by the fact that the physical proximity to the terror site may cause fear and perceived threat, which in turn may lead to psychological distress, as evident in studies conducted after the terrorist attacks on September 11th. These studies show that those with proximity to the attack, experienced elevated symptoms of anxiety and depression (core 309

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Table 2 Correlation coefficients for the study's variables.

1. 2. 3. 4. 5. 6. 7. 8. 9.

Physical proximity. Associative memory by location. Associative memory by similarity. Danger perception of terror attacks Danger perception of missile attack Danger perception of war ISIS anxiety Psychological distress Severe stress symptoms

1

2

3

4

5

1 −0.057 0.035 −0.028 −0.003 0.012 −0.156** −0.137** −0.129*

1 0.112* −0.008 0.016 0.096 −0.047 0.006 −0.037

1 0.113* 0.039 −0.058 0.342** 0.273** 0.253**

0.438** 0.189** 0.316** 0.310** 0.175**

1 0.449** 0.073 0.099* −0.002

6

7

8

1 1 −0.032 −0.007 −0.111*

1 0.349** 0.501**

1 0.414**

* p < 0.05; ** p < 0.01. Table 3 Factors associated with psychological distress following ISIS truck attack in Jerusalem (n = 397). Variables

Table 4 Factors associated with severe stress symptoms following ISIS truck attack in Jerusalem (n = 397).

Statistics

Variables B

S.E

T

Psychological distress

B

S.E

T

P value

Age (years) Sex Marital Status Physical proximity to the site of the terror attack

0.025 −0.032 −0.153 1.863

0.008 0.158 0.174 0.483

3.228 −0.200 −0.879 3.857

0.001 0.842 0.380 0.000

Age (years) Sex Marital Status Physical proximity to the site of the terror attack Reminder of the tractor attack Reminder of the truck attack

0.016 0.116 −0.179 1.972

0.008 0.157 0.170 0.472

2.058 0.738 −1.053 4.175

0.040 0.461 0.293 0.000

−0.042 0.266

0.060 0.056

−0.700 4.727

0.484 0.000

Age (years) Sex Marital Status Physical proximity to the site of the terror attack Reminder of the tractor attack Reminder of the truck attack Danger perception, terror attacks Danger perception, missile attacks Danger perception, war

0.021 −0.011 −0.144 1.865

0.008 0.158 0.165 0.459

2.708 −0.069 −0.873 4.068

0.007 0.945 0.383 0.000

−0.025 0.209 0.594

0.059 0.056 0.118

−0.421 3.736 5.014

0.674 0.000 0.000

−0.045

0.096

−0.464

0.643

−0.039

0.084

−0.464

0.643

Severe stress symptoms

Step 1

Step 1 Age (years) Sex Marital Status Physical proximity to the site of the terror attack

0.028 0.403 −0.717 2.826

0.017 0.333 0.367 1.021

1.662 1.208 −1.952 2.769

0.097 .228 0.052 0.006

Age (years) Sex Marital Status Physical proximity to the site of the terror attack Reminder of the tractor attack Reminder of the truck attack

0.002 0.819 −0.792 3.132

0.016 0.324 0.351 0.975

0.117 2.526 −2.258 3.212

0.907 0.012 0.025 0.001

−0.113 0.754

0.124 0.116

−0.911 6.476

0.363 0.000

Age (years) Sex Marital Status Physical proximity to the site of the terror attack Reminder of the tractor attack Reminder of the truck attack Danger perception, terror attacks Danger perception, missile attacks Danger perception, war

0.012 0.584 −0.716 2.895

0.016 0.324 0.339 0.942

0.728 1.800 −2.115 3.073

0.467 0.073 0.035 0.002

−0.072 0.630 1.334

0.121 0.115 0.243

−0.598 5.495 5.482

0.550 0.000 0.000

−0.183

0.198

−0.925

0.356

−0.129

0.174

−0.741

0.459

Step 2

Step 2

Step 3

Step 3

Step 4

Model Step 1 Step 2 Step 3 Step 4

Statistics

P value

Step 4 Age (years) 0.002 0.016 0.130 0.896 Sex 0.667 0.319 2.094 0.037 Marital Status −0.640 0.333 −1.926 0.055 Physical proximity to the site 2.155 0.941 2.290 0.023 of the terror attack Reminder of the tractor attack −0.030 0.119 −0.253 0.800 Reminder of the truck attack 0.505 0.116 4.338 0.000 Danger perception, terror 0.978 0.254 3.854 0.000 attacks Danger perception, missile −0.136 0.194 −0.699 0.485 attacks Danger perception, war −0.123 0.170 −0.724 0.469 Fear of ISIS 0.144 0.035 4.091 0.000 summary R = 0.181; R2 = 0.033; R = 0.356; R2 = 0.127; R2 change = 0.094; F (2,390) = 20.970; p < 0.001 R = 0.439; R2 = 0.193; R2 change = 0.066; F (3,387) = 10.601; p < 0.001 R = 0.476; R2 = 0.227; R2 change = 0.034; F (1,386) = 16.736; p < 0.001

