June 2007

Grant Results

SUMMARY

From 1995 to 2005, faculty members from the Department of Psychiatry and Behavioral Sciences at the University of Oklahoma Health Sciences Center (OUHSC) provided intensive mental health treatment to people traumatized by the 1995 bombing of the Alfred P. Murrah Federal Building.

The Robert Wood Johnson Foundation (RWJF)-funded clinical services were one component of the Department of Psychiatry and Behavioral Sciences' response to the disaster. With more than $3.5 million in federal grants and other support, faculty members also conducted research on the mental health effects of the Oklahoma City bombing and other terrorist events and considered how communities should organize a mental health response. The research publications are included in the Bibliography, although RWJF did not support this work.

Key Results

  • As of September 30, 2005, faculty clinicians had provided services to 88 individuals for a total of 1,250 visits. Those served included victims and survivors, family members of those directly involved, responders and rescue workers. In a coordinated effort, faculty clinicians focused on long-term psychiatric treatment, medication management and specialized services that other community providers could not offer.
  • The faculty members' direct experience treating trauma victims informed their extensive research and consultation efforts. The faculty members published more than 50 articles and 10 book chapters about mental health issues related to disasters and terrorist events. Their clinical experiences with Oklahoma bombing victims helped prepare them to provide consultation after other disasters, including the September 11th terrorist attacks, Hurricane Katrina and the U.S. Embassy bombing in East Africa.

Funding
RWJF provided an unsolicited grant of $95,990 to cover the cost of long-term mental health treatment not covered by insurance or other funding. The faculty members used the RWJF grant in small increments over 10 years to fill gaps in funding for mental health treatment.

 See Grant Detail & Contact Information
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THE PROBLEM

The bombing of the Alfred P. Murrah Federal Building in Oklahoma City on April 19, 1995, took the lives of 168 people, including 19 children, injured 800 and inflicted significant psychological trauma on an entire community.

More than 16,000 people were in the downtown area at the time and felt and heard the blast. Some 12,000 were involved in rescue efforts, including body handling and caring for the injured. Many others experienced the loss or serious injuries of family members or friends. Community surveys revealed that more than one-third of adults and youths in the city (some 360,000) personally knew someone who was killed or injured in the blast.

(For more statistics on the tragedy, go to the Web site of the Oklahoma City National Memorial.)

The Challenge of Organizing a Mental Health Response to Disaster

As large-scale incidents of terrorism increasingly threaten populations around the world, understanding the mental health effects of terrorism and knowing how to organize (and fund) the mental health system to respond become pressing needs.

State and federal funding sources are geared to provide crisis intervention services, as well as training, outreach and public education. They do not deal with the more serious and enduring psychological consequences that disaster victims often experience.

Months or years after exposure to trauma, victims may experience secondary consequences, such as marital difficulties and job-related problems and for children, school issues. Early intervention, frequent therapy and appropriate medication can help lessen the duration and intensity of these problems.

Soon after the disaster, the Oklahoma Department of Mental Health and Substance Abuse Services used federal funding to establish a clinical center, Project Heartland, to provide assessment and treatment to people with bomb-related mental health problems.

In the weeks and months that followed, as individuals with severe and chronic mental health disorders began seeking assistance at Project Heartland, they had to be referred to other providers with the professional expertise to treat such problems.

Lack of insurance coverage for these intensive, long-term services was a barrier to assistance. Two of the hardest hit groups-rescue workers and their families, and direct victims of the bombing-had little or no insurance coverage for mental health treatment from private practitioners, according to the Oklahoma State Department of Health.

The University's Department of Psychiatry and Behavioral Sciences Gets Involved

The department, part of the University of Oklahoma Health Sciences Center, is located near the state capitol building, just one mile from the scene of the bombing of the Murrah building. By virtue of its location and its staff of faculty clinicians, the department was well situated to play a key role in disaster response by providing direct clinical services and education and training services and by conducting research.

In the immediate aftermath of the April bombing, faculty from the department joined other agencies, such as the Red Cross, in providing crisis intervention services, staffing crisis hotlines and grief counseling centers and debriefing rescue workers.

As the days and weeks went by, the faculty clinicians began seeing more people from the community with symptoms of post-traumatic stress disorder (PTSD), depression and other anxiety disorders, who were unable to find the care they needed from clinics that had been established, such as Project Heartland.

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RWJF STRATEGY

This project was consistent with the response of RWJF to other national disasters. It represented a timely opportunity to help address serious problems related to mental health needs of disaster victims.

Following the September 11, 2001, terrorist attacks in New York City, RWJF made a number of grants addressing the mental health needs of specific populations, especially Latinos and the city's Chinatown neighborhood near the World Trade Center. For more information, see Grant Results on ID# 044116 (Latinos) and ID# 044115 (Chinatown).

In the wake of Hurricane Katrina, funding from the Foundation, through intermediary organizations, has been provided for an array of mental health services, particularly targeting children.

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THE PROJECT

This project, which began in September 1995, about five months after the bombing, and continued until 2005, allowed faculty members to provide the intensive and, in some cases long-term, mental health treatment that people traumatized by the terrorist event needed. Betty Pfefferbaum, M.D., J.D., professor and chair of the Department of Psychiatry and Behavioral Sciences, served as project director.

The department joined in a coordinated effort to meet critical mental health needs and at the same time to avoid duplication of services. Oklahoma City established an "unmet needs committee," which enabled the Red Cross, the Oklahoma City Public Schools, the Oklahoma Public Health Department and other major social service and health providers to meet and match their services to the needs of individuals and families affected by the bombing.

Within the mix of providers, the Department of Psychiatry and Behavioral Sciences became "a key provider of psychiatric care, including medication management," according to Project Director Pfefferbaum.

Funding

Over the 10 years, some 20 faculty members in the department provided mental health services, including psychotherapy and medication management, at significantly discounted rates to those affected by the bombing. Pharmaceutical companies provided medications at no cost to the department.

Additional funds were earmarked for mental health provision from the American Red Cross and the Oklahoma City Community Foundation. Other sources of support for long-term mental health care were: private insurance, federal workers' compensation and Oklahoma workers' compensation.

The department used RWJF funds as the source of last resort when no other funds were available, thereby extending what had been a one-year RWJF grant to 10 years and meeting the objective of providing long-term mental health treatment. The extended grant period proved to be important, as most federal, state and other funding for mental health ended in 2000.

