Can you experience PTSD from watching war from afar?

People search through buildings destroyed by Israeli air strikes in the southern Gaza Strip in November, 2023.

By Susan Pinker

After working for over 20 years as a social-science journalist, I experienced a “first” last week. I interviewed an expert who was sitting in a bomb shelter. The concrete-reinforced room doubles as an office for Danny Horesh, a clinical psychologist and associate professor of psychology at Israel’s Bar-Ilan University, and head of the trauma and stress research lab there. I had contacted him to talk about the psychological after-effects of the attacks on Oct. 7, 2023. More specifically, can someone experience the symptoms of post-traumatic stress disorder (PTSD) by watching a war from afar?

Though more than 9,000 kilometres away, many Canadians feel deeply disturbed by what is happening in the Middle East. Still, in the Canadian context, PTSD might seem like hyperbole. It’s a clinical term that originated with the psychological distress of Vietnam veterans, many of whom returned from combat disoriented and damaged. PTSD has since been catapulted from a technical term defined in the 1980 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) into common parlance. Post-traumatic stress, and even the word “trauma,” have become so pervasive that they now encompass an array of psychological challenges, from marital conflict to workplace bullying. As an indication of how extensively the concept has permeated popular culture, a 2014 tome about the physiological impact of chronic trauma, The Body Keeps the Score by Boston University psychiatrist Bessel van der Kolk, has been on The New York Times bestseller list for 262 weeks and has been translated into 38 languages.

Why PTSD feels so personally apt to so many people, especially those living in stable democracies whose exposure to violence is usually limited to what’s on their screens, is my question. When Israeli civilians, including entire families, were slaughtered or incinerated alive on Oct. 7, people all over the world were horrified. But diaspora Jews were also terrified. Children of Holocaust survivors felt as if their parents’ victimization was being revisited on their own families. Adults whose grandparents barely escaped the pogroms felt like history was repeating itself. The fear of being scapegoated again – often referred to as intergenerational trauma – has been evocatively described in these pages by Marsha Lederman. I heard some of my Jewish neighbours talking about removing their mezuzah – a small box nailed to a door frame containing passages from the Torah – so their houses could not be identified as places where Jews lived.

The degree to which average Canadians feel threatened is scary in itself. Indeed, some of these fears were borne out recently, when a Montreal synagogue and a Jewish non-profit were fire-bombed and two Montreal Jewish schools saw gunfire, one of them twice. At an anti-Israel demonstration at Concordia University, Jewish students were told to “go back to Poland, you … .” The person shouting the offensive epithet at students turned out to be a lecturer from a different Montreal university. Not exactly a role model.

The fear isn’t limited to Jews. My Greek Orthodox hairstylist kept her children home from school on Oct. 13, the day former Hamas chief Khaled Meshaal exhorted all Muslims “to put theory into practice” by annihilating Israel and practising international jihad. The panic, much of it disseminated by social media, was pervasive.

Similar emotional upheaval is happening among the Palestinian diaspora. A friend’s father, a Palestinian physician who has lived in Canada for over 50 years, becomes distressed each time there is violence in the Palestinian territories. “Be prepared for tears,” his adult son said, when I called to ask if I could talk to his father. Could the images of Israel’s invasion of Gaza after Hamas’s atrocities be triggering his father’s traumatic memories of being forced to leave his birthplace at gunpoint? The son readily agreed. “My dad was interested in talking to you at first but decided to decline,” the son texted, adding that the family didn’t want their names used. “He said he has a lot on his mind and is not interested in opening up old wounds.” My friend’s aunt, also a long-standing Canadian, felt “too sad and frightened” to talk to me. “It’s not a good time to be identified as Palestinian right now,” she said.

Does all of this fear, avoidance and rumination add up to PTSD?

