PTSD Effects on Mass Shooting Survivors: Screening & Coping

Introduction

Post-traumatic stress disorder (PTSD) is common among soldiers returning from active duty overseas, where they encountered combat, shelling, and intense encounters with the enemy (Thomas et al., 2010). Symptoms of PTSD can range from anger, hostility, and aggression to depression and suicidal ideation (Jakupcak et al., 2007). While it is understandable that combat veterans might experience PTSD, what is less frequently appreciated is the fact that survivors of mass shootings can also experience PTSD (Cimolai et al., 2021). This is important because PTSD, if undiagnosed and untreated, can wreak havoc on a person's personal and professional life—or on a person's development if the individual is still a child when the traumatic event occurs (Bardeen et al., 2013).

Moreover, this issue is pressing because mass shooting events have occurred with increasing frequency in recent years. There was the Las Vegas shooting in 2017 that killed 60 and injured nearly 1,000; the Orlando nightclub shooting that killed 49 and injured nearly 60; the El Paso Walmart shooting that killed nearly two dozen people and injured just as many; the Virginia Tech shooting of 2007; the Sandy Hook shooting of 2012; the Aurora movie theater shooting of 2012; and dozens of others. Clearly there is a need to understand the impact that PTSD can have on survivors of these shootings. This paper discusses the PTSD effects on mass shooting survivors and argues that survivors should be screened—just as returning soldiers from combat are screened for potential PTSD—and taught coping strategies, because the risk of not treating PTSD among mass shooting survivors is too great to be ignored.

What Is a Mass Shooting?

A mass shooting event has been defined by the nonprofit organization Gun Violence Archive as "an incident in which four or more people, excluding the perpetrator(s), are shot in one location at roughly the same time" (Cimolai et al., 2021, p. 1). Mass shooting events can therefore occur anywhere: beaches, schools, theaters, public places like shopping centers, private places such as temples or churches, stadiums, concerts, parks, workplaces, and so on. In fact, mass shooting events have occurred at all of these venues in recent years.

One of the deadliest settings where mass shootings have occurred is, unfortunately, the school environment. As Cimolai et al. (2021) point out, the prevalence of mass shootings at schools is rare—but when a mass shooting does occur at a school it is often very deadly: "Four of the top deadliest shootings in the past 21 years, where the fatalities were between 13 and 33, were in schools, accounting for a majority of gun violence–related fatalities: Columbine High School, Littleton, CO (1999); Virginia Tech, Blacksburg, VA (2007); Sandy Hook Elementary School, Newtown, CT (2012); and Marjorie Stoneman Douglas High School, Parkland, FL (2018). About 60% of all school shootings occurred in a high school setting" (p. 2). School shootings are especially likely to induce PTSD because survivors are not just the adults and children who were present at the shooting but also members of the broader community—families and others who are impacted indirectly. One does not need to experience a traumatic event directly in order to be traumatized by it (Knight, 2013).

Mental Health Consequences of Mass Shootings

Mass shootings are traumatizing events that can have a severe impact on the mental health of survivors (Lowe & Galea, 2017). Just as soldiers or police officers can experience trauma in the line of duty, survivors of mass shootings can be at double the risk of developing PTSD because they are neither trained for such a situation nor likely to be expecting it in the course of their everyday lives. Likewise, just as a witness of sexual abuse can be counted as a victim of that abuse, a witness of a mass shooting may also experience PTSD as a result. Thus, when a mass shooting occurs and people survive it, returning to a state of normalcy can be quite difficult. North et al. (1997, 2002) have shown that the effects of PTSD can linger for years following a mass shooting event.

One particularly vulnerable population is children. As Cimolai et al. (2021) explain, this group demands careful consideration because "overall, the impact of gun violence is not felt just during the incident but has long-term consequences for onlookers, family, and the community. Children often unwittingly experience the trauma with few psychological tools to deal with the event" (p. 1). Thus, children should receive special attention in any discussion of PTSD effects on mass shooting survivors—especially since "young children (age 2 to 9) when exposed to direct or indirect violence have increased rates of PTSD" (Cimolai et al., 2021, p. 2). One of the most common symptoms among children exposed to gun violence is anxiety sensitivity, characterized by an irrational fear that negatively impairs one's ability to socialize, function physically, or engage in normal cognitive functioning (Cimolai et al., 2021). Children are also more likely to exhibit both internalizing and externalizing problems as effects of PTSD. They may develop physical illnesses because they are unable to express how they feel; these are known as psychosomatic responses, in which the body is made ill even though there is no underlying physical cause—the cause is purely psychological.

But children are not the only ones who can be adversely affected as survivors of mass shootings. Lowe and Galea (2017) show that "mass shootings are associated with a variety of adverse psychological outcomes in survivors and members of affected communities," including the parents of elementary school children who survived a mass shooting at their school (p. 62). Some demographics, however, face a higher risk of being affected by PTSD than others. For instance, Lowe and Galea (2017) found that women with pre-incident psychological symptoms are more likely to develop PTSD effects. Additionally, those who were in close proximity to the shooting and who are acquainted with someone who died are more likely to experience PTSD than those who witnessed the event from a distance and did not know any of the victims. One further factor that heightens susceptibility to PTSD after a mass shooting is the extent to which an individual has access to psychosocial resources, such as social support and emotion regulation exercises (Lowe & Galea, 2017).

