Multiple Vantage Points on the Mental Health Effects of Mass Shootings

Abstract

The phenomenon of mass shootings has emerged over the past 50 years. A high proportion of rampage shootings have occurred in the United States, and secondarily, in European nations with otherwise low firearm homicide rates; yet, paradoxically, shooting massacres are not prominent in the Latin American nations with the highest firearm homicide rates in the world. A review of the scientific literature from 2010 to early 2014 reveals that, at the individual level, mental health effects include psychological distress and clinically significant elevations in posttraumatic stress, depression, and anxiety symptoms in relation to the degree of physical exposure and social proximity to the shooting incident. Psychological repercussions extend to the surrounding affected community. In the aftermath of the deadliest mass shooting on record, Norway has been in the vanguard of intervention research focusing on rapid delivery of psychological support and services to survivors of the “Oslo Terror.”

Grounded on a detailed review of the clinical literature on the mental health effects of mass shootings, this paper also incorporates wide-ranging co-author expertise to delineate: 1) the patterning of mass shootings within the international context of firearm homicides, 2) the effects of shooting rampages on children and adolescents, 3) the psychological effects for wounded victims and the emergency healthcare personnel who care for them, 4) the disaster behavioral health considerations for preparedness and response, and 5) the media “framing” of mass shooting incidents in relation to the portrayal of mental health themes.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.

    Agnich LE. A comparative analysis of attempted and completed school-based mass murder attacks. Am J Crim Justice. 2014. doi:10.1007/s12103-014-9239-5.

    Google Scholar 

  2. 2.

    Agnich LE. Shooting incidents in educational settings. In: ACIA Archives. The Academy for Critical Incident Analysis at John Jay College. 2010. http://archive.aciajj.org/the-acia-archive/datasets-available-for-analysis/shooting-incidents-in-educational-settings/. Accessed June 2014.

  3. 3.

    Böckler N, Seeger T, Sitzer P, Heitmeyer W. School shootings: international research, case studies, and concepts for prevention. New York: Springer Publishing; 2013.

    Google Scholar 

  4. 4.•

    Flannery DJ, Modzeleski W, Kretschmar JM. Violence and school shootings. Curr Psychiatry Rep. 2013;15(1):331. Provides an overview of multiple-homicide school shootings in relation to the ecology of schools and communities and emphasizes the need for “threat assessments.”

    PubMed  Article  Google Scholar 

  5. 5.••

    Shultz JM, Cohen AM, Muschert GW, Flores de Apodaca R. Fatal school shootings and the epidemiological context of firearm mortality in the United States. Disaster Health. 2013;1(2):84–101. Presents a detailed and well-illustrated analysis of the epidemiologic context of school shootings in the United States, distinguishing random/rampage vs. targeted shootings, and relating school shootings to overarching patterns of firearm homicides.

    Article  Google Scholar 

  6. 6.

    Fox JA, DeLateur MJ. Mass shootings in America: moving beyond Newtown. Homicide Stud. 2014;18(1):125–45.

    Article  Google Scholar 

  7. 7.

    International Monetary Fund. World economic outlook: growth resuming, dangers remain: a survey by the staff of the International Monetary Fund. Washington, DC; 2012, pp. 177–80. http://www.imf.org/external/pubs/ft/weo/2012/01/. Accessed June 2014.

  8. 8.

    Sydney School of Public Health, The University of Sydney. GunPolicy.org. http://www.gunpolicy.org/. Accessed October 2013.

  9. 9.

    List of countries by firearm-related death rate. In: Wikipedia. http://en.wikipedia.org/wiki/List_of_countries_by_firearm-related_death_rate. Accessed June 2014.

  10. 10.

    Littleton H, Axsom D, Grills-Taquechel AE. Longitudinal evaluation of the relationship between maladaptive trauma coping and distress: examination following the mass shooting at Virginia Tech. Anxiety Stress Copin. 2011;24(3):273–90.

    Article  Google Scholar 

  11. 11.