Consultation and Research (Not Paid for by RWJF)

In 1995, along with providing clinical services, the department immediately began conducting mental health research related to the Oklahoma City bombing and other terrorist events. The Oklahoma governor identified the University of Oklahoma Health Sciences Center as the overseer of all research and educational activities related to the tragedy.

The Department of Psychiatry and Behavioral Sciences received more than $3.8 million in federal and private foundation grants. Over 10 years, the faculty members, alone and in collaboration with researchers around the country, published more than 50 journal articles and 10 book chapters about the psychological effects of disasters and terrorism, and made some 60 presentations at meetings of health and mental health groups nationwide. See the Bibliography for a list of publications.

This grant supported direct clinical services only. However, the project director saw a critical link between the faculty members' extensive mental health research and their provision of clinical services, which contributed to their understanding of the needs of disaster victims. See Results and Observations.

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RESULTS

  • As of September 30, 2005, the clinicians had provided services to 88 individuals for a total of some 1,250 visits. Patients ranged in age from 6 to 56, including mothers and grandmothers who had lost children in the blast, children, spouses and extended family members of victims, and responders and their families. The faculty members saw patients mostly in their offices at the center, but occasionally in community settings, such as homes or schools.
  • Clinicians focused on long-term psychiatric treatment, medication management and specialized services that other community providers could not offer. They observed that:
    • Post-traumatic stress disorder (PTSD) symptoms occur early and recede with time, often replaced with symptoms of depression. About one-third of the people who experienced the bombing firsthand developed PTSD within the first six months of the incident; about 45 percent developed some other psychiatric disorder.
    • Some of those being treated for psychiatric problems suffered delayed reactions and secondary symptoms associated with events that occurred after the bombing. Events that triggered delayed reactions and increased demand for services included:
      • Anniversaries of the bombing.
      • The federal trials of Timothy McVeigh and Terry Nichols, the McVeigh execution and the state trial of Nichols.
      • The terrorist attacks on September 11, 2001.
      • Tornados that struck Oklahoma in May 1999, killing some 40 Oklahomans and causing extensive property damage and destruction.
  • Different groups of people directly affected by a disaster may have quite dissimilar reactions. For example, when studied, firefighters who responded to the bombing had fewer psychiatric diagnoses than did survivors.
  • Department faculty members continued providing intensive, long-term mental health services after community agencies had discontinued them. Most organizations providing bomb-related mental health, including Project Heartland, discontinued services by the end of 2000. By stretching their RWJF funding over 10 years, faculty clinicians were able to continue meeting the need for services.
  • By providing services over the decade, the faculty clinicians were able to step in at critical points, such as the execution of convicted Oklahoma City bomber Timothy McVeigh. In the spring of 2001, the University of Oklahoma Health Sciences Center helped mobilize a team of providers in the city to address needs that might arise in reaction to McVeigh's execution. Pfefferbaum was part of a team on-site with family members of victims who were allowed to watch a live videotape of the execution on June 11, 2001.
  • The faculty members' direct experience treating trauma victims helped inform their extensive research and consultation efforts. The project director notes that the experience of providing services to the most impaired victims of the bombing helped inform their research efforts.
    • Linkages between research and clinical activities benefited victims as well as researchers. Faculty clinicians provided treatment to some individuals who participated in the research studies. The reverse also happened: Some of the individuals seen for mental health treatment also participated in the faculty members' research studies.
    • Researchers from other institutions were encouraged to link with a local clinician or clinical group that could provide treatment to study subjects if needed. The University of Oklahoma Health Sciences Center's Institutional Review Board consulted with institutional review boards around the country about ethical issues related to bombing research. When these researchers came to Oklahoma to study the effects of the tragedy, they usually contacted the center and were given referrals to local providers. The goal was to protect survivors and families from untoward effects of research procedures and refer them to treatment as needed.
    • The faculty members played a large role in creating the Memorial Institute for the Prevention of Terrorism. The institute is the research arm of the memorial to honor the victims of the bombing and is located at the site of the Murrah building.
    • The faculty members' knowledge and expertise grew to the point that they began providing consultation after a number of other disasters:
      • The 1998 U.S. Embassy bombings in East Africa.
      • The September 11th attacks.
      • The series of hurricanes in 2004.
      • Hurricane Katrina in 2005.

Observations by Project Director: Learning by Providing Direct Clinical Service

Project Director Betty Pfefferbaum made the following observations based on the department's experience working with people traumatized by the bombing:

Individuals who came for treatment tended to have severe symptoms and a picture of chronic illness. Co-morbidity is common, and I think the untold story, particularly as the disaster unfolds, is the level of depression that is often a result of the secondary adversities associated with living in a post-disaster environment.

Paying attention to different kinds of reactions across affected individuals and groups is one of the more important things we learned." Groups such as the firefighters "appeared to be more resilient … but one of the interesting findings was the higher use of alcohol in that sample.

Despite the severity of symptoms, Pfefferbaum also saw "a picture of incredible resilience and resolve." She cites as an example the faculty members' work with mothers whose children perished in the blast. "Most of the children who were killed were young children in day care, so these were, for the most part, young mothers, and in some instances grandmothers, who were raising the children."

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SIGNIFICANCE TO THE FIELD

The department's combined clinical and research efforts helped advance the field of post-disaster mental health services in several critical areas, which emerged into prominence again after the September 11th attacks. Pfefferbaum and her colleagues found that:

  • The psychological reactions and needs of individuals exposed to disasters vary in part depending on their exposure. Exposure has both qualitative and quantitative characteristics. The distinctions in qualitative exposure deserve special attention with respect to terrorist attacks because the intended and potential targets extend beyond directly exposed individuals.
  • Exposure to media coverage of disasters is related to outcomes in children. The goal of terrorism is to affect whole communities and society at large. The media play a role in realizing this goal. The researchers' work in this area is frequently cited in studies of media effects related to the September 11th attacks.
  • The field needs to address serious gaps in funding for traditional psychiatric services after a disaster. Federal funding for mental health focuses on normal reactions to adverse events and provides a host of services including outreach, triage and referral, emergency services and crisis intervention, counseling and therapy and support services. Experiences in Oklahoma City suggest that large-scale, human-caused disasters may result in greater psychiatric impairment of direct victims than do natural disasters.