Longitudinal studies have demonstrated that more than a quarter of survivors of mass shootings experience PTSD, while nearly another fifth experience other psychiatric problems (North et al., 1997). North et al. (1997) also found, after conducting interviews with 136 mass shooting survivors, that those with a previous psychiatric history—particularly involving depression—were most vulnerable to developing PTSD. Moreover, PTSD was unlikely to go into remission even three years after the mass shooting incident (North et al., 2002). North et al. (2002), like Lowe and Galea (2017), also found that women and those with prior psychiatric histories were more likely to develop PTSD.

Adults who survive mass shootings can demonstrate PTSD effects such as "intrusion (flashbacks, nightmares, and unwanted memories); avoidance of trauma-related thoughts, feelings, and external reminders; alteration in arousal and reactivity (irritability, risky behavior, hypervigilance); and negative changes in cognition and mood" (Cimolai et al., 2021, p. 3). One high school survivor of the 2018 Stoneman Douglas High School shooting, for instance, was taken to the emergency room of a local hospital months after the shooting with "intrusive thoughts related to the shooting, nightmares of the shooter entering the building and killing multiple people, and avoidance of school and public places as they induced flashbacks and panic attacks" (Cimolai et al., 2021, p. 3). Her PTSD had been triggered simply by seeing graphic news coverage on television and social media about gun violence.

Adults may not even know they have PTSD until symptoms like these emerge. Children, however, might show signs that adults can identify early on. Behavioral indicators among children experiencing PTSD after a mass shooting can include "increased anxiety, development of new fears, sadness, lack of interest, prolonged crying, low frustration tolerance, and aggression. Parents might notice regressive behaviors (thumb sucking, sleeping in the parental bed), loss of acquired developmental milestones, change in eating habits, and sleep problems (nightmares, frequent wakening)" (Cimolai et al., 2021, p. 4). Children may also engage in repetitive fantasy play in which themes of trauma are consistently explored.

There is another dimension of PTSD among mass shooting survivors that often goes unexplored: guilt. Although there is no rational basis for a survivor to feel guilty, some are so overwhelmed by guilt that they ultimately take their own lives. This is a serious effect of PTSD (Cimolai et al., 2021). Suicide risk is one of the major reasons PTSD needs to be considered more fully in the wake of a mass shooting. Within ten days of two separate mass shooting events, there were three suicides among survivors: "two adolescent survivors of the Stoneman Douglas High School shooting and the father of one of the children killed in the 2012 Sandy Hook Elementary School massacre took their own lives" (Cimolai et al., 2021, p. 4). Guilt can overwhelm a survivor or a grieving parent who believes they could have done something more to stop the shooting. Cimolai et al. (2021) note, for example, that "four students affected by the Columbine High School shooting reported in a qualitative study that guilt grew in the 2 weeks following the event along with ruminations on what they could have done to prevent the attack" (p. 5). Feelings of guilt, therefore, must be recognized as a significant PTSD effect among mass shooting survivors.

Other effects include major depression, social phobia, psychosomatic disorders, and substance abuse (Cimolai et al., 2021). Additionally, school enrollment rates can drop among survivors, and those who remain enrolled may see their academic performance decline. In short, PTSD effects can manifest in many different ways; there is no single characterization that fits all mass shooting survivors. Every affected individual must be considered and evaluated following such an event—not only those who were directly present but also community members, family members, and friends. The effects can vary widely both in how they present and in whom they appear.

Littleton et al. (2011), however, found that one significant factor determining whether a survivor experiences PTSD is the type of coping strategy the individual employs after the shooting. In a longitudinal study of survivors of the Virginia Tech mass shooting, they found that maladaptive coping correlated significantly with psychiatric stress over time. In other words, survivors who lacked effective coping strategies were more likely to experience PTSD in the wake of the shooting, suggesting that coping ability is a meaningful mediating factor in psychological outcomes.

Conclusion

A mass shooting event is any situation in which gun violence impacts more than a handful of people. Such events have become increasingly common in America, and there is a pressing need for authorities to provide proper support for mass shooting survivors given the wide-ranging effects of PTSD that can harm them. The U.S. military screens soldiers returning from combat for PTSD symptoms, and the same approach should be adopted for mass shooting survivors. Anyone who has experienced a mass shooting—directly or indirectly—may be at risk for PTSD. Moreover, certain demographics face elevated risk, including women and individuals with a prior history of psychological problems.

All affected individuals need access to support systems and training in coping strategies to build resilience in the face of ongoing stressors. Crisis response teams should play an integral role following any mass shooting. They should create a registry of all survivors and conduct follow-up contact for up to a year after the event to ensure that PTSD is identified and treated. For those most closely affected, however, time is of the essence: some survivors may be at risk of suicide immediately after the event due to intense feelings of guilt about what could have been done to prevent the shooting. Prompt, sustained, and well-organized mental health intervention is not optional—it is a necessity.

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