    Littleton H, Kumpula M, Orcutt H. Posttraumatic symptoms following a campus shooting: the role of psychosocial resource loss. Violence Vict. 2011;26(4):461–76.

    PubMed Central  PubMed  Article  Google Scholar 

  12. 12.••

    Dyb G, Jensen TK, Nygaard E, et al. Post-traumatic stress reactions in survivors of the 2011 massacre on Utøya Island, Norway. Br J Psychiatry. 2013;204(5):361–7. A landmark paper that presents an analysis of mental health effects of high intensity exposures among survivors of the Utøya Island shooting.

    PubMed  Article  Google Scholar 

  13. 13.

    Bardeen JR, Kumpula MJ, Orcutt HK. Emotion regulation difficulties as a prospective predictor of posttraumatic stress symptoms following a mass shooting. J Anxiety Disord. 2013;27(2):188–96.

    PubMed Central  PubMed  Article  Google Scholar 

  14. 14.

    Suomalainen L, Haravuori H, Berg N, et al. A controlled follow-up study of adolescents exposed to a school shooting - psychological consequences after four months. Eur Psychiatry. 2011;26(8):490–7.

    CAS  PubMed  Article  Google Scholar 

  15. 15.

    Grills-Taquechel AE, Littleton HL, Axsom D. Social support, world assumptions, and exposure as predictors of anxiety and quality of life following a mass trauma. J Anxiety Disord. 2011;25(4):498–506.

    PubMed Central  PubMed  Article  Google Scholar 

  16. 16.

    Mercer KB, Orcutt HK, Quinn JF, et al. Acute and posttraumatic stress symptoms in a prospective gene x environment study of a university campus shooting. Arch Gen Psychiatry. 2012;69(1):89–97.

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  17. 17.••

    Hughes M, Brymer M, Chiu WT, et al. Posttraumatic stress among students after the shootings at Virginia Tech. Psychol Trauma. 2011;3(4):403–11. Examines rates of PTSD and trauma-related stressors in a large survey sample of Virginia Tech University students with widely varying levels of exposure to a major campus shooting.

    Article  Google Scholar 

  18. 18.

    Littleton HL, Grills-Taquechel AE, Axsom D, et al. Prior sexual trauma and adjustment following the Virginia Tech campus shootings: examination of the mediating role of schemas. Psychol Trauma. 2012;4(6):579–86.

    PubMed Central  PubMed  Article  Google Scholar 

  19. 19.••

    Orcutt HK, Bonanno GA, Hannan SM, Miron LR. Prospective trajectories of posttraumatic stress in college women following a campus mass shooting. J Trauma Stress. 2014;27(3):249–56. Examines four distinct trajectories of posttraumatic stress ranging from resilience to chronic dysfunction among college women exposed at various levels to the Northern Illinois University campus shooting.

    PubMed  Article  Google Scholar 

  20. 20.

    Kumpula MJ, Orcutt HK, Bardeen JR, Varkovitzky RL. Peritraumatic dissociation and experiential avoidance as prospective predictors of posttraumatic stress symptoms. J Abnorm Psychol. 2011;120(3):617–27.

    PubMed Central  PubMed  Article  Google Scholar 

  21. 21.

    Turunen T, Haravuori H, Pihlajamäki JJ, et al. Framework of the outreach after a school shooting and the students perceptions of the provided support. Eur J Psychotraumatol. 2014;5:23079.

    Google Scholar 

  22. 22.

    Brewin CR, Andrews B, Valentine JD. Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. J Consult Clin Psych. 2000;68(5):748–66.

    CAS  Article  Google Scholar 

  23. 23.

    Ozer EJ, Best SR, Lipsey TL, Weiss DS. Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychol Bull. 2003;129(1):52–73.

    PubMed  Article  Google Scholar 

  24. 24.

    Murtonen K, Suomalainen L, Haravuori H, Marttunen M. Adolescents' experiences of psychosocial support after traumatisation in a school shooting. Child Adolesc Ment Health. 2012;17(1):23–30.