See Appendix 1: Key Areas From the Body of Research for more information, and Appendix 2 for journal article citations.

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LESSONS LEARNED

  1. Researchers must treat "real" people in order to truly understand the impact of a disaster and reflect that in their clinical research. "If we had not had the experience of treating individuals who were exposed to this [the bombing], we would never have understood disaster mental health or disaster reactions," says Pfefferbaum. Treating real people "has influenced our research, our role in policy and the way we have conceived of and developed interventions." (Project Director)
  2. Create partnerships among mental health providers in order to respond well to disasters. The Health Sciences Center worked closely with other agencies and groups to meet the mental health needs of bombing victims. In particular, the center was able to provide the intensive services and medication management that few other providers could. "No one group can do it all," says Pfefferbaum. (Project Director)
  3. Get good consultation when venturing into new areas of practice. The faculty members conferred with clinicians who had experience with post-disaster mental health issues to create treatment plans. They also collaborated with investigators around the country in researching the effects of the bombing. Now, based on their experience with the Oklahoma City disaster, the faculty members have become consultants-but they could not have developed that expertise without good initial consultation. (Project Director)
  4. Evaluate the effectiveness of various treatment modalities for victims of disaster. The project did not study treatment effectiveness and thus could not offer the field proven methods that could be replicated. "[Evaluating treatment effectiveness] would have been useful and it would have advanced the field measurably," said Pfefferbaum. (Project Director)

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AFTER THE GRANT

The faculty members at the Department of Psychiatry and Behavioral Services at the University of Oklahoma Health Sciences Center continue to provide treatment for people affected by the bombing.

In 2005, the department became home to the Terrorism and Disaster Center of the National Child Traumatic Stress Network (NCTSN), which consists of 70 member centers-45 current grantees and 25 previous grantees. The NCTSN is funded by the Center for Mental Health Services, Substance Abuse and Mental Health Administration in the U.S. Department of Health and Human Services to improve access to care, treatment and services for traumatized children and adolescents exposed to traumatic events.

The network is funded by the Center for Mental Health Services through a congressional initiative: the Donald J. Cohen National Child Traumatic Stress Initiative.

The University of Oklahoma Health Sciences Center will receive nearly $2.4 million from 2006 to 2010.

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GRANT DETAILS & CONTACT INFORMATION

Project

Assessment and Treatment of People with Bomb-related Mental Health Problems

Grantee

University of Oklahoma Health Sciences Center (Oklahoma City,  OK)

  • Amount: $ 95,990
    Dates: October 1995 to September 2005
    ID#:  028142

Contact

Betty Pfefferbaum, M.D., J.D.
(405) 271-5121
betty-pfefferbaum@ouhsc.edu

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APPENDICES


Appendix 1

Key Areas From the Body of Research

The Department of Psychiatry and Behavioral Sciences at the University of Oklahoma Health Sciences Center initiated clinical and research efforts after the 1995 Oklahoma City bombing.

According to the project director, the research helped advance the field of disaster mental health in these key areas:

Reactions and Mental Health Needs Based on Level of Exposure to a Disaster
The psychological reactions and needs of individuals exposed to disasters vary in part depending on their exposure. Exposure has both qualitative and quantitative characteristics. The distinctions in qualitative exposure deserve special attention with respect to terrorist attacks because the intended and potential targets extend beyond directly exposed individuals.

Direct exposure occurs in those physically present during an attack or those infected or contaminated by a biological or other hazardous agent. Eyewitnesses to terrorist attacks are considered directly exposed, but people whose only contact with the event is through media coverage are not directly exposed though they may react emotionally to an incident and the danger it poses.

Less direct forms of exposure occur in relatives and close associates of victims and survivors. Indirectly or secondarily exposed individuals suffer secondary negative consequences of an event such as the threat of near-miss experiences, fear of contagion and disruption in their daily lives. Remotely affected segments of the population, located outside the community where an event occurs, are affected through membership in the greater society (Pfefferbaum et al., 2005a; North & Pfefferbaum, 2004).

Researchers at OUHSC assisted Carol S. North, M.D., M.P.E. (Washington University School of Medicine at the time; North Texas VA Health Care System and University of Texas Southwestern Medical Center currently) in a methodologically rigorous study of directly exposed bombing victims. This study revealed high rates of post-traumatic stress disorder (PTSD) and other disorders, though not new substance use disorders, six months after the incident (North et al., 1999).

Follow-up studies at 17 months and seven years provided rich information on the trajectory of recovery in directly exposed disaster victims. The 17-month follow-up study confirmed the immediacy of onset of PTSD and its persistence over time, pointing to the need for early interventions that continue over the long term (North et al., 2004).

The researchers studied biological markers in a subgroup of the survivors at seven years (Tucker et al., 2007). The researchers also worked with North in her study of Oklahoma City firefighters (North et al., 2002a; North et al., 2002b) and a pilot study of their mates (Pfefferbaum et al., 2002a; Pfefferbaum et al., 2006b).

Given the terrorist goal of instilling fear and intimidation in a population extending beyond those directly affected, the researchers collaborated with colleagues at the Oklahoma State Department of Health and the OUHSC College of Public Health to examine systematically community samples of indirectly exposed residents.

Three surveys comparing Oklahoma City residents to residents of Indianapolis were conducted between 1995 and 1998, and a fourth study of a national sample, which included an oversampling of Oklahoma City residents, was conducted after the September 11th attacks.

Oklahoma City residents reported significantly more post-traumatic and general stress than did Indianapolis residents in the months following the bombing (Smith et al., 1999), but differences decreased over time and Oklahoma City respondents were no different from the rest of the nation on most measures assessed after the September 11th attacks (Pfefferbaum et al., 2006a).

The Effects in Children of Exposure to Media Coverage of Disasters
The goal of terrorism is to affect whole communities and society at large. The media play a role in realizing this goal.

Bombing-related television viewing correlated with post-traumatic stress in middle school children seven weeks after the bombing (Pfefferbaum et al., 1999; 2001) and by elementary school children eight to 10 months after the incident (Gurwitch et al., 2002a; 2002b). While television viewing was a better predictor of post-traumatic stress than either sensory exposure, measured as hearing or feeling the blast, or interpersonal exposure, measured as knowing someone killed or injured, in indirectly exposed children, the effects were small (Pfefferbaum et al., 2001).