Model Step 1 Step 2 Step 3 Step 4

Age (years) 0.013 0.008 1.781 0.076 Sex 0.058 0.149 0.391 0.696 Marital Status −0.081 0.155 −0.523 0.601 Physical proximity to the site 1.254 0.439 2.856 0.005 of the terror attack Reminder of the tractor attack 0.010 0.055 0.182 0.856 Reminder of the truck attack 0.105 0.054 1.939 0.053 Danger perception, terror 0.300 0.118 2.533 0.012 attacks Danger perception, missile −0.006 0.091 −0.063 0.950 attacks Danger perception, war −0.035 0.079 −0.438 0.662 Fear of ISIS 0.119 0.016 7.249 0.000 Summary R = 0.249; R2 = 0.062; R = 0.336; R2 = 0.113; R2 change = 0.059; F (2,390) = 11.174; p < 0.001 R = 0.414; R2 = 0.172; R2 change = 0.099; F (3,387) = 9.181; p < 0.001 R = 0.520; R2 = 0.271; R2 change = 0.087; F (1,386) = 52.547; p < 0.001

Bolded letter represent significant results.

Bolded letter represent significant results.

items of psychological distress) in the ensuing weeks and months (Schlenger et al., 2002). Moreover, physical proximity to the terror site may prompt feelings of extreme threat or horror, consequently leading to the development of

PTSD. As suggested by the ICD-11, PTSD develops upon exposure to an extremely threatening or horrific event or series of events (Maercker et al., 2013). Additionally, physical proximity to the terror site may cause a severe sense of danger and danger was found to be a 310

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world are exposed to images of terror through the media thus to the possibility of experiencing psychological distress (Ring et al., 2018) through the similarity effect. The fact that the reminder of the truck attack in Berlin was not associated with severe stress symptoms may indicate on the stress inoculation model which claims that exposure to stressors that resemble each other may inoculate people and reduce the impact of these stressors (Meichenbaum and Deffenbacher, 1988). Thus, a similar recent event such as the truck attack in Berlin is associated with psychological distress but not with severe stress symptom. An alternative explanation for the memory result may stem from Social identity theory (Tajfel and Turner, 1979). Namely, via its media campaigns, ISIS conveys its vision of a future world where Islam prevails (Hoffman, 2017). Thus, ISIS tries to convince all ``believers" to become a single unitary in-group based on ideology rather than on purely geopolitical considerations. Although through its media campaigns ISIS does manage to intensify feelings of threat among the ``freeworld"; following terror attacks (Hoffman, 2017), our findings may indicate that in the face of the ISIS threat and the ideological in-group it creates, people of the ``free-world" are also becoming an in-group based on resistance to ISIS ideology. According to the social identity theory, all threatened free-people around the world may perceive themselves as an in-group and as positively distinct from ISIS, which is the relevant out-group (Tajfel and Turner, 1979). As Israelis may perceive themselves as a part of the ``free-world" in-group, it is not surprising that the Berlin truck attack reminder was associated with greater psychological distress. Further studies should examine the association between exposure to ISIS media campaigns and psychological distress in the aftermath of an ISIS attack, in light of the Social identity theory. Our research should be interpreted in light of several limitations. First, it should be noted that this study was based on self- reported measures and data was collected using a cross-sectional design. Accordingly, there was no information regarding participants' psychiatric condition prior to data gathering. Moreover, as data was collected through an online survey, the issue of a self-selection bias may be a potential limitation in the current study, and future studies may choose to employ alternative data gathering methods. Lastly, geographic locations where terrorist attacks occur with regularity are also typically encumbered by other terrorist-related stressors, such as likelihood of losing a loved one, personal injury, disruption in routine, and post-disaster stress in the community (Shalev and Freedman, 2005). Therefore, it is important to examine whether the association between the variables varies among different populations and situations. Despite these limitations, to the best of our knowledge, the current study is one of the very few research efforts to examine the association between physical proximity to the site of the attack, danger perception, associative memory of prior events and ISIS anxiety and psychological distress and severe stress symptoms. Revealing vulnerability variables that are associated with psychological distress and severe stress symptoms is important when looking at the impact of a terror attack in order to accurate preventive treatment, as the up to date research on the utility of acute stress disorder diagnosis has found it to be highly predictive of post-traumatic stress disorder status, 3 to 6 months after the trauma. This finding was found valid either in cases with high likelihood of diagnosing post-traumatic stress disorder (i.e. full acute stress disorder criteria were met) or in cases with low likelihood of diagnosing post-traumatic stress disorder (i.e. at least two acute stress disorder criteria were not met) (Cahill and Pontoski, 2005). It is important to note the different role danger perception plays in predicting the various stress-related conditions, assisting in distinguishing between them. As this is the first study to reveal this distinction, future studies should further examine this difference. Moreover, future studies should examine longitudinal measurement of physical proximity to the site of the terror attack, associative memory of prior events, danger perception and ISIS anxiety in order to learn if the results are stable across time. One basic finding is that ISIS terror attacks may be distinctive due to