    Article  Google Scholar 

  25. 25.••

    Thoresen S, Jensen TK, Wentzel-Larsen T, Dyb G. Social support barriers and mental health in terrorist attack survivors. J Affect Disord. 2014;156:187–93. Describes a new line of research inquiry focusing on analysis of barriers to receiving social support among survivors of a mass shooting.

    PubMed  Article  Google Scholar 

  26. 26.

    Charuvastra A, Cloitre M. Social bonds and posttraumatic stress disorder. Annu Rev Psychol. 2008;59:301–28.

    PubMed Central  PubMed  Article  Google Scholar 

  27. 27.

    Hawdon J, Ryan J. Well-being after the Virginia Tech mass murder the relative effectiveness of face-to-face and virtual interactions in providing support to survivors. Traumatology. 2012;18(4):3–12.

    Article  Google Scholar 

  28. 28.

    Vicary AM, Fraley RC. Student reactions to the shootings at Virginia Tech and Northern Illinois University: does sharing grief and support over the internet affect recovery? Pers Soc Psychol Bull. 2010;36(11):1555–63.

    PubMed  Article  Google Scholar 

  29. 29.••

    Thoresen S, Aakvaag HF, Wentzel-Larsen T, et al. The day Norway cried: proximity and distress in Norwegian citizens following the 22nd July 2011 terrorist attacks in Oslo and on Utøya Island. Eur J Psychotraumatol. 2012;3:19709. Documents the widespread and impactful mental health effects of the Utøya Island shooting on a representative sample of the Norwegian population.

    Article  Google Scholar 

  30. 30.

    Nordanger DØ, Hysing M, Posserud MB, et al. Posttraumatic responses to the July 22, 2011 Oslo Terror among Norwegian high school students. J Trauma Stress. 2013;26(6):679–85.

    PubMed  Article  Google Scholar 

  31. 31.

    Nordanger DØ, Breivik K, Haugland BS, et al. Prior adversities predict posttraumatic stress reactions in adolescents following the Oslo Terror events 2011. Eur J Psychotraumatology. 2014;5:23159.

    Article  Google Scholar 

  32. 32.

    Hawdon J, Räsänen P, Oksanen A, Ryan J. Social solidarity and wellbeing after critical incidents: three cases of mass shootings. J Crit Incid Anal. 2012;3(1):2–25.

    Google Scholar 

  33. 33.•

    Dyb G, Jensen T, Glad KA, Nygaard E, Thoresen S. Early outreach to survivors of the shootings in Norway on the 22nd of July 2011. Eur J Psychotraumatology. 2014;5:23523. Describes the early and proactive program of nationwide outreach to survivors of the Utøya Island shooting, demonstrating the value of this approach following high intensity trauma exposure.

    Google Scholar 

  34. 34.

    Reifels L, Pietrantoni L, Prati G, et al. Lessons learned about psychosocial responses to disaster and mass trauma: an international perspective. Eur J Psychotramatol. 2013;4:22897.

    Google Scholar 

  35. 35.

    Séguin M, Chawky N, Lesage A, et al. Evaluation of the Dawson College shooting psychological intervention: moving toward a multimodal extensive plan. Psychol Trauma. 2013;5(3):268–76.

    PubMed Central  PubMed  Article  Google Scholar 

  36. 36.

    Miquelon P, Lesage A, Boyer R, et al. Mental health service utilization among students and staff in 18 months following Dawson College shooting. AIMS Public Health. 2014;1(2):84–99.

    Article  Google Scholar 

  37. 37.

    Daniels JA, Volungis A, Pshenishny E, et al. A qualitative investigation of averted school shooting rampages. Couns Psychol. 2010;38(1):69–95.

    Article  Google Scholar 

  38. 38.•

    Shaw JA, Espinel Z, Shultz JM. Care of children exposed to the traumatic effects of disaster. Arlington: American Psychiatric Publishing; 2012. This text provides a comprehensive description of children’s experiences when exposed to disasters and extreme events.

  39. 39.

    Elklit A, Kurdahl S. The psychological reactions after witnessing a killing in public in a Danish high school. Eur J Psychotraumatol. 2013;4:19826.