A study of media effects in a sample of middle school students residing 100 miles from Oklahoma City two years after the bombing, when the federal trial of Timothy McVeigh was beginning, found a small but significant association between post-traumatic stress and exposure to both print and broadcast media coverage (Pfefferbaum et al., 2000; Pfefferbaum et al., 2003).

The researchers noted that the association between exposure to media coverage and acute and later reactions does not establish a cause-and-effect relationship. Those who are aroused may be drawn to the information provided by the media, and information seeking may be a coping strategy for some. It is also possible that other factors are responsible for the link between exposure to media coverage and these emotional states. The researchers' work in this area is frequently cited in studies of media effects related to the September 11th attacks.

Policy Issues Related to Disaster Mental Health Service Delivery and Funding
The researchers' work in the area of disaster mental health services raised issues about how disaster mental health services are structured and addressed policy implications. Similar issues emerged again after the September 11th attacks.

The federal disaster mental health approach focuses on normal reactions to adverse events and provides a host of services including outreach, triage and referral, emergency services and crisis intervention, counseling and therapy and support services. Experiences in Oklahoma City suggest that large-scale, human-caused disasters may result in greater psychiatric impairment of direct victims than do natural disasters.

Historically, federally funded crisis-counseling programs have not supported traditional treatment, focusing instead on the needs of persons whose reactions do not reach the level of psychopathology. Those needing traditional psychiatric care are referred to providers in the existing mental health system. After a disaster, the potential for serious and enduring pathology is great, and the costs of providing traditional care may be substantial.

The researchers' work raised concerns about issues such as confidentiality and record-keeping and about the need for program evaluation (Pfefferbaum et al., 2002b). The researchers worked with Fran H. Norris, Ph.D. (Dartmouth Medical School and the National Center for PTSD) in a qualitative study of Oklahoma City providers, which revealed conflicts among providers about credentials, referrals, the quality of services provided and the appropriateness of basing services solely on a crisis-counseling model (Norris et al., 2005a).

Disaster mental health care has evolved, and its growth is reflected in the ability to respond to succeeding disasters of increased dimensions in the context of more complex and devastated environments (Pfefferbaum & Stein, 2006).


Appendix 2

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

References for Key Areas in Body of Research

Gurwitch RH, Pfefferbaum B and Leftwich MJT. "The Impact of Terrorism on Children: Considerations for a New Era," Journal of Trauma Practice, 1(3/4): 101–124, 2002a.

Gurwitch RH, Sitterle KA, Young BH and Pfefferbaum, B. "The Aftermath of Terrorism." In, Helping Children Cope with Disasters and Terrorism, A.M. La Greca, W.K. Silverman, E.M. Vernberg and M.C. Roberts (eds.), pp. 327–357. Washington: American Psychological Association, 2002b.

Norris FH, Watson PJ, Hamblen JL and Pfefferbaum BJ. "Provider Perspectives on Disaster Mental Health Services in Oklahoma City." In The Trauma of Terrorism: Sharing Knowledge and Shared Care, An International Handbook, Y. Daniele, D. Brom and J. Sills (eds.), pp. 649–661. Binghamton, N.Y.: Haworth Press, 2005.

North CS, Nixon SJ, Shariat S, Mallonee S, McMillen JC, Spitznagel EL and Smith EM. "Psychiatric Disorders Among Survivors of the Oklahoma City Bombing." Journal of the American Medical Association, 282: 755–762, 1999.

North CS and Pfefferbaum B. "The State of Research on the Mental Health Effects of Terrorism." Epidemiologia e Psichiatria Sociale, 13(1): 409, 2004.

North CS, Pfefferbaum B, Tivis L, Kawasaki A, Reddy C and Spitznagel EL. "The Course of Posttraumatic Stress Disorder in a Follow-up Study of Survivors of the Oklahoma City Bombing." Annals of Clinical Psychiatry, 16(4): 209–215, 2004.

North CS, Tivis L, McMillen JC, Pfefferbaum B, Cox J, Spitznagel EL, Bunch K, Schorr J and Smith EM. "Coping, Functioning, and Adjustment of Rescue Workers after the Oklahoma City Bombing. Journal of Traumatic Stress, 15(3): 171–175, 2002a.

North CS, Tivis L, McMillen JC, Pfefferbaum B, Spitznagel EL, Cox J, Nixon S, Bunch, K, Schorr, J and Smith EM. "Psychiatric Disorders in Rescue Workers after the Oklahoma City Bombing. American Journal of Psychiatry, 159(5): 857–859, 2002b.

Pfefferbaum B, Nixon SJ, Krug RS, Tivis RD, Moore VL, Brown JM, Pynoos RS, Foy D and Gurwitch RH. "Clinical Needs Assessment of Middle and High School Students Following the Oklahoma City Bombing." American Journal of Psychiatry, 156(7): 1069–1074, 1999.

Pfefferbaum B, Nixon SJ, Tivis RD, Doughty DE, Pynoos RS, Gurwitch RH and Foy DW. "Television Exposure in Children After a Terrorist Incident." Psychiatry, 64(3): 202–211, 2001.

Pfefferbaum B, North CS, Bunch K, Wilson TG, Tucker P and Schorr JK. "The Impact of the 1995 Oklahoma City Bombing on the Partners of Firefighters." Journal of Urban Health, 79(3): 364–372, 2002a.

Pfefferbaum B, North CS, Flynn BW, Norris FH and DeMartino R. "Disaster Mental Health Services Following the 1995 Oklahoma City Bombing: Modifying Approaches to Address Terrorism." CNS Spectrum, 7: 575–579, 2002b.

Pfefferbaum B, North CS and Pfefferbaum RL. "Psychosocial issues in bioterrorism." In M.S. Bronze and R.A. Greenfield (eds.), pp. 135–164. U.K.: Horizon Scientific Press Ltd, 2005.

Pfefferbaum B, Pfefferbaum RL, Christiansen EH, Schorr JK, Vincent RD, Nixon SJ and North CS. "Comparing Stress Response to Terrorism in Residents of Two Communities Over Time." Brief Treatment and Crisis Intervention, 6(2): 137–143, 2006a.

Pfefferbaum B, Seale TW, McDonald NB, Brandt EN Jr., Rainwater SM, Maynard BT, Meierhoefer B and Miller PD. "Posttraumatic Stress Two Years After the Oklahoma City Bombing in Youths Geographically Distant from the Explosion." Psychiatry, 63(4): 358–370, 2000.