The answer is a qualified yes. According to the latest edition of the DSM, the American Psychiatric Association’s diagnostic bible, the label post-traumatic stress disorder applies when a person experiences a traumatic event directly, or when that person has seen it or learned that it happened to a family member or a close friend. It requires being repeatedly exposed firsthand to aversive details of that event. And it matters if the distress impairs their daily life – the ability to concentrate, to have friends, to work. A PTSD diagnosis hinges on mood and cognitive disturbances resulting from re-experiencing the distressing event. Unless someone has firsthand experience of violence, the feelings elicited by seeing it on screen would not merit a diagnosis of PTSD.

According to these criteria, the typical Canadian wouldn’t qualify for a PTSD diagnosis, but most Israelis and Gazans would. “It’s not like 9/11,” when most people were observing the events from a distance, said Rivka Tuval-Mashiach, a psychology professor at Bar-Ilan University and the chief psychologist at NATAL, Israel’s trauma centre. She says almost everyone in Israel knows someone who was killed on Oct. 7. “Even living in Tel Aviv, I am exposed to constant missiles and sirens,” she said, adding that her own 21-year-old son is a soldier in a dangerous situation, with no way to communicate with her. I asked about how it feels to treat people for the kind of anxiety she is feeling herself. The term is “shared reality,” she answered. ”It’s about treating trauma, but also experiencing it yourself,” adding, “Nothing is the same when you see it from afar.”

Dr. Horesh doesn’t call the situation Israelis are facing post-traumatic stress, but peri-traumatic, meaning the damage is continuing, is all around them and no one knows when it will end. “This is a major mental-health crisis for the entire country,” he says. Every psychologist, psychiatrist and social worker he knew was engaged in tamping down the grief and uncertainty, as well as training volunteers to do the same.

To be sure, some Canadians can also feel traumatized during this horrific war. The violence in Israel and Gaza is triggering continuing fear and grief in Palestinian Canadians, such as my friend’s family. Even if they’ve lived in Canada for decades, the term PTSD would still apply. Holocaust survivors or their family members would also qualify.

There are individual differences, to be sure, and the resilience of some survivors is a hopeful sign. Zvi Solow, an 89-year-old Holocaust survivor, was living on Kibbutz Nirim near the Gaza border when the Hamas attack took place. The retired philosophy of science professor is now an internally displaced person living in temporary housing. I asked him what was most important to know. “I was almost killed with my partner, who is 90 years old, for no other crime than for being two kilometres from the border.” He saw what was happening from his safe room. “I saw them at 6:30 a.m. between our house and next door, running around with weapons. They kidnapped my neighbour Hannah and her adult son. I heard later that they killed her other son, who lived on the other side of the kibbutz.”

Prof. Solow was 7 when he first immigrated to Israel from Poland. “Most of my family had been exterminated. We came to Israel as stateless refugees.” How do you feel about having survived two calamities? I asked. Are you bitter? “No, I’m a rational person. This should never have happened. Our army messed up. I’m angry at whoever is responsible,” he told me calmly.

“But I have nothing against the people in Gaza. The attack was not them, but from Hamas. They don’t represent the Palestinians. Hamas is not just anti-Jewish and anti-Israel, they’re anti-modern. And I’m proud that I survived.”

Clearly, PTSD is not everyone’s experience of a traumatic event. Though Prof. Solow and I didn’t discuss his feelings at length, I was struck by how measured and balanced he sounded.

To be sure, there are a range of reactions to traumatic events. Some are immediate, others delayed, and yet other people cope by helping others or by viewing what’s happening through a rational lens. Dr. Horesh described the complexity of the crisis for psychologists as “a whole new animal, a gestalt that is more than the sum of its parts.”

For those of us who are observing the war in the Middle East and feeling stressed and worried, the situation may not qualify as PTSD, but it is certainly a normal, human reaction. The best way to cope, according to Dr. Horesh, is to connect with our loved ones and tap into social supports. “Loneliness and trauma are a toxic combination. Having a strong network, a strong community, is the best protective factor.”