gradient gateway to PTSD exposure (Mahat-Shamir et al., 2017). These findings imply that even though the world is much more connected today via smart phone and media, and an ISIS attack may be very detrimental to people are far from the terror incident, physical proximity to the terror site still has an immense effect on individuals' Psychological distress and severe stress symptoms. The hypothesis regarding memory will be addressed below after addressing danger perception and ISIS anxiety. Danger perception was measured for the following potential events “terror attacks”, “missile attacks” and “war” In line with our hypothesis, only danger perception of terror attacks was associated with both psychological distress and with severe stress symptoms. One way to explain these findings relates to the fact that due to the ongoing Israeli-Palestinian conflict, Israeli citizens are continuously exposed to terror attacks thus may be experiencing a “sensitization” process that puts individuals who have recently experienced trauma, at risk of developing either psychological distress or severe stress symptoms. Moreover, Israelis’ constant exposure to terror may heighten death anxiety and psychiatric morbidity (Hoelterhoff and Chung, 2013), which in turn are significantly associated with psychological distress (Abdel-Khalek, 1998) and with PTSD symptoms (Hamama-Raz et al., 2016). Finally, these findings may be interpreted in light of the unpredictable, man-made and intentional nature of a terror attack, creating a political, social and ideological overlay not always associated with more conventional forms of trauma. Mansdorf (2008) noted other details distinguishing terror attacks such as the lack of any warning whatsoever, the lack of familiarity with the particular details of the event, the particular scope and nature of the destruction and the uncertainty and disrupted social systems that affect an entire community. While some of these characteristics may also typify aspects of conventional war or a missile attacks, terrorism is distinguished by its focus on more ideological rather than purely geopolitical motivations. Whether it is the radical ideology or a more religious ideology, conventional wars have a distinct end while terrorism, with its focus on altering an ideology rather than simply attaining a geopolitical goal, is neverending (Mansdorf, 2008). Thus, a terror attack may be perceived as more dangerous and be associated with psychological distress and with severe stress symptoms. Results regarding ISIS anxiety were also in line with our hypothesis, as ISIS anxiety was associated with psychological distress and with severe stress symptoms. These results may also be interpreted by the fact that ISIS attacks seem to combine both present and future elements of anxiety (Hoffman, 2017), thus creating fear and perceived threat which were previously found to be associated with psychological distress (Schlenger et al., 2002). Moreover, our results are in line with previous findings indicating the association between ISIS anxiety and PTSD (Hoffman, 2017). Lastly, results regarding associative memory were only partially in line with our hypothesis. Whereas being reminded of the 2014 Jerusalem tractor attack (tapping to association via location) was neither associated with psychological distress nor with severe stress symptom, the reminder of the truck attack in Berlin (tapping into association by recency and similarity) was associated with psychological distress but not with severe stress symptoms. The fact that the reminder of the truck attack in Berlin was associated with psychological distress is in line with a previous study indicating that major life events may abide the similarity and recency in their association with psychological distress (Ben-Ezra et al., 2016). Hence, as hypothesized, the events that people rated as more frequent immediately in the aftermath of the terror attack in question was the one with higher similarity and recency (the truck attack in Berlin). Thus, although one may think that an attack in the same place may act as a similarity effect due to the same location, our study indicates that it is not the geographical place per se, rather it is more the exact type of attack that makes for the similarity effect. Thus although Berlin is quite far from Jerusalem, the world is increasingly becoming a "global village", virtually everyone around the 311

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the aforementioned special characteristics. Moreover, our findings suggest that in parallel to the psychological and psychiatric effects of global terror, there may be a parallel psychological effect that leads to the creation of a cohesive in-group of ``free-world" ideology which in turn impacts one's level of distress.

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