Pfefferbaum B, Seale TW, Brandt EN Jr., Pfefferbaum RL, Doughty DE and Rainwater SM. "Media Exposure in Children One Hundred Miles From a Terrorist Bombing." Annals of Clinical Psychiatry, 15(1): 1–8, 2003.

Pfefferbaum B and Stein BD. "Taking Issue." Psychiatric Services, 57(9): 1251, 2006.

Pfefferbaum B, Tucker P, North CS, Jeon-Slaughter H, Kent AT, Schorr JK, Wilson TG and Bunch K. "Persistent Physiological Reactivity in a Pilot Study of Partners of Firefighters After a Terrorist Attack." Journal of Nervous and Mental Disease, 194(2): 128–131, 2006b.

Smith DW, Christiansen EH, Vincent R and Hann NE. "Population Effects of the Bombing in Oklahoma City." Journal of the Oklahoma State Medical Association, 92(4): 193–198, 1999.

Tucker P, Pfefferbaum B, North CS, Kent A, Burgin CE, Parker DE, Hossain A, Jeon-Slaughter H and Trautman R. "Physiologic Reactivity Despite Emotional Resilience Several Years After Direct Exposure to Terrorism." American Journal of Psychiatry, in press.


Appendix 3

Glossary of Terms

Post-traumatic stress disorder. The essential feature of the disorder is the development of characteristic symptoms following exposure to an extreme traumatic stressor involving:

  • Direct personal experience of an event that involved actual or threatened death or serious injury, or
  • Witnessing an event that involves death, injury or threat to the physical integrity of another person, or
  • Learning about unexpected or violent death, serious harm or threat of death or injury experienced by a family member or other close associate.

The person's response to the event must involve intense fear, helplessness or horror (or in children, the response must involve disorganized or agitated behavior). The characteristic symptoms resulting from the exposure to the extreme trauma include:

  • Persistent reexperiencing of the traumatic event.
  • Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness.
  • Persistent symptoms of increased arousal.

The full symptom picture must be present for more than one month, and the disturbance must cause clinically significant distress or impairment in social, occupational or other important areas of functioning.

Source: Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), Fourth Edition, Text Revision. Arlington, Va.: American Psychiatric Association, 2000.

Institutional review board (IRB). A committee at academic institutions and medical facilities that monitors research studies to ensure, both in advance and by periodic review, that appropriate steps are taken to protect the rights and welfare of human subjects.

Source: en.wikipedia.org/wiki/Institutional_Review_Board.

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Book Chapters

Allen JR, Tucker P and Pfefferbaum B. "Community Outreach Following a Terrorist Act: Violent Death and the Oklahoma City Experience." In Violent Death: Resilience and Intervention Beyond the Crisis. Rynearson EK (ed.). New York: Taylor & Francis, 2006.

Gurwitch RH, Pfefferbaum B and Leftwich MJT. "The Impact of Terrorism on Children: Considerations for a New Era." In Trauma Practice in the Wake of September 11, 2001. Gold SN and Faust J (eds.). Binghamton, N.Y.: Haworth Press, 2002b.

Gurwitch RH, Sitterle KS, Young BH and Pfefferbaum B. "The Aftermath of Terrorism." In Helping Children Cope With Disasters and Terrorism. La Greca AM, Silverman WK, Vernberg EM and Roberts MC (eds.). Washington: American Psychological Association, 2002.

Norris FH, Watson PJ, Hamblen JL and Pfefferbaum BJ. "Provider Perspectives on Disaster Mental Health Services In Oklahoma." In The Trauma of Terrorism: Sharing Knowledge and Shared Care. Daniele Y, Brom D and Sills JB (eds.). Binghamton, N.Y.: Haworth Press, 2005.

Ørner RJ, Kent AT, Pfefferbaum BJ Raphael R and Watson PJ. "The Context of Providing Immediate Postevent Intervention." In Interventions Following Mass Violence and Disasters: Strategies for Mental Health Practice. Ritchie EC, Watson PJ and Friedman MJ (eds.). New York: Guilford Press, 2006.

Pfefferbaum B. "Mental Health Services After a Disaster." In Emergency Preparedness: Bioterrorism and Beyond. Rubin ER, Osterweis M and Lindeman LM (eds.). Washington: Association of Academic Health Centers, 2002.

Pfefferbaum B. "The Children of Oklahoma City." In Terrorism and Disaster: Individual and Community Responses. Ursano RJ, Fullerton CS and Norwood AE (eds.). Cambridge, England: Cambridge University Press, 2003.

Pfefferbaum B. "Victims of Terrorism and the Media." In Terrorists, Victims and Society: Psychological Perspectives on Terrorism and Its Consequences. Silke A (ed.). Chichester, U.K.: John Wiley, 2003.

Pfefferbaum B, Devoe ER, Stuber J Schiff M, Klein TP and Fairbrother G. "Psychological Impact of Terrorism on Children and Families in the United States." In The Trauma of Terrorism: Sharing Knowledge and Shared Care. Danieli Y, Brom D and Sills JB (eds.). Binghamton, N.Y.: Haworth Press, 2005.

Pfefferbaum B, North CS and Pfefferbaum RL. "Psychosocial Issues in Bioterrorism." In Biodefense: Principles and Pathogens. Bronze MS and Greenfield RA (eds.). Norwich, U.K.: Horizon Scientific Press, 2005a.

Pfefferbaum B, Reissman DR, Pfefferbaum RL, Klomp RW and Gurwitch RG. "Building Resilience to Mass Trauma Events." In Handbook on Injury and Violence Prevention. Doll L, Bonzo S, Mercy J and Sleet DA (eds.). New York: Kluwer Academic Publishers, 2007.

Pynoos RS, Schreiber MD, Steinberg AM and Pfefferbaum B. "The Impact of Terrorism on Children." In Comprehensive Textbook of Psychiatry, Volume 8. Saddock B and Saddock V (eds.). New York: Lippincott Williams & Wilkins, 2005.

Steinberg AM, Brymer MJ, Steinberg JR and Pfefferbaum B. "Conducting Research on Children and Adolescents after Mass Trauma." In Research Methods for Studying Mental Health after Disasters and Terrorism: Community and Public Health Approaches. Norris F, Friedman M and Reissman D (eds.). New York: Guildford Press, 2006.