    Google Scholar 

  40. 40.

    Borum R, Cornell DG, Modzeleski W, Jimerson SR. What can be done about school shootings? A review of the evidence. Educ Res. 2010;39(1):27–37.

    Article  Google Scholar 

  41. 41.

    Pfefferbaum B, Sweeton JL, Newman E, et al. Child disaster mental health interventions, part II: timing of implementation, delivery settings and providers, and therapeutic approaches. Disaster Health. 2014;2(1):13–24.

    Google Scholar 

  42. 42.

    Kalish R, Kimmel M. Suicide by mass murder: masculinity, aggrieved entitlement, and rampage school shootings. Health Sociol Rev. 2010;19(4):451–64.

    Article  Google Scholar 

  43. 43.

    Knoll JL. The "pseudocommando" mass murderer: part I, the psychology of revenge and obliteration. J Am Acad Psychiatry Law. 2010;38(1):87–94.

    PubMed  Google Scholar 

  44. 44.

    Knoll JL. The "pseudocommando" mass murderer: part II, the language of revenge. J Am Acad Psychiatry Law. 2010;38(2):263–72.

    PubMed  Google Scholar 

  45. 45.

    Lankford A, Hakim N. From Columbine to Palestine: a comparative analysis of rampage shooters in the United States and volunteer suicide bombers in the Middle East. Aggress Violent Behav. 2011;16(2):98–107.

    Article  Google Scholar 

  46. 46.

    Thompson S, Kyle K. Understanding mass school shootings: links between personhood and power in the competitive school environment. J Prim Prev. 2005;26(5):419–38.

    PubMed  Article  Google Scholar 

  47. 47.

    Hong JS, Cho H, Allen-Meares P, Espelage DL. The social ecology of the Columbine High School shootings. Child Youth Serv Rev. 2011;33(6):861–8.

    Article  Google Scholar 

  48. 48.

    Greenspan AI, Kellerman AL. Physical and psychological outcomes 8 months after serious gunshot injury. J Trauma. 2002;53(4):709–16.

    PubMed  Article  Google Scholar 

  49. 49.

    Zatzick D. Interventions for acutely injured survivors of individual and mass trauma. In: Ursano RJ, Fulerton CS, Weisaeth L, Raphael B, editors. Textbook of disaster psychiatry. Cambridge, UK: Cambridge University Press; 2007. p. 190–205.

    Google Scholar 

  50. 50.

    Michaels AJ, Michaels CE, Moon CH, et al. Posttraumatic stress disorder after injury: impact on general health outcome and early risk assessment. J Trauma. 1999;47(3):460–7.

    CAS  PubMed  Article  Google Scholar 

  51. 51.•

    Santiago PN, Ursano RJ, Gray CL, et al. A systematic review of PTSD prevalence and trajectories in DSM-5 defined trauma exposed populations: intentional and non-intentional traumatic events. PLoS One. 2013;8(4):e59236. Contrasts the effects of exposure to intentional acts of mass violence (using school shooting examples), in relation to higher observed rates of PTSD.

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  52. 52.

    Rundell JR. Psychiatric issues in medical-surgical disaster casualties: a consultation-liaison approach. Psychiatr Q. 2000;71(3):245–58.

    CAS  PubMed  Article  Google Scholar 

  53. 53.

    Rundell JR. Assessment and management of medical-surgical disaster casualties. In: Ursano RJ, Fulerton CS, Weisaeth L, Raphael B, editors. Textbook of disaster psychiatry. Cambridge: Cambridge University Press; 2007. p. 164–89.

    Google Scholar 

  54. 54.

    Victorson D, Farmer L, Burnett K, et al. Maladaptive coping strategies and injury-related distress following traumatic physical injury. Rehabil Psychol. 2005;50(4):408–15.

    Article  Google Scholar 

  55. 55.

    Richmond TS, Kauder D. Predictors of psychological distress following serious injury. J Trauma Stress. 2000;13(4):681–92.

    CAS  PubMed  Article  Google Scholar 

  56. 56.

