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Psychiatric Disorders Among Survivors of the Oklahoma City Bombing

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Psychiatric Disorders Among Survivors of the Oklahoma City Bombing ORIGINAL CONTRIBUTION Psychiatric Disorders Among Survivors of the Oklahoma City Bombing Carol S. North, MD, MPE Context Disasters expose unselected populations to traumatic events and can be used Sara Jo Nixon, PhD to study the mental health effects. The Oklahoma City, Okla, bombing is particularly sig- nificant for the study of mental health sequelae of trauma because its extreme magni- Sheryll Shariat, MPH tude and scope have been predicted to render profound psychiatric effects on survivors. Sue Mallonee, RN, MPH Objective To measure the psychiatric impact of the bombing of the Alfred P. Mur- J. Curtis McMillen, PhD rah Federal Building in Oklahoma City on survivors of the direct blast, specifically ex- amining rates of posttraumatic stress disorder (PTSD), diagnostic comorbidity, func- Edward L. Spitznagel, PhD tional impairment, and predictors of postdisaster psychopathology. Elizabeth M. Smith, PhD† Design, Setting, and Participants Of 255 eligible adult survivors selected from a confidential registry, 182 (71%) were assessed systematically by interviews approxi- mately 6 months after the disaster, between August and December 1995. ISASTERS OFFER UNIQUE OP- portunities to study mental Main Outcome Measures Diagnosis of 8 psychiatric disorders, demographic data, health effects of traumatic level of functioning, treatment, exposure to the event, involvement of family and friends, events in unselected popula- and physical injuries, as ascertained by the Diagnostic Interview Schedule/Disaster Supple- tions.D Because most disasters strike ran- ment. domly, studies of disasters circumvent Results Forty-five percent of the subjects had a postdisaster psychiatric disorder and 34.3% had PTSD. Predictors included disaster exposure, female sex (for any postdi- the limitations of research on trauma to 2 saster diagnosis, 55% vs 34% for men; x1 = 8.27; P = .004), and predisaster psychi- individuals in the community, where x 2 atric disorder (for PTSD, 45% vs 26% for those without predisaster disorder; 1 = 6.86; risk for traumatic events is con- P = .009). Onset of PTSD was swift, with 76% reporting same-day onset. The rela- founded with vulnerability to psycho- tively uncommon avoidance and numbing symptoms virtually dictated the diagnosis 1 pathology. The extreme magnitude and of PTSD (94% meeting avoidance and numbing criteria had full PTSD diagnosis) and intensity of the Oklahoma City, Okla, were further associated with psychiatric comorbidity, functional impairment, and treat- bombing made it a particularly signifi- ment received. Intrusive reexperience and hyperarousal symptoms were nearly uni- cant subject for the study of mental versal, but by themselves were generally unassociated with other psychopathology or health effects of trauma because of the impairment in functioning. profound effects anticipated among its Conclusions Our data suggest that a focus on avoidance and numbing symptoms survivors, including persons with no could have provided an effective screening procedure for PTSD and could have iden- predisaster psychiatric history.2-6 tified most psychiatric cases early in the acute postdisaster period. Psychiatric comor- The bombing of the Alfred P. Mur- bidity further identified those with functional disability and treatment need. The nearly rah Federal Building in Oklahoma City universal yet distressing intrusive reexperience and hyperarousal symptoms in the ma- jority of nonpsychiatrically ill persons may be addressed by nonmedical interventions on April 19, 1995, was the most se- of reassurance and support. vere incident of terrorism ever experi- JAMA. 1999;282:755-762 www.jama.com enced on American soil.7,8 The death count totaled 167, including 19 chil- dren; the number of persons injured to- cluded documenting rates of postdi- Author Affiliations: School of Medicine, Depart- ment of Psychiatry (Drs North and Smith), George War- taled 684. The fatality rate inside the saster psychopathology, examining ren Brown School of Social Work (Dr McMillen), and Murrah Building was 46%, and 93% of functional impact, and identifying pre- Department of Mathematics and Statistics (Dr Spitzna- survivors who were in the building were dictors of these difficulties to help guide gel), Washington University, St Louis, Mo; and De- 9 partment of Psychiatry and Behavioral Sciences, Uni- injured. The explosion demolished or mental health intervention workers in versity of Oklahoma Health Sciences (Dr Nixon), and damaged more than 800 building struc- future disasters. We anticipated that the the Oklahoma State Department of Health (Mss Shariat and Mallonee), Oklahoma City. tures, with an estimated property dam- scope and