Watson PJ, Ritchie EC, Demer J, Bartone P and Pfefferbaum B. "Improving Resilience Trajectories Following Mass Violence and Disaster." In Interventions Following Mass Violence and Disasters: Strategies for Mental Health Practice. Ritchie EC, Watson PJ and Friedman MJ (eds.). New York: Guilford Press, 2006.

Articles

Allen JR. "Of Resilience, Vulnerability, and a Woman Who Never Lived." Child and Adolescent Psychiatry Clinics of North America, 7(1): 53–71, 1998. Abstract available online.

Allen JR. "After the Bombing: Public Scenarios and the Construction of Meaning." Journal of the Oklahoma State Medical Association, 92(4): 187–192, 1999. Abstract available online.

Allen JR and Allen BA. "After the Bombing: TA Notes from Oklahoma City." Journal of Transactional Analysis, July 1998.

Allen JR, Pfefferbaum B, Hammond D and Speed L. "A Disturbed Child's Use of a Public Event: Cotard's Syndrome in a Ten-Year-Old." Psychiatry, 63(2): 208–213, 2000. Abstract available online.

Allen JR, Whittlesey S, Pfefferbaum B and Ondersma M. "Community and Coping of Mothers and Grandmothers of Children Killed in a Human-Caused Disaster." Psychiatric Annals, 29(2): 85–91, 1999.

Allen SF and Dlugokinski EL. "How to Talk to Children about the Oklahoma City Disaster." Oklahoma Department of Mental Health and Substance Abuse Services Publication, 1995.

Allen SF, Dlugokinski EL, Cohen LA and Walker JL. "Assessing the Impact of a Traumatic Community Event on Children and Assisting with heir Healing." Psychiatric Annals, 29: 93–97, 1999.

Call JA and Pfefferbaum B. "Lessons From the First Two Years of Project Heartland, Oklahoma's Mental Health Response to the 1995 Bombing." Psychiatric Services, 50(7): 953–955, 1999. Abstract available online.

Geis HK, Whittlesey SW, McDonald NB, Smith K and Pfefferbaum B. "Bereavement and Loss in Childhood." Child and Adolescent Psychiatric Clinics of North America, 7(1): 73–85, 1998. Abstract available online.

Gurwitch RH, Kees M and Becker SM. "In the Face of Tragedy: Placing Children's Reactions to Trauma in a New Context." Cognitive and Behavioral Practice, 9: 286–295, 2002.

Gurwitch RH, Kees M, Becker SM, Schreiber M, Pfefferbaum B and Diamond D. "When Disaster Strikes: Responding to the Needs of Children." Prehospital and Disaster Medicine, 19(1): 21–28, 2004. Abstract available online.

Gurwitch RH, Pfefferbaum B and Leftwich MJT. "The Impact of Terrorism on Children: Considerations for a New Era." Journal of Trauma Practice, 1(3/4): 101–124, 2002a.

Gurwitch RH, Sullivan MA and Long PJ. "The Impact of Trauma and Disaster on Young Children." Child and Adolescent Psychiatric Clinics of North America, 7(1): 19–32, 1998. Abstract available online.

Krug RS, Nixon SJ and Vincent R. "Psychological Response to the Oklahoma City Bombing." Journal of Clinical Psychology, 52(1): 103–105, 1996. Abstract available online.

Miranda R Jr., Myerson LA, Marx BP and Tucker PM. "Civilian-Based Posttraumatic Stress Disorder and Physical Complaints: Evaluation of Depression as a Mediator." Journal of Traumatic Stress, 15(4): 297–301, 2002. Abstract available online.

Nixon SJ, Schorr J, Boudreux A and Vincent RD. "Perceived Sources of Support and their Effectiveness for Oklahoma City Firefighters." Psychiatric Annals, 29: 101–105, 1999.

Nixon SJ, Schorr J, Boudreux A and Vincent RD. "Perceived Effects and Recovery in Oklahoma City Firefighters." Journal of the Oklahoma State Medical Association, 92(4): 172–177, 1999. Abstract available online.

Nixon SJ, Vincent R, Krug RS and Pfefferbaum B. "Structure and Organization of Research Efforts Following the Bombing of the Murrah Building." Journal of Personal and Interpersonal Loss, 3: 99–115, 1998.

Norris FH, Watson PJ, Hamblen JL and Pfefferbaum BJ. "Provider Perspectives on Disaster Mental Health Services in Oklahoma City." Journal of Aggression, Maltreatment and Trauma, 10(1/2): 649–661, 2005.

North CS, Nixon SJ, Shariat S, Mallonee S, McMillen JC, Spitznagel EL and Smith EM. "Psychiatric Disorders among Survivors of the Oklahoma City Bombing." Journal of the American Medical Association, 282(8): 755–762, 1999. Abstract available online.

North CS and Pfefferbaum B. "The State of Research on the Mental Health Effects of Terrorism." Epidemiologia e Psichiatria Sociale, 13(1): 4–9, 2004.

North CS, Pfefferbaum B, Narayanan P, Thielman S, McCoy G, Dumont C, Kawasaki A, Ryosho N and Spitznagel EL. "Comparison of Post-disaster Psychiatric Disorders after Terrorist Bombings in Nairobi and Oklahoma City." British Journal of Psychiatry, 186: 487–493, 2005. Abstract available online.

North CS, Pfefferbaum B, Tivis L, Kawasaki A, Reddy C and Spitznagel EL. "The Course of Posttraumatic Stress Disorder in a Follow-up Study of Survivors of the Oklahoma City Bombing." Annals of Clinical Psychiatry, 16(4): 209–215, 2004. Abstract available online.

North CS, Pfefferbaum B and Tucker P. "Ethical and Methodological Issues in Academic Mental Health Research in Populations Affected by Disasters: Oklahoma City Experience Relevant to September 11, 2001." CNS Spectrums, 7(8): 580–584, 2002. Abstract available online.

North CS, Tivis L, McMillen JC, Pfefferbaum B, Cox J, Spitznagel EL, Bunch K, Schorr J and Smith EM. "Coping, Functioning, and Adjustment of Rescue Workers after the Oklahoma City Bombing." Journal of Traumatic Stress, 15(3): 171–175, 2002. Abstract available online.