    Geisser ME, Roth RS, Bachman JE, Eckert TA. The relationship between symptoms of post-traumatic stress disorder and pain, affective disturbance and disability among patients with accident and non-accident related pain. Pain. 1996;66(2):207–14.

    CAS  PubMed  Article  Google Scholar 

  57. 57.

    Maes M, Mylle J, Delmeire L, Altamura C. Psychiatric morbidity and comorbidity following accidental man-made traumatic events: incidence and risk factors. Eur Arch Psychiatry Clin Neurosci. 2000;250(3):156–62.

    CAS  PubMed  Article  Google Scholar 

  58. 58.

    Burke RV, Iverson E, Goodhue CJ, et al. Disaster and mass casualty events in the pediatric population. Semin Pediatr Surg. 2010;19(4):265–70.

    PubMed  Article  Google Scholar 

  59. 59.

    Mass shooting in Colorado: practice drills, disaster preparations key to successful emergency response. ED Management: AHC Media. 2012;24(10):109–12.

  60. 60.

    Gaarder C, Jorgensen J, Kolstadbraaten KM, et al. The twin terrorist attacks in Norway on July 22, 2011: the trauma center response. J Trauma Acute Care Surg. 2012;73(1):269–75.

    PubMed  Article  Google Scholar 

  61. 61.

    Grieger TA, Fullerton CS, Ursano RJ, Reeves JJ. Acute stress disorder, alcohol use, and perception of safety among hospital staff after the sniper attacks. Psychiatr Serv. 2003;54(10):1383–7.

    PubMed  Article  Google Scholar 

  62. 62.

    Sollid SJM, Rimstad R, Rehn M, et al. Oslo government district bombing and Utoya island shooting July 22, 2011: the immediate pre-hospital emergency medical service response. Scand J Trauma Resusc Emerg Med. 2012;20(1):3.

    PubMed Central  PubMed  Article  Google Scholar 

  63. 63.

    Lockey D. The shootings in Oslo and Utøya island July 22, 2011: lessons for the international EMS community. Scand J Trauma Resusci Emerg Med. 2012;20(1):4.

    Article  Google Scholar 

  64. 64.••

    Flynn BW, Speier AH. Disaster behavioral health: Legal and ethical considerations in a rapidly changing field. Curr Psychiatry Rep. 2014;16(8):457. Examines legal and ethical issues in disaster behavioral health – important themes that are underrepresented in the published literature.

    PubMed  Article  Google Scholar 

  65. 65.

    Muschert GW. School shootings as mediatized violence. In: Böckler N, Seeger T, Sitzer P, Heitmeyer W, editors. School shootings: international research, case studies, and concepts for prevention. New York: Springer Publishing; 2012. p. 265–82.

    Google Scholar 

  66. 66.

    Muschert GW, Ragnedda M. Media and violence control: the framing of school shootings. In: Heitmeyer W, Haupt HG, Malthaner S, Kirschner A, editors. The control of violence in modern society: multidisciplinary perspectives, from school shootings to ethnic violence. New York: Springer Publishing; 2010. p. 345–61.

    Google Scholar 

  67. 67.

    Muschert GW, Sumiala J. School shootings: mediatized violence in a global age (Studies in media and communications, volume 7). Emerald Group: Bingley, UK; 2012.

    Google Scholar 

  68. 68.

    Woodthorpe K. Public dying: death in the media and Jane Goody. Sociol Compass. 2010;4(5):283–94.

    Article  Google Scholar 

  69. 69.

    Suimala J. Media and ritual: death, community, and everyday life. New York: Routledge; 2013.

    Google Scholar 

  70. 70.

    Hakala S. The mediatized victim: school shootings as distant suffering. In: Muschert GW, Sumiala J, editors. School shootings: mediatized violence in a global age (Studies in media and communications, volume 7). Bingley, UK: Emerald Group Publishing Limited; 2012. p. 255–78.

    Google Scholar 

  71. 71.

    Shultz JM, Muschert GW, Dingwall A, Cohen AM. The Sandy Hook Elementary school shooting as tipping point: “this time is different.". Disaster Health. 2013;1(2):1–18.