severity of this event would †Dr Smith died March 7, 1997. age of $625 million. elicit higher rates of psychopathology Corresponding Author and Reprints: Carol S. North, MD, MPE, Department of Psychiatry, Washington Uni- We studied direct survivors of the than previous disasters studied using versity School of Medicine, 4940 Children’s Pl, St Louis, blast. Our research objectives in- similar research methods. MO 63110 (e-mail: [email protected]). ©1999 American Medical Association. All rights reserved. JAMA, August 25, 1999—Vol 282, No. 8 755 Downloaded From: https://jamanetwork.com/ on 10/02/2021 PSYCHIATRIC IMPACT ON OKLAHOMA CITY BOMBING SURVIVORS METHODS Journal Record buildings) or in less able during the design of longitudinal Subjects damaged buildings, or outdoors. The disaster studies.11,12 Diagnostic infor- Declaration of all bombing-associated remaining 18% were more than 184 m mation was obtained for 8 psychiatric injuries and illnesses as reportable cases from the detonation point. disorders: posttraumatic stress disor- by the Oklahoma State Department of The 35 individuals (16% of those lo- der (PTSD), major depression, panic Health commissioner led to the devel- cated and eligible) who did not partici- disorder, generalized anxiety disor- opment of a confidential registry of sur- pate did not differ from study partici- der, somatization disorder, alcohol use vivors, from which the study sample pants in age, sex, injury rates, or disorder, drug use disorder, and anti- was drawn. The registry contained 1092 medical treatment received. Signifi- social personality disorder. The inter- names of survivors directly exposed to cantly more participants than nonpar- view also documented demographic the blast based on their proximity to the ticipants were in the most heavily dam- data, level of functioning, and treat- x 2 Murrah Building. Persons exposed only aged buildings (79% vs 55%; 1 = 9.69, ment received. The Disaster Supple- indirectly through search and rescue or P = .002), indicating that persons with ment elicited subjects’ disaster-related clean-up efforts or by bereavement less intense exposure may have been experience including exposure to the alone were not listed. Further detail on less likely to participate in the study. event, involvement of family and the development of the Oklahoma State The sample was representative of the friends, and physical injuries. All in- Department of Health registry is pro- health department’s registry popula- terviews were administered by mem- vided in an earlier publication.8 tion with respect to sex and age. Com- bers of the Washington University di- Participation in the study was lim- pared with the registry population, sig- saster research team who received ited to subjects at least 18 years old. nificantly more study subjects had been formal training to administer the DIS. Those too severely injured to partici- in the most heavily damaged build- Sixty-three percent of the interviews x 2 , pate were excluded as ineligible. To com- ings (79% vs 66%; 1 = 11.25, P .001) were conducted in person, but due to mence with interviewing with minimal and specifically in the Murrah build- logistics in the field, 25% were con- x 2 , delay, the first 20 registry members to ing (31% vs 18%; 1 = 15.88, P .001). ducted by telephone, and another 12% complete and return a preliminary health The nonrandomly selected subjects initiated in person were completed by department survey of their demograph- did not differ from the 162 selected by telephone. No associations of any rel- ics, exposure to the blast, injuries, and randomization in demographics, pre- evant variables with telephone inter- medical treatment were selected for this disaster psychiatric disorder, or any di- views were identified in the data. study. Subsequently, using an SAS com- agnosis made after the disaster. A higher puter program (SAS 6.12; SAS Institute proportion of them, however, were in Data Analysis Inc, Cary, NC), names of 242 addi- the Murrah building (50% vs 27% of the Because individuals could have had x 2 tional eligible registry entries were ran- others; 1 = 4.45, P = .04). Removal of PTSD resulting from other traumatic domly selected from the registry, which the 20 nonrandomly selected subjects events besides the bombing, diagnoses included 1 of the 20 nonrandomized from the sample effectively reduces the and symptoms of bombing-associated subjects. Of the 261 subjects thus se- proportion of Murrah building occu- PTSD were tabulated separately from lected, 3 had left the country, 1 did not pancy from 31% to 27%, but the dif- those associated with other traumas. It speak English, and 2 had died in the in- ference from the registry remains sig- is well established that traumatic events x 2 terim, precluding their participation. Of nificant ( 1 = 9.68, P = .002). experienced by individuals
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