North CS, Tivis L, McMillen JC, Pfefferbaum B, Spitznagel EL, Cox J, Nixon S, Bunch KP and Smith EM. "Psychiatric Disorders in Rescue Workers after the Oklahoma City Bombing." American Journal of Psychiatry, 159(5): 857–859, 2002. Abstract available online.

Pfefferbaum B. "Caring for Children Affected by Disaster." Child and Adolescent Psychiatric Clinics of North America, 7(3): 579–597, 1998. Abstract available online.

Pfefferbaum B. "The Impact of the Oklahoma City Bombing on Children in the Community." Military Medicine, 166(12 Suppl.): 49–50, 2001. Abstract available online.

Pfefferbaum B. Editorial: "Lessons from the 1995 Bombing of the Alfred P. Murrah Federal Building in Oklahoma City." Lancet, 358: 940, 2001.

Pfefferbaum BJ. "Aspects of Exposure in Childhood Trauma: The Stressor Criterion." Journal of Trauma & Dissociation, 6(2): 17–26, 2005. Abstract available online.

Pfefferbaum B, Allen JR, Lindsey ED and Whittlesey SW. "Fabricated Trauma Exposure: An Analysis of Cognitive, Behavioral, and Emotional Factors." Psychiatry, 62(4): 293–302, 1999. Abstract available online.

Pfefferbaum B, Call JA, Doughty DE, Traxler WT, Pai MN, Borrell GK and Stein BD. "Impact of Injury on Posttraumatic Stress in Survivors Seeking Counseling After the 1995 Bombing in Oklahoma City." Journal of Trauma Practice, 2(2): 1–17, 2003.

Pfefferbaum B, Call JA, Lensgraf SJ, Miller PD, Flynn BW, Doughty DE, Tucker P and Dickson WL. "Traumatic Grief in a Convenience Sample of Victims Seeking Support Services after a Terrorist Incident." Annals of Clinical Psychiatry, 13(1): 19–24, 2001. Abstract available online.

Pfefferbaum B, Call JA and Sconzo GM. "Mental Health Services for Children in the First Two Years After the 1995 Oklahoma City Terrorist Bombing." Psychiatric Services, 50(7): 956–958, 1999. Abstract available online.

Pfefferbaum BJ, DeVoe ER, Stuber J, Schiff M, Klein TP and Fairbrother G. "Psychological Impact of Terrorism on Children and Families in the United States." Journal of Aggression, Maltreatment & Trauma, 9(3/4): 305–317, 2004.

Pfefferbaum B and Doughty DE. "Increased Alcohol Use in a Treatment Sample of Oklahoma City Bombing Victims." Psychiatry, 64(4): 296–303, 2001. Abstract available online.

Pfefferbaum B, Doughty DE, Reddy C, Patel N, Gurwitch RH, Nixon SJ and Tivis RD. "Exposure and Peritraumatic Response as Predictors of Posttraumatic Stress in Children Following the 1995 Oklahoma City Bombing." Journal of Urban Health, 79(3): 354–363, 2002. Abstract available online.

Pfefferbaum B, Flynn BW, Brandt EN Jr and Lensgraf SJ. "Organizing the Mental Health Response to Human-Caused Community Disasters with Reference to the Oklahoma City Bombing." Psychiatric Annals, 29(2): 109–113, 1999.

Pfefferbaum B, Gurwitch RH, McDonald NB, Leftwich MJ, Sconzo GM, Messenbaugh AK and Schultz RA. "Posttraumatic Stress among Young Children after the Death of a Friend or Acquaintance in a Terrorist Bombing." Psychiatric Services, 51(3): 386–388, 2000. Abstract available online.

Pfefferbaum B, Moore VL, McDonald NB, Maynard BT, Gurwitch RH and Nixon SJ. "The Role of Exposure in Posttraumatic Stress in Youths Following the 1995 Bombing." Journal of the Oklahoma State Medical Association, 92(4): 164–167, 1999. Abstract available online.

Pfefferbaum B, Nixon SJ, Krug RS, Tivis RD, Moore VL, Brown JM, Pynoos RS, Foy D and Gurwitch RH. "Clinical Needs Assessment of Middle and High School Students Following the 1995 Oklahoma City Bombing." American Journal of Psychiatry, 156(7): 1069–1074, 1999. Abstract available online.

Pfefferbaum B, Nixon SJ, Tivis RD, Doughty DE, Pynoos RS, Gurwitch RH and Foy DW. "Television Exposure in Children after a Terrorist Incident." Psychiatry, 64(3): 202–211, 2001. Abstract available online.

Pfefferbaum B, Nixon SJ, Tucker PM, Tivis RD, Gurwitch RH, Moore VL, Pynoos RS and Geis HK. "Posttraumatic Stress Responses in Bereaved Children Following the Oklahoma City Bombing." Journal of the Academy of Child and Adolescent Psychiatry, 38(11): 1372–1379, 1999. Abstract available online.

Pfefferbaum B, Nixon SJ, Tucker PM, Vincent RD, North CS, Allen JR and Whittlesey SW. "Consequences of the Oklahoma City Bombing in 1995." Russian Journal of Psychiatry, 5: 26–30, 1999.

Pfefferbaum B, North CS, Bunch K, Wilson TG, Tucker P and Schorr JK. "The Impact of the 1995 Oklahoma City Bombing on the Partners of Firefighters." Journal of Urban Health, 79(3): 364–372, 2002. Abstract available online.

Pfefferbaum B, North CS, Doughty DE, Gurwitch RH, Fullerton CS and Kyula J. "Posttraumatic Stress and Functional Impairment in Kenyan Children Following the 1998 American Embassy Bombing." American Journal of Orthopsychiatry, 73(2): 133–140, 2003. Abstract available online.

Pfefferbaum B, North CS, Flynn BW, Norris FH and DeMartino R. "Disaster Mental Health Services Following the 1995 Oklahoma City Bombing: Modifying Approaches to Address Terrorism." CNS Spectrums, 7(8): 575–579, 2002. Abstract available online.

Pfefferbaum B, Pfefferbaum RL, Christiansen EH, Schorr JK, Vincent RD, Nixon SJ and North CS. "Comparing Stress Responses to Terrorism in Residents of Two Communities over Time." Brief Treatment and Crisis Intervention, 6(2): 137–143, 2006.