    Article  Google Scholar 

  72. 72.

    Haravuori H, Suomalainen L, Berg N, et al. Effects of media exposure on adolescents traumatized in a school shooting. J Trauma Stress. 2011;24(1):70–7.

    PubMed  Article  Google Scholar 

  73. 73.

    Thoresen S, Jensen TK, Dyb G. Media experiences and mental health in terrorist attack survivors. J Trauma Stress. (in press).

  74. 74.

    Holman EA, Garfin DR, Silver RC. Media’s role in broadcasting acute stress following the Boston Marathon bombing. Proc Natl Acad Sci U S A. 2014;111(1):93–8.

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  75. 75.••

    Schildkraut J, Muschert GW. The usual suspects: violent media, guns, and mental illness. In: Agger B, Luke TW, editors. Gun violence and public life. Boulder: Paradigm Publishing; 2014. p. 59–78. Juxtaposes the media coverage of guns and mental illness, a polemic that plays large in media accounts of mass shootings.

    Google Scholar 

  76. 76.

    McGinty EE, Webster DW, Barry CL. Effects of news media messages about mass shootings on attitudes toward persons with serious mental illness and public support for gun control policies. Am J Psychiatry. 2013;170(5):494–501.

    PubMed  Article  Google Scholar 

  77. 77.••

    McGinty EE, Webster DW, Jarlenski M, Barry CL. News media framing of serious mental illness and gun violence in the United States, 1997–2012. Am J Public Health. 2014;104(3):406–13. Describes how news media framing of mass shootings is negatively influencing public perceptions of serious mental illness (SMI).

    PubMed  Article  Google Scholar 

  78. 78.

    Muschert GW. School shootings. In: Herzog-Evans M, editor. Transnational criminology manual, vol. 2. Nijmegan, Netherlands: Wolf Legal Publishing; 2010. p. 73–89.

    Google Scholar 

  79. 79.••

    Schildkraut J, Muschert GW. Media salience and the framing of mass murder in schools: a comparison of the Columbine and Sandy Hook massacres. Homicide Stud. 2014;18(1):23–43. Describes shifts in the media framing of school shootings marked by an increasing focus on gun control and mental health issues.

    Article  Google Scholar 

  80. 80.

    Kellner D. The Sandy Hook slaughter and copy cat killers in a media celebrity society: analysis and plans for action. Logos: A Journal of Modern Society and Culture. 2013;12(1).

  81. 81.

    Muschert GW, Henry S, Bracy NL, Peguero AA. Responding to school violence: confronting the Columbine effect. Boulder: Lynne Rienner Publishers; 2014.

    Google Scholar 

  82. 82.

    Schildkraut J, Hernandez TC. Laws that bit the bullet: a review of legislative responses to school shootings. Am J Crim Just. 2014;39(2):358–74.

    Article  Google Scholar 

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Conflict of Interest

James M. Shultz, Siri Thoresen, Brian W. Flynn, Glenn W. Muschert, Jon A. Shaw, Zelde Espinel, Joshua B. Gaither, Yanira Garcia-Barcena, Kaitlin O’Keefe, and Alyssa M. Cohen declare that they have no conflict of interest.

Frank G. Walter has financial relationship with and has received paid travel expenses from Heyltex Corp.

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Correspondence to James M. Shultz.

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Shultz, J.M., Thoresen, S., Flynn, B.W. et al. Multiple Vantage Points on the Mental Health Effects of Mass Shootings. Curr Psychiatry Rep 16, 469 (2014). https://doi.org/10.1007/s11920-014-0469-5

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Keywords

  • Mental health
  • Mental disorders
  • PTSD
  • Stress disorders/post-traumatic
  • Shooting
  • Mass shooting
  • Shooting massacre
  • Rampage shooting
  • Weapons
  • Firearms
  • Guns
  • Gunshot wounds
  • Violence
  • Firearm violence
  • Workplace violence
  • Homicide
  • Gun control
  • Media framing