Pfefferbaum B, Pfefferbaum RL, Gurwitch RH, Doughty DE, Pynoos RS, Foy DW, Brandt EN Jr. and Reddy C. "Teachers' Psychological Reactions 7 Weeks After the 1995 Oklahoma City Terrorist Bombing." American Journal of Orthopsychiatry, 74(3): 263–271, 2004. Abstract available online.

Pfefferbaum B, Sconzo GM, Flynn BW, Kearns L, Doughty DE, Gurwitch RH, Nixon SJ and Nawaz S. "Case Finding and Mental Health Services for Children in the Aftermath of the Oklahoma City Bombing." Journal of Behavioral Health Services & Research, 30(2): 215–227, 2003. Abstract available online.

Pfefferbaum B, Seale TW, Brandt EN Jr., Pfefferbaum RL, Doughty DE and Rainwater SM. "Media Exposure in Children One Hundred Miles from a Terrorist Bombing." Annals of Clinical Psychiatry, 15(1): 1–8, 2003. Abstract available online.

Pfefferbaum B, Seale TW, McDonald NB, Brandt EN Jr., Rainwater SM, Maynard BT, Meierhoefer B and Miller PD. "Posttraumatic Stress Two Years After the Oklahoma City Bombing in Youths Geographically Distant from the Explosion." Psychiatry, 63(4): 358–370, 2000. Abstract available online.

Pfefferbaum B. "Disasters in the 21st Century: Lessons from Project Liberty." Psychiatric Services, 57(9): 1251: 2006.

Pfefferbaum B, Tucker P, North CS, Jeon-Slaughter H, Kent AT, Schorr JK, Wilson TG and Bunch K. "Persistent Physiological Reactivity in a Pilot Study of Partners of Firefighters After a Terrorist Attack." Journal of Nervous and Mental Disease, 194(2): 128–131, 2006. Abstract available online.

Pfefferbaum B, Vinekar SS, Trautman RP, Lensgraf SJ, Reddy C, Patel N and Ford AL. "The Effect of Loss and Trauma on Substance Use Behavior in Individuals Seeking Support Services After the 1995 Oklahoma City Bombing." Annals of Clinical Psychiatry, 14(2): 89–95, 2002. Abstract available online.

Pfefferbaum RL, Brandt EN Jr., Patel HP, Gurwitch RH, Schreiber MD and Pfefferbaum B. "Psychological Issues Associated with Terrorism: A Guide for Physicians." Journal of the Oklahoma State Medical Association, 96(11): 526–529, 2003.

Pfefferbaum RL, Gurwitch RH, Robertson MJ, Brandt EN Jr., and Pfefferbaum B. "Terrorism, the Media, and Distress in Youth: Research Implications for Prevention and Intervention." Prevention Researcher, 10(2): 14–16, 2003.

Smith DW, Christiansen EH, Vincent R and Hann NE. "Population Effects of the Bombing in Oklahoma City." Journal of the Oklahoma State Medical Association, 92(4): 193–198, 1999. Abstract available online.

Tassey JR. "The Application of Critical Incident Stress Debriefing in the Oklahoma City Bombing." Psychology Bulletin, 31(3): 44–45, 1996.

Trautman R, Tucker P, Pfefferbaum B, Lensgraf SJ, Doughty DE, Buksh A and Miller PD. "Effects of Prior Trauma and Age on Posttraumatic Stress Symptoms in Asian and Middle Eastern Immigrants after Terrorism in the Community." Community Mental Health Journal, 38(6): 459–474, 2002. Abstract available online.

Tucker PM, Boehler S, Dickson W, Lensgraf SJ and Jones D. "Mental Health Response to the Oklahoma City Bombing." Journal of the Oklahoma State Medical Association, 92(4): 168–171, 1999.

Tucker PM, Dickson W, Pfefferbaum B, McDonald NB and Allen G. "Traumatic Reactions as Predictors of Posttraumatic Stress Six Months After the Oklahoma City Bombing." Psychiatric Services, 48(9): 1191–1194, 1997. Abstract available online.

Tucker PM, Pfefferbaum B, Doughty DE, Jones DE, Jordan FB, Vincent RD and Nixon SJ. "Body Handlers After Terrorism in Oklahoma City: Predictors of Posttraumatic Stress and Other Symptoms." American Journal of Orthopsychiatry, 72(4): 469–475, 2002. Abstract available online.

Tucker P, Pfefferbaum B, Nixon SJ and Dickson W. "Predictors of Post-traumatic Stress Symptoms in Oklahoma City: Exposure, Social Support, Peri-traumatic Responses." Journal of Behavioral Health Services, 27(4): 406–416, 2000. Abstract available online.

Tucker PM, Pfefferbaum B, Nixon SJ and Foy DW. "Trauma and Recovery Among Adults Highly Exposed to a Community Disaster." Psychiatric Annals, 29(2): 78–83, 1999.

Tucker PM, Pfefferbaum B, North CS, Kent A, Burgin C, Parker DE, Hossain A, Jeon-Slaughter H and Trautman RP. "Physiologic Reactivity Despite Emotional Resilience Several Years after Direct Exposure to Terrorism." American Journal of Psychiatry, 164(2): 230–235, 2007. Abstract available online.

Tucker P, Pfefferbaum B, Vincent R, Boehler SD and Nixon SJ. "Oklahoma City: Disaster Challenges, Mental Health and Medical Administrators." Journal of Behavioral Health Services & Research, 25(1): 93–99, 1998. Abstract available online.

Tucker P and Trautman R. "Understanding and Treating PTSD: Past, Present, and Future." Bulletin of the Menninger Clinic, 64(3 Suppl. A): A37–A51, 2000. Abstract available online.

Whittlesey SW, Allen JR, Bell BD, Lindsey ED, Speed LF, Lucas AF, Ware MM, Allen SF and Pfefferbaum B. "Avoidance in Trauma: Conscious and Unconscious Defense, Pathology, and Health." Psychiatry, 62(4): 303–312, 1999. Abstract available online.

Whittlesey SW, Vinekar S and Tucker P. "The Oklahoma City Bombing: Learning from Disaster." Psychiatric Times, XVI: 43–46, 1999.

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Report prepared by: Antonia Sunderland
Report prepared by: Kelsey Menehan
Reviewed by: Jayme Hannay
Reviewed by: Molly McKaughan
Program Officer: Nancy J. Kaufman
Program Officer: Robert Hughes

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